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Pregnant mothers’ exposure to the flu was associated with a nearly fourfold increased risk that their child would develop bipolar disorder in adulthood, according to an NIH study published last month.

What Delays Puberty?


ORGANIC better for kids?


he nutritional choices you make for your children are crucial, setting the stage for good health and good habits for years to come. So if you’ve heard about the benefits of organic food, you may be wondering if it’s worth the extra expense, especially if you’re on a budget. Whether conventionally or organically grown, what’s most important is that children eat a variety of fruits, vegetables, lean meats, whole grains, and low-fat or fat-free dairy products, according to the American Academy of Pediatrics (AAP), which recently weighed in on the organic food subject for the first time. Organic foods do have lower levels of pesticides and drug-resistant bacteria, said Dr. Thomas K. McInerny, AAP president. “That may be important for kids because young children are more vulnerable to chemicals, but we simply don’t have the scientific evidence to know if the difference will affect a person’s health over a lifetime,” said McInerny. Both organic and conventionally grown foods have the same vitamins, minerals, antioxidants, proteins, lipids and other nutrients

that are important for children’s health. “If you’re on a budget, don’t buy the more expensive organic option if it’s going to reduce your family’s overall intake of healthy foods like fresh produce,” said McInerny. “It’s better for kids to eat five servings of conventionally grown produce a day than for them to eat one serving of organic vegetables.” Families can also be selective in choosing particular organic foods to stretch their budget. The Environmental Working Group has created a Shopper’s Guide that rates the level of pesticides in produce. Their guide indicates that conventionally grown onions, sweet corn and pineapples have relatively low pesticide rates, making them safer to purchase. If you can budget a few extra dollars to spend on groceries, opt for organic apples and celery, which are among the most pesticide-laden crops. According to the AAP, organic milk is not healthier for kids than conventional milk, but parents should make sure all milk they purchase is pasteurized. Find nutrition tips for kids on the AAP website for parents, –STATEPOINT

The late onset of puberty, defined as no menstrual period by 16 or no enlargement of the testicles by 14, can run in families and most commonly is simply a case of the child being a “late bloomer,” according to the Hormone Health Network. Less commonly, it can be the result of medical conditions like celiac disease that prevent absorption of nutrients; malfunction of the thyroid or pituitary glands; genetic conditions; and medications that decrease appetite, such as those that treat attention deficit hyperactivity disorder. Some cancer treatments, as well as eating disorders like anorexia, can also delay puberty, according to the network. If you or your teen are concerned about it, talk to a doctor, especially if development began then stopped suddenly.

Women More Attuned To Baby’s Cry What many moms have long suspected seemss to have been confirmed by a recently published study: women’s brains appear ear to be hardwired to respond to the cries of a hungry infant. In the National Institutes of Health study, men and women were asked to let their minds wander, and then listened to a recording of white noise interspersed with the sounds of a crying infant. In the women, patterns of brain activity abruptly switched to an attentive mode when they heard the cries, whereas the men’s brains remained in a resting state. The brain patterns did not vary between parents and nonparents. While previous studies have shown that men and women respond to the crying differently on an emotional level, this study showed “marked differences in terms of attention as well.”


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Boys are usually ready to use the potty between 18 and 30 months; girls between 18 and 24 months.



Gazette Health Health || Summer Summer 2013 2013 6 Gazette



efore Maurine Kelly became a psychologist, her now-adult son was nearly 3 and not using a toilet. “Like many parents in this situation, I was feeling like I had failed, especially when my mother-in-law made a point that her son was trained at 9 months,” said Kelly, who is in private practice with a focus on children in Silver Spring and Bethesda. “No way can you train a baby at that age. She put him on the toilet after he ate, and he eventually went. It is actually the parent who is trained in this case.” According to Kelly, many parenting experts who deal with young children actually refrain from using the word “trained” because they consider toileting something that should happen naturally. “It’s a natural part of development, and that’s the main point to parents; that and the fact that it’s important to be respectful of a child’s readiness,” said Kelly. But there are ways to encourage children once they show readiness, as well as ways to coax them should they become resistant—and without a fullblown power struggle. Nichole Glass, M.D., a pediatrician at Children’s Pediatricians and Associates in College Park, said readiness is age- and sex-dependent. “Boys are usually ready between 18 and 30 months,” she said, “and girls are typically between 18 and 24 months. “At well-baby checks, I ask parents if their child is going in a corner or squatting or saying ‘I have to poo.’ If they are doing these things or taking off their diaper and giving it to you, they are probably ready,” said Glass. Still, incentives can help, but there are subtle differences in how you incentivize that can make the difference between success and failure, according to


Read to your child while he is on the potty—perhaps a book on children’s toileting.

Caren Glassman, M.D., of Potomac Pediatrics in Rockville. “For instance, never reward for peeing or pooping on the potty. Reward for staying dry,” she said. “If you give a child an M&M every time they urinate a little, they learn all they have to do is tinkle here and there. They will get plenty of M&M’s, and when they are full, they are done with that game. So reward for the goal, which is periods of dryness, rather than the means to the goal, which is urinating or defecating.”

Consider these tips:


Be aware of signs of readiness, including development of language and other skills. According to Kelly, children are ready to use a potty if they can: • Tell you they have to “pee pee” or “poo poo” or ask for a diaper change • Dress and undress themselves; they will need to pull their pants down and up. • Walk and climb; they will need to get on their potty chair. • Control their urine, which you will know they were successful at if they have a dry diaper for two hours.



Motivate them with rewards. Kelly suggested the following: • Tell children that once they use a toilet they can wear Pull-Ups and underwear with a favorite character or flowers. • Have them watch a parent or older sibling use the toilet, and then praise them for being grown up when they use theirs, too.


If a child is resistant, understand why. Some factors that can delay or complicate toileting, according to Kelly, are: • Birth of a baby • Entering child care • Moving • Death of a loved one, including a pet • Constipation Ask your pediatrician for advice in these situations.


While experts suggest many active steps to take to help children along, some behaviors are best avoided. • Don’t be overly eager. Pushing children may encourage them to become resistant as they realize their bodies are one thing they can control, according to Glassman.


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• Don’t make the urine or stool into a prize, or the child may not want to flush, said Kelly. • Don’t use training diapers as children first begin to use the toilet because they keep the children dry and unaware of when they begin to urinate, Glassman advised.


