Bad news from America’s “diabesity” epidemic: A new report says that the number of teens with diabetes or prediabetes more than doubled between 1999 and 2008 – from 9 percent to 23 percent. That’s nearly one in four kids. And it doesn’t include another group worth watching: Kids and teens with metabolic syndrome, an early warning sign for future blood-sugar problems (as well as for blood pressure and cholesterol problems, too.)

One in ten young teens may have metabolic syndrome, say researchers who checked up on over 1,200 eighth-graders in three states for a 2008 study. They looked at five factors: A wide waistline, higher-than-healthy blood pressure, raised triglycerides (a blood fat), lower-than-healthy levels of helpful HDL cholesterol, and blood sugar. In general, having three of these can mean metabolic syndrome. But since healthy numbers for most of these vary with a kids’ age and gender, it’s worth talking with your child’s doctor if you’re concerned.

But tracking numbers isn’t the way to avoid diabetes. A couple of healthy habits can. A few years ago, I interviewed child diabetes expert Francine Kaufman, M.D., former head of the Center for Endocrinology, Diabetes and Metabolism at Children’s Hospital Los Angeles and author of Diabesity The Obesity-Diabetes Epidemic That Threatens America--And What We Must Do to Stop It  (Bantam Dell/Random House). Her advice:

• Eat well. “Aim for at least five servings of fruit and vegetables a day—and more is better,” Kaufman says. “Cut out high-sugar snacks, limit sugary desserts, and switch from refined grains like white bread to whole-grain, higher-fiber breads and grains.” Replace soda and sweet drinks (like bottled, sweetened iced teas and energy drinks) with low-fat or fat-free milk, unsweetened or lightly-sweetened homemade iced tea. Have less fast food (stop by the supermarket for quick, healthier take-out like a rotisserie chicken, salad and whole-grain bread).  And cut back on saturated fat (the kind in full-fat milk, cheese and ice cream as well as in fatty meats and baked goods. It messes with your body’s ability to absorb blood sugar.

• Go for active fun.  Take a family walk, hit the pool over the weekend, drag out the Frisbee, croquet set and kickball, take everybody to the local playground and be the crazy parent climbing and swinging with the kids. Kids and teens need 60 minutes of activity daily.

• Turn out the lights – including theirs.  Kids who get enough sleep get some protection against blood sugar-processing problems. Experts say getting a good night’s sleep may help teens (and adults) lower diabetes risk. The reason? It may be that sleep deprivation increases levels of stress hormones, which in turn interfere with the way cells absorb blood sugar.

• Ask about their risk.  Being overweight and obese increase their odds. So do genetics. Your child’s risk may be higher than normal if diabetes runs in the family, or if she is of African-American, Hispanic, Asian, Pacific Islander, or Native American descent. Also look for patches of thickened, velvety, or darker skin behind the neck, under arms or at the groin. Called acanthosis nigricans, it’s a  sign of insulin resistance — meaning that your child’s body isn’t processing blood sugar normally.

• Don’t overlook symptoms. Often, diabetes has no symptoms. But common signs of type 2 diabetes include frequent infections that are not easily healed, frequent urination, extreme hunger but loss of weight, unusual thirst, blurred vision, extreme weakness and fatigue, irritability and mood changes, nausea and vomiting, dry, itchy skin and tingling or loss of feeling in the hands or feet. For more information, check out the online diabetes-information pages of the Children’s Hospital of Philadelphia and The Nemours Foundation’s KidsHealth website.

by Gary A. Emmett, M.D.

It’s a creepy-crawly fact: Humans have 10 times the number of bacteria in our bodies than we have human cells. In some sense, that makes each of us just 9 percent human. These bacteria exist in symbiosis (Greek for “living together”) with us. They’re vital to many of our basic functions – including digestion, helping keep immunity strong and more. Maintaining these important “commensal” (Old Latin for “food sharing” – yes, they eat what you, or your kids, eat!) bacteria should always be in a doctor’s mind when he or she treats a patient.

I was thinking about good bacteria when the mother of Madison, an 18 month-old, emailed to tell me her daughter had been up all night —crying on and off and holding her right ear. Madison had a fever, but her mother did not have a thermometer to measure it, and she had had a runny nose and a cold for 3 days. She went to day-care. Her father smoked, but “only outside.” I asked her to come in so I could look in her ear.

