Prevention is the best medicine

Proper hygiene, sleep, exercise and nutrition play important roles in staving off illnesses and avoiding future health problems

More important than diagnosis and treatment, preventive medicine is the only guaranteed way to keep your young patients safe. Infectious Diseases in Children spoke with experts in four key areas of illness prevention, who gave an overview of the main issues affecting children in each area with a special focus on the new school year.

During examination, be sure to screen for sleep disturbances

Earlier wake up times and anxiety about social interactions, tests and other changes at the start of the school year often means a disruption in children’s sleep schedules, and the effects of these disruptions and underlying sleep disorders may take a toll on children in the classroom.

“In addition to a weakened immune system, a lack of healthy sleep can lead to learning problems and behavioral problems at school,” Darius Loghmanee, MD, FAAP, a pediatric sleep specialist at Children’s Memorial Hospital in Chicago, said in an interview. “For younger children, sleep is a noxious state. Rather than just doze off like adults, they’ll do whatever they can to stay awake.”

Children with sleep disorders can have fragmented sleep patterns, often caused by obstructive sleep apnea or periodic limb movement disorder, and may appear hyperactive during the school day. The symptoms of sleepiness frequently overlap with those of attention deficit/hyperactivity disorder, and the link between the two is gaining increased attention, Loghmanee said. A recent meta-analysis of 16 studies found that children with ADHD were significantly more impaired than controls in several sleep measures, including sleep onset difficulties, night awakenings, sleep disordered breathing and daytime sleepiness.

As sleep disorders continue untreated, academic performance is likely to suffer, Loghmanee noted. A recent study by Gruber et al of 39 children aged 7 to 11 found that short sleep duration was associated with lower measures of overall IQ, perceptual reasoning, competence and academic performance.

“If a child has a sudden onset of poor grades or behavior problems and their parents have noted snoring, a sleep evaluation should be performed,” Loghmanee said.

The BEARS sleep screening algorithm, developed by physicians at Brown University, is a user-friendly pediatric sleep screening tool that measures problems at bedtime, daytime sleepiness, awakenings during the night, regularity and duration of sleep and snoring. The tool is comprehensive enough to screen patients and determine if further evaluation by a sleep specialist is needed, Loghmanee said.

Pediatricians must be especially vigilant for sleep disorders, as a large-scale review of 154,957 pediatric electronic medical records found that primary care practices only diagnosed 3.7% of young patients with sleep disorders — significantly lower than prevalence rates seen in epidemiological studies.

“Primary care providers may be underdiagnosing sleep disorders in children and adolescents,” wrote Lisa J. Meltzer, PhD, of Children’s Hospital of Philadelphia, and colleagues.

Sleep disorders have also been linked to childhood and adolescent obesity. Current research has placed special focus on hormones such as leptin, resistin, and ghrelin which modulate appetite, Loghmanee said. When sleep is disturbed, especially when due to obstructive sleep apnea, researchers have observed derangements in these hormone levels leading to increased appetite.

A study of 126 Saudi Arabian girls aged 14 to 18 found that those who slept less than 5 hours per day had a higher carbohydrate intake and ghrelin levels. “Long and uninterrupted sleep was associated with a better diet and a more favorable hormonal profile,” the researchers wrote.

Recommend at least one hour of physical activity per day

America’s youth are not getting enough exercise, according to a May 2010 CDC report, and the effects on their health and the nation’s health care system may be devastating. Only about 17% of high school students get the recommended hour or more of physical activity per day, and nearly one in three children are overweight or obese.

“One third of children born in 2000 are predicted to get type 2 diabetes, which is unbelievable,” Thomas Repas, DO, FACP, FACE, CDE, a South Dakota-based endocrine and nutrition specialist, told Infectious Diseases in Children. “Now we’re seeing it in teenagers and people in their 20s. A generation ago, this wouldn’t happen to someone until they were in their 60s.”

In addition to diabetes, lack of exercise places children at risk of cardiovascular disease and obesity, which in turn increases their risk of osteoarthritis and even certain cancers. A recent historical cohort study suggested an association between body mass index and colorectal cancer and mortality, and the authors concluded that targeting obesity in young adulthood might prevent “a significant number of colorectal cancer deaths.”

A main reason for the dearth of exercise is the notion of increased “screen time,” defined as time spent in front of the TV, computer or a video game system, Repas said, noting that more than 40% of children between the ages of four to six have a TV in their bedroom. A recent national survey of children’s health found that children who engage in low physical activity and “high leisure sedentary behavior” are twice as likely to be overweight than their more active peers.

Likewise, a cross-sectional analysis of 8,550 4-year-old children found that children who ate regular evening meals with their family, got adequate sleep and reported less than two hours of screen time daily had a 40% lower incidence of obesity.

When talking with parents of overweight children, “pediatricians must be up front about the health implications over the long term, but they also need to be supportive and encouraging,” Repas said. “Be specific. Simply saying a child has to lose weight is too general. Give very specific recommendations, like limiting screen time, or suggesting that the family do an active activity once a week, so it becomes part of their lifestyle.”