Make potty training fun, Kelly suggested, with activities that generate enthusiasm. • High-five, hug, kiss and praise them. • Give stickers. • Read to them when they are on the potty; you may want to get a children’s toileting book. • When they are done, let them flush the toilet. • Suggested Glass: Let them have a coloring book or toy on the potty.


If a child is resistant, have mandatory potty time, said Glass. • Length should be three minutes. Be consistent and realize it could take up to six months to get the desired behavior. • Tell children ahead of time that if they go in their pants they will have this potty time. Do not change your tone to sound angry.

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Don’t use toothpaste with fluoride until a child is able to spit.


To Get Your Toddler to Brush His Own Teeth Haskell. “If the parents do not brush and floss their teeth, neither will the child.” If the child has a big brother or sister, include them in the routine, Kwatra suggested. “Toddlers love to do what you do or what a big brother or sister does,” he said. “It’s a great motivator, and a lot of times the older sibling loves to show them.”




Children can begin brushing their own teeth when they show an interest in putting the toothbrush in their mouth. This is where good oral hygiene habits begin to take hold. “The best way to get children to brush and floss their teeth is to set a good example,” said

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Stuffed animals also can get in on the act, Kwatra noted. “Give a kid a toothbrush for a stuffed animal to introduce the concept,” he said. “That workss a lot of times.”

Read books about toothbrushing with kids, said Kwatra. “Parents Parents remember books they read when they were little. They can read the same books.” One option is “The Berenstain tain Bears Visit the Dentist” by Stan and Jan Berenstain, he said. Books also help to establish lish a nighttime routine that incorporates brushing. “This includes putting on pajamas, as, brushing your teeth … and sitting down n and reading a book before going to bed,” ” he said.


Sing a song while your our child brushes. “You can use singing ging as a natural timer,” Kwatra said. d. “Two minutes is the recommended time to brush your teeth, so you can sing a song ong for up to two minutes.” Children will sing along ong even while brushing their teeth, he added. “They do it in the [dental] office. It’s more like humming.”



Sparkly toothbrushes and bubble gum-flavored toothpaste exist for a reason. Get a themed toothbrush with your child’s favorite character.


arly visits to the dentist are important to toddlers, and not only so the practitioner can examine the child’s teeth, or tooth, as the case may be. Establishing good dental habits, which include regular toothbrushing, according to area dentists, is key to future good oral health. “A child should have the first dentist checkup before the age of 1 or when the first tooth comes in,” said Kim S. Haskell, D.D.S., who has a practice in Upper Marlboro. “Probably the most important reason for any early visit is to educate the parents on proper oral hygiene for the child, how diet affects dental health and to be sure the child has the proper amount of fluoride.” Parents should clean and brush a child’s teeth before he can do it himself, Haskell said, which is when the first tooth comes in. “Parents should begin caring for the teeth as soon as the first tooth appears,” she said. “Typically the front teeth come in first. Because of the shape of those teeth, they can often be easily cleaned by just wiping them with gauze or even a baby washcloth.” When the back teeth come in, it’s time for a toothbrush, said Haskell. When it’s time to start brushing a child’s teeth, it should be done twice a day, said Naveen Kwatra, D.D.S., of MVPsmiles, a pediatric dentistry and orthodontics practice in Gaithersburg. Flossing should begin around age 4, or when teeth begin to touch, he added. While getting a small child to brush his teeth might not always be the easiest thing to accomplish, Haskell and Kwatra offer some tips on how to make the practice go smoothly.

“We do say get them a cool toothbrush with Spider-Man or a princess or whatever to get them more excited about it,” Kwatra said. As for toothpaste, don’t use one with fluoride before a child can spit; after that, use toothpaste that contains fluoride, but only put a pea-sized amount on the child’s brush, Haskell said. “Small children should be supervised to be sure they do not swallow the toothpaste,” she said.


Only 19 percent of children get the 60 minutes of recommended daily physical activity.

Not [just] your father’s FITNESS Why gyms are for kids, too BY SCOTT HARRIS



yms are typically considered the domain of adults. But, what benefits can they hold for kids? Gaithersburg resident Jeffrey Brown, 12, wanted to find out. Things weren’t working out on his youth baseball team, so he and his parents decided to do something about it. “The coach didn’t play me as much as I wanted to, which really made me feel bad about my abilities,” Jeffrey said. His mother was already a member of the local Sport&Health Club, a regional chain with more than 20 locations in Maryland, Northern Virginia and Washington, D.C. Jeffrey teamed up with a trainer at the club’s Rio location in Gaithersburg who helped him with quickness, core strength and other skills that help with baseball. These days, after approximately a year, Jeffrey has a new story to tell. “I beat someone in a sprint,” he said. “I’m on a new team with a really good coach. I think I’m really happy with what’s going on.” WHETHER IT’S A MIDDLE SCHOOLER LOOKING TO

pump up performance or a preschooler simply in need of a place to play, many gyms are dedicating themselves to the youngest demographic. According to a YMCA parent survey, only 19 percent of children get the 60 minutes of daily physical activity that experts, including the Centers for Disease Control and Prevention (CDC), recommend. Younger children do not usually need formal muscle-strengthening programs; gymnastics and play on a jungle gym typically are sufficient, according to the CDC. Many gyms can provide age-appropriate exercise, keeping in mind both the unique physical and mental attributes of children. “Kids are inherently active,” said Mindy Pierce, director of programming for Sport&Health Clubs. “Inside, they want to run and jump and play. They thrive on having scheduled days but also lots of stimuli.”

Ethan Hall, 11, and Connor Hall, 9, enjoy the pool at Sport&Health’s Club’s North Frederick location.