In the office Madison had a temperature of 101.4, she was tired and clearly in pain, but she would smile if I acted silly. She was happy to get a lollipop after I was done. On exam there was puss in the discharge from her nose and her right eardrum was red and swollen with fluid behind it. All you parents out there know this could mean an ear infection. We immediately gave her some medicine for her pain and fever (acetaminophen also call Tylenol), e-prescribed some ear pain drops to kill the ear pain and, after thinking about it, e-prescribed some amoxicillin for 10 days.

This simple case should raise many questions for both parents and healthcare providers – questions you’re probably asking yourself right now such as:

1) Why didn’t I just prescribe amoxicillin on the phone when Madison’s mom contacted me?

a. When antibiotics first became available, doctors over-used these drugs, which made them ineffective in many cases. Doctors should only use them when we know they can help a good deal.

b. Antibiotics can have serious side-effects such as allergy and profound diarrhea

c. Only about half of the children with the symptoms mentioned in the mother’s email actual turn out to have a middle ear infection and need antibiotics

d. We also know that children who get an antibiotic before their first birthday are more likely to get asthma later because the antibiotic disturbs the body’s bacteria and that disturbance changes how we react to lung irritation

2) What should be prescribed on the phone?

a. Pain killers such as acetaminophen or ibuprofen because we should treat the problem, which is a painful ear

b. Lidocaine containing ear drops, if we know there is not an ear-tube in place or that the ear drum is not broken

3) Why do you have to think twice about giving antibiotics?

a. In children after their second birthday the current recommendation for ear pain with middle ear infections is treat with just pain killer for 3 days, and if not getting better start antibiotics. Almost 80 percent of children with ear infections get better even if they are not treated with antibiotics.

b. Not using antibiotics is more questionable before the second birthday, because the immune system is not complete until the end of the second year of life and we are afraid an ear infection may spread even to the brain.

4) What does all this have to do with the commensal (or normal) “good” bacteria?

a. We each are born sterile of bacteria and get our first dose as we come down the birth canal. From then on we pick up over 500 different species of bacteria that help us digest our food, teach our immune system how to distinguish between ‘good” and “bad” microorganisms, and generally work with our bodies to protect us against the dangers in the world.

b. When we give antibiotics, we can kill the bad bacteria causing the infection, but we also kill some of the good bacteria we need.

5) If a child needs antibiotics, how can we protect his or her good bacteria?

One good preventative is to take some normal bacteria (“probiotics”) such as in live-culture yogurt or the commercial products containing lactobacillus and others available over the counter. A recent study shows that taking live-culture yogurt every day while on antibiotics markedly decreases abdominal pain and diarrhea.

The take-home lessons for parents: See the big picture if your child’s doctor doesn’t prescribe antibiotics immediately. And when she or he does give you or your child antibiotics, remember to also be nice to those friendly bacteria in your body and think about taking some probiotics.

What do you think? Do you give your children yogurt or a probiotic supplement when they’re taking antibiotics?

Garry A. Emmett, M.D., F.A.A.P., has been a primary care pediatrician in South Philadelphia and Center City since 1979. He is currently an attending pediatrician at Nemours Pediatrics, Philadelphia and Director of Hospital Pediatrics at Thomas Jefferson University Hospital.

The CDC estimates that 4 million children in the U.S. suffer from some form of food allergy, up from 2.5 million a decade ago. Most common allergens are eggs, milk, soy, wheat, peanuts, tree nuts, fish and shell fish.

This week's segment of the Healthy Kids Minute offers some precautions to follow for children with food allergies

Girls have a higher risk for concussions than boys who play the same sport – and a new study in the American Journal of Sports Medicine says female athletes also have more symptoms and take longer to bounce back from these head injuries than boys. So do younger girls compared to older girls.

The Healthy Kids Blog turned to Prithvi Narayan, M.D., chief of neurosurgery at St. Christopher’s Hospital for Children in Philadelphia, to understand why this is happening – and to find out what parents, coaches and athletes can do. Over 1.6 million Americans suffer a sports-related concussion every year; a growing number are high school and college athletes.

Why would girls have more concussions, more symptoms and take longer to heal than boys?