But many children may not have the luxury of heading outdoors to engage in physical activity. Urban settings may pose immediate dangers that far outweigh the risk of sedentary activity, Repas said. The same CDC report on childhood obesity found that only 20% of neighborhood have parks within a half mile of their boundaries, and even fewer have fitness or recreation centers.

Limited research shows children may be able to get moderate exercise within their homes. Research funded by Nintendo showed that playing motion-controlled video games such as WiiSports and WiiFit may equal moderate-intensity exercise and meets daily exercise requirements set forth by the American Heart Association.

“The best activity you can recommend to a parent or child is the one they’re going to want to keep doing,” Repas said. “If someone doesn’t like an activity or doesn’t have access to it, it’s fruitless to recommend it.”

Families that eat together are generally healthier

For many children, especially those in low income areas, the bulk of their daily caloric intake comes from the food they receive at school, though this food frequently lacks nutritional value, Repas said. According to CDC data from 2008, sugary sodas, sports drinks, candy and salty snacks were available in almost 40% of schools.

“Our current nutritional crisis has been described as ‘overfed and undernourished,’” Repas said. “Our kids don’t have a caloric deficit; rather, they’re getting too much food, and not enough of what they need.”

Researcher from the University of Michigan who studied 1,297 sixth graders found that students who ate school-provided lunches regularly had higher LDL and consumed twice as many fatty meats and sugary drinks than kids who brought their lunches from home.

There have been many efforts to increase the availability of healthy foods and decrease unhealthy ones in schools, and indeed the CDC has seen significant improvement in these areas, including 19 more states instituting nutritional standards for school-based snacks between 2004 and 2009.

“But it’s important to note that just because you add a salad bar to a high school cafeteria doesn’t mean that kids are going to use it,” Repas said. “If the unhealthy options are still available, kids are going to revert to them.”

Other legislative methods, such as a tax on soda and fast food, and color-coded food labels denoting nutritional value have been proposed. Both methods would mirror similar restrictions imposed on the tobacco industry. For perspective, half the amount of Americans smoked in 2007 compared to the number who smoked in 1965, noted Arthur Garson, Jr., MD, MPH, provost of the University of Virginia in Charlottesville and former dean of the school of medicine, in a 2010 presentation on food legislation measures.

Widely available and inexpensive, processed foods are a staple of the American child’s diet, and very likely a leading cause of malnutrition. “During processing, foods lose many of their nutrients, such as fiber or vitamins, and fortification just isn’t as effective as getting your nutrients from a brightly colored fruit or vegetable,” Repas said. “And there are additives that are problematic, like high fructose corn syrup, fat and salt.”

A recent concept to emerge in the battle against American malnutrition is the notion of “food deserts,” defined as an area, typically urban or rural, where there’s a dearth of fresh, healthy foods. Typically these areas are served almost exclusively by fast food restaurants or corner stores. “Low income people have the highest incidence of obesity, type 2 diabetes and cardiovascular disease,” Repas. “They should be able to eat healthy, but they’re the least able to afford high-quality foods.”

When advising patients and their parents on proper nutrition, Repas follows the Food Pyramid guidelines issued by the U.S. Department of Agriculture. “I also recommend that families sit down and eat together. They’ll tend to eat slower, consume fewer calories and set forth a healthy model for their children.”

Emphasize hand hygiene in the classroom

As children head back to school, confined classrooms and close contact with their peers put them at an increased risk of a variety of illnesses, including cold viruses, influenza and Staphylococcus aureus. Therefore, proper hygiene practices are one of the first lines of defense against their risk of infection, according to Infectious Diseases in Children Editorial Board Member Edward Bell, PharmD.

“By far, the single most effective thing kids can do to decrease their risk of infectious disease is to wash their hands with soap and water,” Bell, who is a Professor of Clinical Sciences at Drake University College of Pharmacy said in an interview. He noted that 30 seconds of handwashing with plain soap reduces bacterial counts by 2.8 log10. But not all handwashing is equal, he cautioned.

“A good analogy is sunscreen — it is as not effective if it is not used correctly,” he said. Proper handwashing, as defined by the CDC, involves applying soap to wet hands and rubbing them together for at least 20 seconds. Children should be told to sing “Happy Birthday to You” two times before rinsing their hands.

Antibacterial soaps containing triclosan have not been proven any more effective than regular soap, and may even be contributing to a rise in antibiotic resistance, Bell said.

Because most children at school do not have access to soap and water throughout the day, Bell recommends that parents give them small bottles of alchohol-based hand sanitizer, such as Purell.

The CDC recommends these products when hands are not visibly soiled and soap and water are not available. Most of the products contain ethyl alcohol in 60% to 95% concentrations, and are effective against gram-positive and –negative bacteria, including Staphylococcus aureus, some fungi and enveloped viruses, including flu, herpes simplex and respiratory syncytial virus, according to Bell.

Because formulations differ by brand, the effective volume of product is not known. However, Bell recommends using enough product so that it takes 20 to 30 seconds of rubbing before the hands are completely dry. —by Andy Moskowitz

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