The Little Gym, which has more than 300 locations worldwide and offers programs for children as young as 4 months, engages young children with a blend of structure and autonomy. “We have a format,” said Fletcher White, owner of The Little Gym of Clinton. “We have a circle and we have group activities. We have time with balls and we have time blowing bubbles. And the kids know the format. If you forget the bubbles, they let you know.” For kids in the upper grades of elementary school or in middle school, the technological trappings of a sedentary lifestyle can make encouraging exercise a bit trickier. At the same time, gym classes can use the same tools to encourage fitness while offering an environment of encouragement, with minimal competition. “The 6- to 12-year-olds have been introduced to the iPads and iPhones,” said White. “They like video, they like to see themselves; so we videotape them doing different routines. We also have learned that one child motivates the other. We want to make them all feel good for just doing their best. You get high fives and hugs for just doing your best.” Sport&Health offers a special Kidz Klub as the core of its children’s programming. Open to children 11 and up, a three-hour course teaches them cardio, nutrition and how to use the equipment, and customizes a program based on what they like to do, according to Pierce. After they pass the

course, kids can workout unsupervised as long as a parent or guardian is in the club. THERE ALSO ARE COUNTY FITNESS PROGRAMS FOR

children that are free or offered at a low cost. Katrina C. Williams, health and wellness officer for the Prince George’s County Department of Parks and Recreation, said the county offers many kids’ programs at no cost. For example, kids 6 to 17 with a county Youth ID have free access to gyms and other structured programs. The county also offers fee assistance of up to 90 percent for eligible participants. Prince George’s County programs range from open gyms, in which kids play games or use sporting equipment under supervision, to structured sports leagues and formal exercise programs. There is a variety of locations and offerings, Williams said. “We’re open seven days a week and we have many facilities across the county,” she said. “If you have a child who is an outdoor enthusiast, they don’t have to come indoors to participate.” At the Bladensburg Community Center, the Fun, Fly & Fit program for elementary- and middle-school students provides an introduction to fitness. “The whole goal is exercise, with warmups, stretching and moving for 45 to 60 minutes,” Williams said. “But it’s still play.” GAZETTE.NET

Summer 2013 | Gazette Health 9




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glucose levels that can lead to Type 2 diabetes; and bone and joint problems, among other short- and longterm health problems. CHILDREN ARE, OF COURSE, STILL

growing, and limiting calories or nutrition may simply not be a good idea. “A kid shouldn’t really be put on a diet,” said Ernest Carter, M.D., a pediatrician and deputy health officer for Prince George’s County. “But being obese as a child can lead to obesity in adulthood. There is a higher incidence of Type 2 diabetes [and] asthma, and there is a stigma that goes along with it. It’s important to nip it in the bud.” Kids often gain weight for different reasons than adults do. According to Laura Power, a nutritional biochemist based in Rockville, new fat cells develop during puberty—one of only a few times in life when this happens. Normally, existing fat cells simply expand as they fill with fat. This occurs during puberty as the body prepares for a growth spurt.


“Once they get past the age of 8 or 9, they may put on weight,” Power said. “Around age 11, kids will tend to grow out in preparation for growing up. They will lose that [weight].” There is also a slim possibility that a thyroid condition or other problem might be causing or exacerbating a weight issue for a child, according to Carter and Power. They recommend seeing a doctor or a nutritionist, particularly if there is uncertainty about the factors behind weight gain. “It could be more,” Carter said. “If there’s something more fundamental going on, we need to address it just like any other condition.” IF CAUSES OUTSIDE NUTRITION HAVE

been ruled out, it may then be appropriate to consider examining a child’s nutrition. For kids, a poor diet manifests itself in more than just a number on a scale. Unhealthy foods don’t keep you full as long as healthier alternatives, and can cause blood sugar spikes and crashes. Both of these things can lead to emotional

or mental changes, according to Kait Fortunato, a dietitian with Greenbeltbased nutrition group Rebecca Bitzer & Associates. “A lot of refined sugar and processed foods can affect moods,” said Fortunato. “Kids can start to overreact to things, have headaches or not be able to focus in school. A lot of the time, they can’t engage at home or are tired.” In addition, negative comments or a strong-arm approach to eating and nutrition can lead to self-esteem problems or even to eating disorders in children, according to Fortunato. “Talk not about dieting, but about feeling good about themselves,” said Fortunato. “Talk not so much about foods to cut out, but foods to add in. Don’t use food as a reward or a punishment.” Use more neutral rewards like outings, she said, and instead of using dessert to acknowledge good grades, choose a couple of nights each week when you’re going to serve dessert and serve it regardless of circumstance or behavior.


o parents want to find themselves using the D-word around their kids. But sometimes the actions it implies are necessary. Dieting, at least in the way the term is understood for adults, may not be appropriate for children. Nevertheless, with approximately or 12.5 million children 2 to 19 years old that are obese, according to the Centers for Disease Control and Prevention (CDC), paying special attention to eating and nutrition is a needed step for a wider number of parents. Obesity is defined by the CDC as a body mass index (BMI) at or above the 95th percentile for children of the same age and sex. BMI is an indicator of body fat based on a child’s height and weight. According to the CDC, obese children are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure; higher blood

Talk not so much about foods to cut out of a child’s diet, but about foods to add to it.

Don’t use food as a punishment or as a reward.

This sort of consistency helps children adhere to a better nutrition plan. Changing or creating a daily structure can improve the chances that children will stick with a new lifestyle. “Give them the opportunity to get hungry and get full. Get organized,” said Daisy Miller, a family therapist and nutritionist based in Gaithersburg. “When you think about feeding your family, think about breaking up the days into meals and snacks. Plan ahead. Everyone is overcommitted and overstressed. You have to sit down with your spouse or partner and talk and think through how to get it done.” SO WHAT ARE THE ACTUAL CHANGES

Ernest Carter, M.D., suggests the following ideas as healthy menu options. Menu can vary based on circumstances, preferences and other conditions, like allergies.

BREAKFAST Glass of orange juice, cereal with 2-percent milk and a medium-sized banana Optional: slice of whole-grain toast LUNCH Sliced turkey sandwich with a little cheese and a fruit or vegetable, such as applesauce or raw carrot sticks SNACK OPTIONS Fruit of choice Vegetable of choice Low-salt, low-sugar trail mix Peanut butter and jelly sandwich For drinks, water or juice (not a juice drink containing ingredients other than juice)


that work if you want to create a healthier eating environment? The first step lies with the parents. “Obese children come from obese parents a whole lot of the time,” Carter said. “Parents have to be sure they’re eating right.” Any new plan can begin by addressing more easily achievable goals, like reducing sugary drinks, said Carter. There are plenty of possible levers that parents can pull. Make sure kids are getting enough physical activity, too. “The regimen can’t start by saying ‘cut out all these things,’” Carter said. “It should be a slow decrease. Slowly decrease the amount of sugar in the diet, especially in drinks. They need protein, meat, fat and carbohydrates. Increase their water consumption. And there should be more play or exercise in the day.” Fruits and vegetables are a key part of any effort to improve health and nutrition, but that doesn’t have to mean boiled lima beans—quite the opposite. According to Fortunato, it’s entirely possible to make vegetables and fruits a more fun (and tasty) dining option. “Families can try roasted and grilled veggies and different spices, so kids actually like what they’re eating,” Fortunato said. “Take a trip to the farmer’s market and let the kids pick