There are two possible reasons. One theory is that because girls usually have smaller, more slender necks with smaller neck muscles, their heads may wobble more if they hit their heads or are heading the ball in soccer. That could raise risk for a concussion and for more severe symptoms. The second theory is that female athletes report concussions and symptoms more often and more accurately than boys do. They may be less likely to just shake it off and get back in the game or the practice – something that was ingrained in male athletes for decades before we knew that a potential concussion needs to be taken seriously.

Which sports have a higher risk for concussions in girls?

Soccer is one, in large part due to heading the ball. Basketball is second, according to research from the National Children’s Hospital in Columbus, Ohio. Girls’ lacrosse comes in third – and has a higher risk for head injuries because girls don’t wear helmets. (This is because checking is banned in women’s lacrosse.) Helmets really don’t protect against concussions, but can cut risk for skull fractures and bleeding in the brain. Cheerleading also has its share of concussions – it’s not pompoms on the sidelines anymore. Girls are doing very gymnastic routines with flips and tumbles. Any time you fall and hit your head, or something else hits your head – another player, a ball, a stick – you’re at risk for a concussion. And it doesn’t even have to be a hit to the head. Being hit on any part of neck or shoulders -- anything that causes brain to shake – can cause one.

What should happen if an athlete – girl or boy – gets hit in the head during a game or practice?

Players, coaches and parents should know the signs of a potential concussion. A player may pass out – but you can have a concussion without passing out. Warning signs include feeling dazed, dizzy, or lightheaded; memory loss; nausea or vomiting; a headache; blurry vision and light sensitivity; speech that’s slurred; saying things that don’t make sense; difficulty concentrating or thinking; trouble with coordination or balance. A suspected concussion should be evaluated by a doctor. If a player’s been hit, they should leave the game. If a parent or another player sees an athlete suffer a head injury that a coach doesn’t see, they should tell the coach right away.

What happens next?

It can seem tough on a kid who wants to get back in the game, or who wants to play the next big game or finish the season. But after a concussion the brain needs rest in order to recover. Without that, the brain can’t recover properly and a child or teen could be facing lasting changes. At first, it’s important to let the brain “cool” – no TV, texting, video games. And the American Academy of Pediatrics recommends not returning to contact sports for four weeks from the date of the concussion. It’s really important to avoid a situation where a kid has a second or third concussion in the same season. Some kids even switch sports – going from a contact sport to something like tennis or swimming.

What do researchers want to learn about concussions in teens and younger athletes?

Most studies have been done in college athletes and in professional players, such as pro football players, hockey players and boxers. We want to know what happens in younger brains after a concussion. You can’t see the evidence on a regular MRI or CT scan. We’re collaborating with doctors in the Princeton Health System to start using special techniques to scan the brains of kids who’ve suffered concussions.

What about you? Any experience with concussions with your family and friends?

With the coverage we have given breastfeeding in this blog, we couldn’t not comment on the recent TIME magazine cover showing a mother nursing her 3-year-old son. The headline: Are You Mom Enough?”. The photo and article have generated lots of discussion, pro and con, about long-term breastfeeding and the larger issue of attachment parenting – a “stay close” philosophy that also advocates bed-sharing with kids.

The cover got skewered on Saturday Night Live and was called a “shocking stroke of genius” by the Los Angeles Times. The mom, Jamie Grumet, told ABC News, “"The statement that I wanted to make was this is a normal option for your child and it should not be stigmatized. I'm never saying this is for everybody, but it should be something that's accepted."

Attachment parenting isn’t easy. True confession: I tried bed-sharing many years ago, but stopped when I read ahead in my copy of Dr. Sear’s The Baby Book to a section that, at least in my sleep-deprived state, seemed to be saying not to worry, my child would be out of our bed by age 7. AGE SEVEN? I love my kid, but she was back in the bassinet after that. (I’m glad I did, with what I know now about the risks for babies.) But I continued to breastfeed well past her first birthday.