DINNER Chicken breast or leg and thigh (avoid too much fatty red meat), potatoes, green beans or spinach, water; “a little” dessert is OK

something out for a family taste test. You can drizzle carrots with olive oil and put them on the grill. If you cut them up, they’re like french fries.” According to Power, yogurt can be a good and less-allergy-inducing alternative to other dairy items like milk or cheese. Also consider a multivitamin. “Buy a quality multivitamin, even chewable or liquid,” Power said. “No diet is perfect.” Above all, involve kids in the process. Making them a partner in any plan to improve nutrition will give a sense of empowerment and ownership. “Sit down with your kids and say, ‘I want you to have your own sense of how your body feels,’” Miller said. “There’s a difference between eating when you’re hungry and eating for other reasons. What are those reasons? Let’s figure them out.”



Summer 2013 | Gazette Health 11



Long after the hangover is gone, damage to the teenage brain lingers. “There are parts of the adolescent brain that are very vulnerable to insult from alcohol,” said Mimi Fleury, who spearheaded development of the booklet “A Parent’s Guide for the Prevention of Alcohol, Tobacco, and Other Drug Use” as a parent at Georgetown Preparatory School in North Bethesda in 1999. Since then, the science surrounding adolescent alcohol use has exploded, causing Fleury and her panel of parents and researchers to update the guide—1.9 million copies of which have been distributed in 36 states and five countries—numerous times. There is mounting evidence that teen drinking not only causes changes in the brain that

can adversely affect learning, but also dramatically increases the risk of alcoholism later in life. Children who begin drinking by 13 have a 45 percent chance of becoming alcohol dependent, according to the parent’s guide. That risk drops to 9 percent when a person takes his first drink after 21. While teenagers may be considered young adults, their brains are not yet grown up. Brain development often is not complete until one’s 20s, according to the National Institute on Alcohol Abuse and Alcoholism (NIAAA). High levels of alcohol interfere with a process called myelination, “which insulates nerve cells with white fatty material,” said Fleury. Myelination helps nerve cells transmit information faster and allows for more complex brain function. During the teen years, myelination occurs primarily in the brain’s frontal lobe, which controls self-regulation, judgment, reasoning, problem-solving and impulse control.

Another part of the brain may suffer as well. The hippocampus, responsible for memory and learning, can be 10 percent smaller in underage drinkers, reported the American Medical Association. “With MRIs, you can compare the brains of 15-year-olds who never had any alcohol and 15-year-olds being treated for alcohol-related problems,” said Fleury. “When you give them the same memory test, asking them to memorize and recall, and graph the results, there’s a 10 percent difference.” Scans, included in her group’s guide, show significantly more activity in the brain of the 15-year-old nondrinker. STUDIES REVEALTHAT DRINKINGCAN AFFECT

boys and girls differently. Girls, who seem to be more vulnerable to the deleterious effects of binge drinking, showed “diminished abilities to do nonverbal, spatial tasks, like putting together puzzles or reading a map,” according to the parent’s ISTOCKPHOTO/ALAINJUTEAU

12 Gazette Health | Summer 2013



Boys who drink excessively have more difficulty paying attention.

guide. Boys who drink excessively have more difficulty paying attention. Alcohol’s disruption of sleep cycles can further interfere with learning. That’s because information and instruction, absorbed during the day, get transferred from short-term to longterm memory during sleep. “Alcohol impairs the quality of sleep and can significantly diminish a person’s ability to learn and remember,” noted the parent’s guide. Teens who drink may be less likely than adults to feel sleepy. Combine that with impaired judgment and the result is that many believe they are able to drive. “Teen driving, in general, is a high-risk activity. Add alcohol into the mix and it can be lethal,” said Robert Wack, M.D., medical director of pediatric services at Frederick Memorial Hospital. Drivers between 16 and 20 are 17 times more likely to die in a crash when they have a blood alcohol concentration of .08 percent, the threshold for legal intoxication in Maryland, than when they have not been drinking, according to the Centers for Disease Control and Prevention. While the percentage of high school students who drink and drive dropped by more than half between 1991 and 2011, 1 in 10 teens 16 or older drinks and drives. TOO MUCH ALCOHOL CAN BE FATAL,

said Anoop Kumar, M.D., an emergency physician with Medical Emergency Professionals, headquartered in Germantown, who has privileges at MedStar Southern Maryland Hospital Center in Clinton. “Drinking to the point of losing consciousness puts you at risk for things like aspiration. That’s when things, such as vomit, go down the trachea,” he said. High concentrations of alcohol can disable the epiglottis, which automatically covers the trachea when food or drink is consumed. When the body tries to rid itself of excessive amounts of alcohol by vomiting, a person may inhale vomited material into his lungs. “That can cause inflammation and infection,” said Kumar, and may lead to death.

“If you drink to the point where you start to puke, that’s your body telling you that you need to stop or the alcohol will kill you,” said Wack. “Alcohol is a depressant. It basically deadens the nervous system. When it causes respiratory depression, your breathing stops and you die.” A disturbing teen trend—the mixing of alcohol and energy drinks— “can make your system crazy,” said Kumar. “People come in [to the emergency room] totally out of control, not so dissimilar to those on PCP.” The stimulant in the energy drink combats the sedative effects of the alcohol, giving teens “the sense that they are not as drunk as they really are,” said Wack. Because teens do not immediately feel the effects of the alcohol, they may drink more in a shorter time. GENETICS, EMOTIONAL STRESS AND

associating with peers who imbibe are factors that might lead a teen to drink, said Wack. Age may be another risk factor, according to a NIAAA Alcohol Alert on underage drinking: “As children move from adolescence to young adulthood, they encounter dramatic physical, emotional, and lifestyle changes. Developmental transitions, such as puberty and increasing independence, have been associated with alcohol use. So in a sense, just being an adolescent may be a key risk factor not only for starting to drink but also for drinking dangerously.” “Adolescence is the time that kids are drawn to risky behaviors because they are trying to become independent,” said Fleury. “When parents realize that this is a normal developmental stage, they can look for healthy ways to encourage risk-taking.” Parents are key to nipping teen drinking in the bud, said Wack. “Parents have to model responsible drinking. Kids have acute noses for hypocrisy. If you BS them—‘do as I say, not as I do’—you’re done.” “Talking to kids about alcohol and sharing the science is valuable and empowers both parents and students to make healthy decisions and build a support network,” said Fleury. continued on 21



Summer 2013 | Gazette Health 13


More than 40 percent of adolescents have acne or acne scarring by their midteens that require treatment.



Treatments for Acne Abound BY KAREN FINUCAN CLARKSON



For some, acne is a minor annoyance—a few whiteheads or blackheads on the face, chest or back—while oth-

14 Gazette Health | Summer 2013


holds that carbohydrates, due to the way the body processes them, and milk, increase the amount of male hormones in the body.


There is no cure for acne. Treatment focuses on “controlling acne until you grow out of it on your own,” said Green. Virtually all acne treatments take weeks if not months to work. “It’s important that the parent and adolescent have reasonable expectations when it comes to treatment and therapy,” said Sarmiento. “Don’t think it’s going to disappear overnight. “The first line of defense is something that’s not dangerous and is easy to use,” said Sarmiento. This includes over-the-counter (OTC) topical products that contain benzoyl peroxide or salicylic acid as their active ingredient. Benzoyl peroxide kills acne-promoting bacteria, while salicylic acid

causes the skin to peel or exfoliate, thereby unclogging pores and helping get rid of blackheads. Part of the reason teens with mild acne may not get good results from OTC creams or lotions is that they apply them incorrectly. “These products are preventative; they’re not treating what’s there. To be effective, they must be used regularly on the whole face, not just one spot,” said Green. When acne doesn’t respond to OTC treatments, an appointment with a pediatrician or dermatologist may be helpful. “There is such a variety of topical and oral medications available. The key is selecting the right treatment—one that addresses the type of lesions and the patient’s preferences and lifestyle,” said Sarmiento. Retinoids are derived from vitamin A and work to unclog the pores. Available as a cream or gel, a retinoid can cause skin to peel and turn red. When used on “super dry skin,


arents may view it as a rite of passage. But that’s a mistake. There’s no reason a child needs to suffer with acne when it can be treated and controlled,” said Lawrence Green, M.D., a dermatologist at Shady Grove Adventist Hospital in Rockville. The bane of adolescence, acne afflicts nearly 85 percent of all people, according to the American Academy of Dermatology (AAD). “It’s one of the most common reasons why adolescents seek medical advice,” said Pedro Sarmiento Jr., M.D., a Waldorf pediatrician with privileges at MedStar Southern Maryland Hospital Center in Clinton. That acne primarily afflicts people during their teen years, a time when many become increasingly concerned with their appearance, is an irony not lost on the physicians. “Children can by psychologically affected when their skin—once beautiful, serene and undamaged—is covered with acne. It can be distressing,” said Green. By their midteens, more than 40 percent of adolescents have acne or acne scarring that require treatment by a dermatologist, according to the AAD. “Why take a chance when it comes to scarring? By treating acne early, we can stave off damage,” both physical and emotional, said Green.

ers suffer from pus-filled pimples or boil-like lumps called cysts beneath the surface of the skin. It’s not completely clear why some teens are more prone to severe cases than others, but family history plays a part. “It is genetic,” said Green. At the root of teen acne are androgens, hormones present in both boys and girls that control development of masculine characteristics. Increased amounts of these hormones during puberty can cause oil glands, also known as sebaceous glands, to become overactive. These glands may produce excessive amounts of sebum, an oily substance that moisturizes the skin. As a result, hair follicles, which are connected to the sebaceous glands, become clogged with oil and dead skin cells. These plugged pores serve as a breeding ground for bacteria called Propionibacterium acnes (P. acnes). Parents of today’s teens may recall being told during their own adolescence that dirty skin or certain foods triggered acne. “It’s not related to hygiene,” said Sarmiento. “Even kids who adhere to regular cleaning routines get acne.” Teens with a taste for chocolate or french fries need not abandon these foods. “Greasy foods and chocolate have proved to have little to no effect on the development or course of acne,” according to the Mayo Clinic website. What’s less clear is whether the consumption of lots of high-glycemic carbohydrates—such as white bread, rice and potatoes—or milk makes teens more susceptible to acne. While Green was skeptical, he noted that the theory

Acne is not related to hygiene. Even those who clean regularly can get it.

you can get dermatitis or psoriasis,” said Sarmiento, “and sun protection is essential when you’re on retinoids.” Antibiotics—in topical or pill form—attack P. acnes and fight inflammation. “You can use creams long term but pills for just a few months,” said Green. “Since oral antibiotics were first used to treat acne, antibiotic resistance has increased significantly in people with acne,” noted the Mayo Clinic website. That’s why physicians recommend tapering off antibiotics once symptoms improve or it appears the drugs aren’t helping. Given concerns over antibiotic resistance and that antibiotics are not 100 percent effective in treating acne, dermatologists may opt for isotretinoin, believed to be the most powerful medication available. “If the choice for my child was an antibiotic for 12 months to control acne until he grew out of it or isotretinoin for five or six months and never have acne again, I’d choose the latter,” said Green. Teens taking isotretinoin—a vitamin A derivative marketed under names such as Amnesteem, Claravis and Sotret—must be closely monitored for side effects. All patients, doctors and pharmacists must adhere to the U.S. Food and Drug Administration’s iPledge program (ipledgeprogram. com), which requires informed consent, prohibits blood donations, and mandates two forms of birth control and monthly pregnancy tests for girls of reproductive age due to the high chance of birth defects in babies born to mothers taking isotretinoin. Isotretinoin has been linked to rare but serious side effects, such as damage to the liver, pancreas, bowels and esophagus, as well as depression, psychosis and suicide. “Patients with severe depression shouldn’t be taking the drug,” said Green. Neither should those with “high triglyceride levels, as the drug will raise them.” Triglycerides are a fat found in the blood. Accutane, the first FDA-approved isotretinoin, was taken off the market in 2009 after a number of class-action lawsuits. The existence of these “class-

ACNE CAREE • Don’t pick orr squeeze pimples, ples, ause as that may cause scarring. • Allow six to eight weeks for medications to work, and be sure to use se as directed. • If acne does not respond to overthe-counter medications, see a doctor. • Avoid scrubbing, which can worsen the condition; wash twice daily with a mild soap. • If you use makeup, make sure it is oil-free and noncomedogenic (does not clog pores). Sunscreen should be oil-free as well. • Don’t use alcohol-based cleaners, as they remove moisture from skin.