As regular readers of this blog know, we’re big breastfeeding advocates here. Back in March, we asked readers to share their breastfeeding-in-public stories. This is a great time to share my favorites:

On the steps of The Supreme Court: Well, I briefly nursed my baby daughter on the steps of the Supreme Court in Washington, DC, until I was asked to move. It was not the nursing, it was just that no one is allowed to sit on the steps for any reason! I would have stayed awhile and nursed her twin sister too if I had been allowed. When there are hungry twins, you sit down wherever you can and nurse! My girls are now 16, and very healthy and bright, thanks in part to the sacrifices made to breastfeed them. — Melanie M.R.

At restaurants, on the train: I was sitting at a table outside the Earl of Sandwich at Disney World's Pleasure Island with a blanket over myself. A man sat next to me and started asking if I enjoyed breastfeeding and did it make me uncomfortable to do it outside. I just remember thinking to myself, "I'm only uncomfortable with complete strangers asking me if I enjoy it." Other places include while dining at OUTBACK restaurant with family, I refused to go out to the car. Oh, and on an AMTRAK train to Orlando, my son was only 2 weeks old and I felt like there were eyes on me all the time while I was breastfeeding. — BeckyN

During a parade and while dancing: I breastfed my toddler in a parade, and also while performing a contra dance on stage for a New York State celebration in Kingston (1975 or 1976). There was a photograph of the dance performance on the front page of a local newspaper. While the other dancers knew I was breastfeeding, one looking at the picture probably wouldn't have known. I got very adept at switching sides during a dance! — nleeguitar

Everywhere ... except this spot: Everywhere, discreetly, including at church, at work, in restaurants, but never in the bathroom. I don't eat in the bathroom, why should my kids? — Jane Von Bergen

In a car dealership and beyond: I have breastfed my three-month-old at my older children's schools, at McMenamin's in Mount Airy, at Frankford Hall in Fishtown, at the Toyota dealership in Ardmore. I discreetly breastfed my son when he is hungry, no matter where that might be. I always look for a discreet place, but I do not intentionally hide. I dind anti-breastfeeding-in-public conversations highly offensive and insensitive. What is the big deal? Babies have to eat. Is it our culture's sexualization of the female breast that causes some people to have such a visceral reaction to the image of child breastfeeding? Should mothers and breastfeeding babies be prisoners in their homes until the baby stops breastfeeding all together? Breastfeeding is a choice, a very healthy one, that mothers are encouraged to make. Furthermore, mothers are asked to sustain the breastfeeding relationship for as long as possible to help best protect baby's health. — kszumanski

by W. Douglas Tynan, Ph.D.

Frequently as part of my practice I will recommend that a parent set up a reward system at home to increase desirable behaviors such as cleaning up a room, doing homework or getting ready for school on time. Inevitably, a parent will tell me that they do not want to bribe their child to do the right thing, and will argue about using a reward.

It doesn’t help me make my point that major magazines on parenting run cover stories about whether you should ‘bribe’ your child. And famous media mental health types often weigh in on the issue, usually against the ‘bribe’.

But do we ever bribe kids? A bribe is defined in the dictionary as paying someone to do something illegal or immoral. People attempt to bribe government officials to bypass rules, or gamblers try to bribe coaches and players to throw games. We never bribe kids to do bad things. So how did this word get associated with trying to modify a child’s behavior?

When I discuss the “B” word with parents, what I am usually told is that either their child will then want a bribe for every little behavior, or their child will act up without a bribe. In these situations, it turns out we aren’t talking about bribes (or incentives) at all. I’ve realized we’re discussing the child extorting the parent.

What’s the difference between a bribe (aka an incentive) and extortion? It’s all about power. What parents call bribes often mean control of the situation has moved from the parent being in charge to the child being in charge. At those times, the parent pays off the child with a reward to prevent the child from doing something bad or undesirable. You can see it in the mall, the desperate mom or dad promising a reward if only the child will not cause such a scene. That is extortion, defined as demanding payment to prevent something terrible from happening. You’ll know in your gut which it is: If it feels wrong to you, you are not bribing or rewarding -- you are being extorted.

The difference is who sets the rules and who is in control. If the parent discusses with the child, offers a reward if the child does what is asked of them and then pays off, the parent is in charge and it is truly a reward. The child will likely behave well in the future. Incentives require advance planning. If you go to the mall and prior to entry you tell your child what to expect, how many stores you will visit and what they must do to earn their reward (a toy, a ride on the merry-go-round, a little treat after lunch), that is a good way to manage a potentially difficult situation. Thinking ahead is crucial. If you don’t say anything and only when the child starts to fuss do you offer an incentive, that’s extortion. In that situation the child has learned how to control you.