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action lawsuits doesn’t mean [prescribing isotretinoin] is bad science,” said Green. It does, however, reinforce the need for “dermatologists to weigh the treatment options and discuss the risks and benefits” with patients and their parents. Recent research may pave the way for improved acne treatment. A September study published in mBio, the American Society for Microbiology’s online journal, reported that scientists have identified 11 viruses, known as phages, that can infect and kill P. acnes. After sequencing the phages’ genomes, researchers discovered properties that make them ideal for treating P. acnes, including a high level of shared DNA among the 11 viruses. That, said scientists, makes development of immune resistance unlikely. While acne is not a serious medical condition, it can result in scarring—both physical and emotional. “Treatment plans today are better than ever,” said Sarmiento, “but results are best when you start early.”

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Fifteen percent of kids who take an antibiotic suffer from diarrhea or vomiting.


why doctors usually say wait & see before treating

BY KAREN FINUCAN CLARKSON Ear infections are: a. the most common reason parents bring their child to a doctor. b. likely to clear up on their own. c. responsible for more than half of all antibiotic prescriptions for preschoolers in the U.S.

16 Gazette Health | Summer 2013

or life threatening,” noted the American Academy of Pediatrics (AAP) in a fact sheet explaining its new guidelines for diagnosing and treating middle ear infections, also known as acute otitis media, in otherwise healthy children. Also driving the guidelines, which were released in February, are concerns about antibiotic-resistant bacteria. More than 5 million cases of acute otitis media, the most common type of ear infection, occur annually in U.S. children. The result is more than 10 million antibiotic prescriptions and 30 million physician visits. “Using an observation option could reduce antibiotic prescriptions annually by up to 3 million and would significantly reduce the prevalence of resistant bacteria,” the AAP reported. A MIDDLE EAR INFECTION OCCURS WHEN FLUID

builds up behind the eardrum and is invaded by a virus or bacteria. “Bacteria love to party in warm, moist, dark places,” said Lester. “That’s why the onset [of an ear infection] is so rapid.”



All are correct. If you have a child, chances are he’s had an ear infection. If he’s had an ear infection, chances are he’s been prescribed an antibiotic. If he’s been prescribed an antibiotic, chances are he didn’t need it. “Most kids get better in 48 hours without treatment,” said Heather Schwartzbauer, M.D., an otolaryngologist with Chrosniak, Schwartzbauer & Mehta and privileges at MedStar Montgomery Medical Center, both in Olney. “Ear infections are overtreated with antibiotics. Parents don’t want to see their children suffer. But in healthy children over 6 months old with a robust immune system, watching them for 48 hours and giving Motrin or Tylenol to help with pain and other symptoms” is likely to yield the same result as treating with an antibiotic. What many parents don’t realize is that antibiotics can pose more danger to a child than an ear infection, said Norman Lester, M.D., an otolaryngologist with Clinton/Lakeside ENT and privileges at MedStar Southern Maryland Hospital Center, both in Clinton. He pointed to a study that “looked at over 4,000 kids [with ear infections] who didn’t get antibiotics, unless they didn’t improve in three days. In that entire study, only two kids developed mastoiditis,” an infection in the mastoid bone of the skull. “That’s a very low number. Think of how many people we make sick—rashes, stomach problems, or worse—with antibiotics.” “About 15 percent of children who take antibiotics suffer from diarrhea or vomiting and up to 5 percent have allergic reactions, which can be serious

“Sudden fever, irritability, pulling on the ear or rubbing the ear,” are often signs of an infection, according to Schwartzbauer. Because ear infections are most common between the ages of 6 and 11 months, according to the University of Maryland Medical Center, “it can be really hard for a parent to tell,” said Schwartzbauer. It sometimes can be hard for a physician to tell, as well. The new AAP diagnostic guidelines call for the presence of both fluid and inflammation. “If you have a true, acute ear infection, the eardrum will be bright red and bulging. It will really look angry. More subtle is the presence of fluid,” said Schwartzbauer. “It’s like looking in a fishbowl and trying to decide if water is in there. Fluid is overdiagnosed.” What makes children more susceptible to fluid buildup than adults is the shape and angle of the Eustachian tubes, according to the Mayo Clinic website. The tube, which connects the middle ear to the back of the throat, regulates air pressure behind the eardrum and allows secretions to drain. Because Eustachian tubes in children tend to be narrower and more horizontal, they have a more difficult time draining and are more likely to get clogged, especially when irritated by allergies, colds or tobacco smoke. Pressure from the fluid trapped in the middle ear can cause pain. The AAP guidelines recommend the use of ibuprofen or acetaminophen for pain relief, especially during the first 24 hours. Antibiotics do not relieve pain in the first 24 hours and have only a minimal effect thereafter. Antibiotics should be the treatment of choice for ear infections in infants 6 months and younger and, when severe symptoms are present, in children up to 12 years of age. Otherwise, observation is encouraged. Children whose symptoms have not improved in 48 to 72 hours are candidates for antibiotic treatment.


infections in a year.” That, said Schwartzbauer, is the rule of thumb physicians use to determine when a discussion about whether inserting tubes into the ear might be beneficial. “Chronic or severe otitis media with effusion, when fluid is present for more than three months, may require tubes,” said Lester. This is especially true for children whose hearing is affected and who are experiencing language delays. “With fluid, there’s always some amount of hearing loss as the eardrum vibration is much less efficient.” Fortunately, he said, “because there’s no nerve damage, hearing loss isn’t permanent.” When the fluid leaves, hearing returns. To place the tube, physicians “make a small incision in the eardrum and insert a tiny silicon or hard plastic tube—sort of like a miniature sewing bobbin. It ventilates the ear nicely,” equalizing pressure and preventing the buildup of fluid, said Lester. “Tubes last six months to two years. They normally come out on their own and the hole closes. Eighty percent of kids who get tubes do not need a second set,” Lester said. While it may not be possible to prevent all ear infections, there are ways to lessen the likelihood of developing them. Begin by eliminating a child’s expo-


Three out of 4 kids will get an ear infection at some point. sure to secondhand smoke. “It’s hugemade with a live but weakened flu ly important for kids, especially those virus, significantly lowers the risk with asthma, to live in a nonsmokof acute otitis media. ing home,” said Lester. “Children of A needle-free vaccine, now There is some smokers are much more likely to have under development by researchers ear infections.” evidence that the at Ohio’s Nationwide Children’s Breast-feed your baby for at least FluMist vaccine Hospital, is designed to fight six months. “The data is pretty nontypeable Haemophilus influreduces the good showing that kids who are enzae, a bacteria associated with frequency of ear ear infections. Delivered through a breast-fed are less prone, at least as young children, to get ear infecpatch, the vaccine not only attacks infections...” tions,” Lester said. the bacteria, but also helps jump– Norman Lester, M.D. Vaccinate your child. Since the start the body’s immune system, 2000 introduction of the pneumococaccording to results of animal cal conjugate vaccine, which protects against “bacte- study data published in the October issue of Vaccine. rial meningitis, the number of ear infections has been Despite the progress, ear infections remain one going down,” said Schwartzbauer. A study in the of childhood’s most common ailments, afflicting April 2007 issue of Pediatrics showed a 28 percent 75 percent of all children. During the first year of decline in frequent ear infections between children in life, 60 percent of children will have at least one ear New York born in 1998 and 1999 and those born infection and 17 percent will have three or more, in 2000 and 2001. according to the University of Maryland Medical “There is some evidence that the FluMist vaccine Center’s website. reduces the frequency of ear infections by about 30 The good news, according to the AAP, is that 80 percent,” said Lester. Studies over the past two years percent of the time, ear infections will resolve on their show that FluMist, a nasal spray manufactured by own. The hurdle, said Lester and Schwartzbauer, is MedImmune, headquartered in Gaithersburg, and convincing parents to adopt a wait-and-see approach.



Summer 2013 | Gazette Health 17


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hether small in stature due to an underlying condition or genetically destined to be short, kids may be able to boost their adult height by several inches with the help of growth hormone injections. But given the significant cost and questions about future health implications, the treatment is one that requires careful consideration. “There may be long-term risks associated with growth hormone therapy,” said Radha Nandagopal, M.D., a pediatric endocrinologist at the Children’s [National Medical Center] Outpatient Center in Laurel. “Parents need to weigh the possibility of a few inches with what it will cost,” in terms of the family’s finances and the child’s health. Growth hormone treatment “is indicated for only a very small group of children,” said Cong Ning, M.D., a pediatric endocrinologist with Adventist Medical Group in Rockville. It’s not for the NBA wannabe, hoping to hit 6 feet 7 inches. “We’re looking at children with true growth hormone deficiency, those who have certain genetic syndromes, and kids who are very short”—in the lowest 1.2 percentile for their age.


pituitary gland, situated in the brain, must produce sufficient amounts of growth hormone, which it then releases during sleep. When the body neither produces nor releases enough

growth hormone, symptoms—such as slow or no growth or facial features that make the child look younger than his peers—appear. Inadequate growth can be the result of numerous factors—everything from poor nutrition to chronic diseases, such as Crohn’s or celiac, to thyroid issues. Treating the underlying problem can often resolve the growth problem, said Nandagopal. “Growth problems can present at any stage during childhood—infancy to puberty,” she said. That’s why pediatricians track a child’s height and weight annually, beginning at birth. “Anytime a child is not growing as expected or in keeping with the way his family has historically grown, it’s time to have a discussion with the pediatrician,” said Nandagopal. Those discussions are had more often by parents of boys. “More boys are referred to us for being short,” she said. “There seems to be more of a social stigma associated with being a short boy or man.” While short kids are sometimes teased and, occasionally, bullied, most do well socially and emotionally, according to several studies. In fact, researchers have been unable to link a child’s diminutive height with a lack of friends, low popularity or poor reputation among peers. It’s not surprising then that “there’s not good evidence that growth hormone [therapy] improves self-esteem, quality of life or other psychological or social outcomes,” said Nandagopal. “Short children do just as well as their peers.”


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runs anywhere from “$20,000 to $40,000 per year, depending on the dosage,” said Ning. “Treatment can take years.” If, for example, the problem is caught early in a boy, “say 15 months of age, he’ll be on growth hormone for at least 14 years. Then, after we retest him, we’ll see if he needs it as an adult.” Health insurance may not cover the full cost of growth hormone therapy, especially when there is no hormone deficiency or underlying medical condition. “For children who are very short and whose height is in the lowest 1.2 continued on 20




been treated with growth hormone for more than 50 years. The therapy initially was not widespread, as supplies of the drug, created from growth hormone extracted from the pituitary gland of cadavers, were limited. After batches of human growth hormone became infected with a potentially lifethreatening disease and pulled off the market, a synthetic version, known as recombinant growth hormone, was introduced in 1985. Today, the use of growth hormone is no longer restricted by supply. Cost is the limiting factor. The price tag

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percentile, they may meet FDA [U.S. Food and Drug Administration] criteria for treatment, but have to pay” out of pocket, said Ning. Those in the lowest percentile who lack a diagnosis are said to have idiopathic short stature. The FDA’s 2003 decision, allowing them to be treated with growth hormone, was intended to give children who appeared headed for a short adulthood—under 5 feet 4 inches for boys and 4 feet 11 inches for girls—the opportunity to add an additional 2 to 3 inches to their final height, according to The Nemours Foundation, a nonprofit organization dedicated to improving the health of children. IT CAN TAKE UP TO SIX MONTHS

of growth hormone injections before any height difference is noticeable, according to Children’s Hospital of Pittsburgh of UPMC. One or two inches of growth during that time period is common. Look for a child’s shoe size to go up, too. And, while his appetite may increase, e, he may actually appear trimmer, ass lean body mass replaces fat. Those might not be the only benefits. A 2010 report in Pediatrics atrics noted that during treatment some me children experienced increased bone one density, improved body proportions ortions and reduced blood lipid levels, evels, depending on the cause of the short stature. What’s not known iss whether the metabolic and cardiovascular improvements will remain once theraherapy stops, which usually occurs ccurs around puberty, when the growth plates fuse. Also unclear is whether ether growth hormone therapy will uture compromise a child’s future atients health. “We counsel patients rmone when we start growth hormone treatment that it can worsen vature scoliosis,” a sideways curvature gopal. of the spine, said Nandagopal. isk for “It can also increase the risk Type 2 diabetes and causee probdren lems with hip joints. Children ncer with a prior history of cancer face an increased risk of a

second cancer, and there’s data coming out of Europe showing that in the second stage of life there may be an increased risk for cancer. We need a lot more data to determine what the long-term consequences are of treating a child, even for just a few years, with growth hormone.” The FDA has been reviewing the results of French research—the Santé Adulte GH Enfant (SAGhE) study—which shows a 30 percent increased risk of death among people who underwent recombinant human growth hormone therapy in childhood when compared to the general population of that country. “The data suggest an increase in mortality due to bone tumors and cardiovascular diseases including cerebrovascular events,” such as stroke and brain aneurysms, noted a FDA Safety Review Update from December 2010. The FDA’s initial review in 2011 of “the evidence regarding recombinant human growth hormone and increased risk of death is inconclusive.”