The bottom line is that rewards are a very useful way to help children do things they find difficult. We never actually bribe kids, and we should watch out to make sure they are not extorting us.

What types of rewards and incentives have helped your child develop healthy habits or good behaviors?

W. Douglas Tynan, Ph.D., joined Nemours/Alfred I. duPont Hospital for Children in 2001 as a clinical psychologist and currently serves as chief psychologist with Nemours Health and Prevention Services, and associate professor of pediatrics at Jefferson Medical College

by Rima Himelstein, M.D.

When people discover that I am a doctor for teenagers, they frequently look at me with disbelief.  How could I willingly spend my entire day in the company of teenagers? Easily — because with teenagers, there’s never a dull moment.

Adolescence comes from the Latin word, adolescere, meaning “to grow up.” There is no single pathway for every adolescent. The road may be bumpy or smooth. Each path is unique to a culture, family, and individual. Yet, all adolescents work on certain tasks — and, like the “3 Rs,” they are required!

Here are a few examples of these tasks, along with some good and not so good ways that today’s teenagers (and their parents) are handling them.

Shift to independence

• Good: Disagreements can be healthy. While parents often find arguing with their teens stressful, verbal disagreements help adolescents gain independence from their parents. Warning: occasional rudeness may occur! And I don’t mean just from the kids.
• Not so good: When all that parents and kids do together is argue, no one grows; when they go to the other extreme, no one grows either. Parents should stay involved with their teenagers even though avoiding conflict may seem like the easier path. They need to know where their teens are, whom they are with, and what messages they may be sending around the globe on the internet. The American Academy of Pediatrics  urges parents to make sure: Teens spend no more than two hours online per day; get at least nine hours of sleep per night; get at least one hour of exercise per day; and eat at least one meal per day with their family.      

Dressing and acting like their peers

• Good: Teenagers need to feel like they fit in with their friends. Wearing flip flops or distressed jeans may not seem like “fashion” to us, but clothes like these are usually harmless and let your teenagers feel like they belong.
• Not so good: Girls whose hemlines are ultra-high and boys whose pants are ultra-low may attract the wrong kind of attention even though these outfits may be the fashion. Parents need to explain the mixed messages that wearing these clothes may send. It might be even better if they hear it from other teens.

Developing body image

• Good:  Teenagers’ bodies are changing constantly, and it is normal for them to feel self-conscious — as if they are in front of an imaginary audience. This is one reason why teens need some privacy: time “off-stage” lets them come to terms with their new body image.
• Not so good: Is thin too “in”? A Medical College of Wisconsin study found that most female high school athletes (78 percent) — and many less active girls (65 percent) — have one or more parts of the “female athlete triad”: poor eating habits, irregular menstruation, and decreased bone density. 

Establishing their identity

• Good: Teens need to develop their identity along with their cognitive skills. They experience a greater range of feelings, including compassion, and start to realize what it means to be a true friend. They also develop values — including some you may recognize as your own!
• Not so good: Teens may believe in the personal fable: that they are immune to harm. So while they are figuring out who they are, they may be taking serious risks. We need to talk with both boys  and girls  about substance abuse, teen pregnancy and sexually transmitted infections (STIs).     

As the mother of an early, middle, and late adolescent, I’m living through the tasks of adolescence as I write this! Here are a few suggestions we might use to help our teens as they figure out “what’s it all about:”

• Let them win a few arguments — it helps them gain independence.
• Set limits about sleep, screen time, exercise, and meals.
• Let them dress in style, within limits; they should understand the attention it may attract.
• Give them the space to separate from you as they need to, but be there when they come back!  

Rima Himelstein, M.D., is a Crozer-Keystone Health System pediatrician and adolescent medicine specialist.

Over 2 million kids, ages 14 and younger, show up in hospital emergency rooms each year with fall-related injuries. Kids tumble down stairs, fall off playground equipment, take spills from bikes, scooters and skateboards – or fall out windows. About 80 die.