GROWTH, continued from 19

ALCOHOL, continued from 13 “A sense of community can stave off premature problems relating to alcohol,” said Kumar. Alcohol “doesn’t discriminate. Anybody, and everybody, is susceptible.” Building that sense of community is one of the goals of Conversations that Count, a program that promotes education and dialogue. An offshoot of the parent’s guide, Conversations that Count “puts everyone on the same page, demonstrates how to have a discussion about alcohol and pushes ownership of the challenge of substance abuse prevention down to families,” said Fleury. Parents and students leave knowing “they are not alone in dealing with the challenge,” she said. In schools hosting Conversations that Count, “there’s been a gradual cultural shift, partly the result of positive peer pressure, that’s encouraging.” Underage drinking is on the decline, according to the National Institute on Drug Abuse. In 2009, 36.6 percent of eighth-graders and 72.3 percent of



If you drink to the point where you start to puke, that’s your body telling you that you need to

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12th-graders reported drinking during their lifetime. Three years later, the percentages had dropped to 29.5 and 69.4. Despite all the research into alcohol and its effect on the teen brain, much is not known. “The million-dollar question is whether the damage done by alcohol to the adolescent brain is reversible,” said Fleury. “The 10-million-dollar question is ‘why risk it?’”


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Summer 2013 | Gazette Health 21

Experts’ Advice

“Parents are children’s most enriching plaything.”

The Play’s the Thing


22 Gazette Health | Summer 2013


negotiate and release stress. Free play often involves fantasy; if children want to learn about being a firefighter, for example, they can imagine and act out what a firefighter does. And if something scary happens, free play can help defuse emotions by letting the child work them out. “Sports are a kind of play, but it’s not the kids calling the shots,” said Golinkoff. It’s important to engage in a variety of activities, including physical play, social play and solitary play. “The key is that in free play, kids are making the decisions.” There’s also been a national trend toward eliminating school recess. It’s being pushed aside for academic study, including standardized test preparation. “Thousands of children have lost recess altogether,” said Dr. Kathryn Hirsh-Pasek, a child development expert with Temple University. “Lack of recess has important consequences for young children who concentrate better when they come inside after a break from the schoolwork.” Play also may offer advantages within the classroom. In an NIH-funded study, Hirsh-Pasek, Golinkoff and their colleagues found a link between preschoolers’ math skills and their ability to copy models of two- and three-dimensional building-block constructions. Play with building blocks—and block play alongside adults—can help build children’s spatial skills so they can get an early start on the later study of science, technology, engineering or math. “In a way, a child is becoming a young scientist, checking out how the world works,” said Hirsh-Pasek. “We never outgrow our need to play.” Older children, including teens, also need to play and daydream to help with problem-solving and creative imagination. At the NIH Clinical Center in Bethesda, “Recreation therapy services are seen as essential to the patients’ recovery,” said Donna Gregory, chief of recreational therapy. She and her team tailor activities for both children and adults. Games can get patients moving, even for just minutes at a time, which improves their functioning. Medical play helps children cope with invasive procedures. A 2-yearold can be distracted by blowing bubbles; older kids can place their teddy bear in the MRI machine or give their doll a shot before they get an injection. It gives kids a sense of control and supports their understanding in an age-appropriate, meaningful way. Without play and recreation, people can become isolated and depressed. “There’s therapeutic value in helping patients maintain what’s important to them,” said Gregory. –NIH NEWS IN HEALTH


laytime during youth, it turns out, is essential to growing up healthy. Research shows that active, creative play benefits just about every aspect of child development. “Play is behavior that looks as if it has no purpose,” said Dr. Stephen Suomi, a National Institutes of Health (NIH) psychologist. “It looks like fun, but it actually prepares for a complex social world.” Evidence suggests that play can help boost brain function, increase fitness, improve coordination and teach cooperation. Suomi noted that all mammals—from mice to humans—engage in some sort of play. His research focuses on rhesus monkeys. While he’s cautious about drawing parallels between monkeys and people, his studies offer some general insights into the benefits of play. Active, vigorous, social play during development helps to sculpt the monkey’s brain. It grows larger. Connections between brain areas may strengthen. Play also helps young monkeys learn how to fit into a social group. Both monkeys and humans live in highly complex social structures, said Suomi. “Through play, rhesus monkeys learn to negotiate, to deal with strangers, to lose gracefully, to stop before things get out of hand and to follow rules,” he said. These lessons prepare them for life after they leave their mothers. Play may have similar effects in the human brain, helping to lay a foundation for learning the skills needed for social interaction. If human youngsters lack playtime, said Dr. Roberta Golinkoff, an infant language expert at the University of Delaware, “social skills will likely suffer. You will lack the ability to inhibit impulses, to switch tasks easily and to play on your own.” Play helps young children master their emotions and make their own decisions. It also teaches flexibility, motivation and confidence. Kids don’t need expensive toys to get a lot out of playtime. “Parents are children’s most enriching plaything,” said Golinkoff. Playing and talking to babies and children are vital for their language development. Golinkoff said that kids who talk with their parents tend to acquire a vocabulary that will later help them in school. “In those with parents who make a lot of demands, language is less well developed,” she said. The key is not to take over the conversation, or you’ll shut it down. Unstructured, creative, physical play lets children burn calories and develops all kinds of strengths while learning how the world works. In free play, children choose the games, make the rules and learn to



Summer 2013 | Gazette Health 23


24 Gazette Health | Summer 2013


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