While fall-related deaths among kids have dropped in recent years, falls remain a leading cause of unintentional injury for children. Parents can take steps to keep kids safe – without padding them with bubble-wrap before they head out to the park or keeping the training wheels on their bikes til they turn 18.

I was curious about the types of falls that are most common – and most dangerous. One study of national injury data found that these are most common:

Estimated yearly injuries seen in emergency rooms from falls off: 

• Stairs or Steps: 250,000
• Playground Equipment: 218,000
• Beds: 212,000
• Shopping Carts: 23,000
• Bleachers: 15,000
• High chairs and baby seats: 14,000
• Baby walkers: 4,700
• Tree houses/Play Houses: 4,000
• Baby changing tables: 2,700 

I asked Jack Kelly, M.D., associate chairman for the Department of Emergency Medicine at Einstein Medical Center in Philadelphia what parents should know – and do:

Which falls should concern parents most?

A common fall history is a fall down stairs. Parents/grandparents/babysitters must use safety fences to block stairs. Children need to be supervised ... constantly.

How can parents balance safety on playground with letting kids be kids, take risks, run around and have fun?

At playgrounds, it is essential to know if there is a "soft surface" or if the ground is blacktop or concrete. Falls at a soft surface playground may have less critical injuries. Many playground swings/slides/etc. may be too high and too dangerous for very small children, and parents must be concerned and savvy about this. If the distance of potential fall is twice the height of the child, that is a dangerous height. The child should not be on that ride/swing/slide/monkey bars. Parents will always have to balance letting the child play, with understanding that they are in dangerous territory. We let children play ... but not with matches. Parents need to be smart about this.

What about helmets to prevent head injuries in falls when riding bikes, roller-blading — skiing and sledding, too? Would helmets reduce injuries or severity significantly and should more parents kids wear them?

Helmets for bike riding, skiing, horseback riding and other activities are essential, and as important as seat belts. Parents must mandate that their children wear helmets during these specific activities, and enforce it.

High blood pressure sounds like a problem that pops up late in middle age – coinciding with a growing collection of elastic-waist pants in the closet, walking shoes that are gathering dust and perhaps an uptick in stress as you worry about your parents, your kids, your job and more! But a recent report from the University of Michigan Health System suggests high blood pressure may be a rising health concern for kids and teens – yet it’s often missed. 

One reason for the slip-up is that doctors don’t take kids’ blood pressure at every visit, and only write it down about 26 percent of the time. Another reason is that a healthy blood pressure reading for a child or teen varies with his or her age, sex and height. “When it comes to young people’s blood pressure, we can’t use a flat number value for what’s normal or abnormal like we do in adults. They may have a reading of 80/40, which sounds good, but that may actually be high,” lead author Margaret Riley, M.D., told a Detroit TV station.

You can see blood pressure tables for kids and teens here, on the website of The National Heart Lung and Blood Institute’s website.

The most important reason to know whether your child’s blood pressure is healthy is that high blood pressure’s extra force can do damage early. “High blood pressure may start causing problems even in childhood, including changes to the structure of the heart that damage blood vessels, and can also be associated with high cholesterol, diabetes and other health issues,” Riley said. The good news is that healthy eating and regular activity are the usual treatments – drugs are used way less often in kids and teens than in adults.

But there’s another reason to pay attention to your child’s blood pressure: It may reflect your own. It turns out, another recent study says, that when a child has high blood pressure or cholesterol his or her parents are often at higher risk for diabetes and heart disease, too. The connection reflects the genes and lifestyle habits that you both share.

Here’s how to stay on top of your child’s blood pressure:

• Be sure the doctor measures and writes down your child’s blood pressure at every visit started at age 3. The doctor’s office should have cuffs of various sizes to fit kids of various sizes; the wrong size can result in a reading that’s too low or too high.
• Ask if the number is in a healthy range. Your doctor should consult a blood pressure table – on paper, on computer or on her smart phone – to tell.
• If your child’s blood pressure seems too high or too low, ask what happens next. One reading won’t lead to a diagnosis. Doctors usually check three times, at separate visits. If high blood pressure is diagnosed, more medical tests will be conducted to look for a cause. While a growing number of kids have higher-than-healthy blood pressure numbers due to obesity, other factors include heart defects, kidney disease and hormonal disorders.