Thursday, August 28, 2014

Hookah Smoking Increasingly Popular Among Teens

A recent report from the Centers for Disease Control and Prevention (CDC) found that use of alternative tobacco products such as hookah is on the rise among teenagers although cigarette smoking among United States high school students has slowed.

Additionally, a study published online in July’s Pediatrics focused on which teenagers seem to gravitate toward hookah smoking.

“Hookah use began centuries ago in ancient Persia and India,” according to a CDC factsheet. “Today, hookah caf├ęs are gaining in popularity around the world, including Britain, France, Russia, the Middle East, and the United States.”

But hookah smoking has many of the same health risks as smoking cigarettes, despite myths of its safety, according to Brooke Rosman Bokor, MD, MPH, a physician in the Division of Adolescent and Young Adult Medicine at Children’s National Health System.

We spoke with Dr. Bokor about this practice and its health implications.

What do children and adults like about hookah use?

Motivations for use include socializing, relaxation, pleasure, and entertainment. Hookah use is increasingly popular on college campuses and among high school seniors, particularly those of higher socioeconomic status.

Why do users of hookah believe it is much less harmful than conventional cigarettes? Is this the case?

Hookah is also known as shisha, narghile, or waterpipe. Users and non-users believe that smoking tobacco through a water filter makes it less harmful and non-addictive. This is a myth. The current lack of regulation against hookah lounges and the cheaper price of hookah tobacco (shisha) facilitate the false impression that hookah smoking is safer.

What are the health risks associated with hookah smoking?

Because cigarettes and hookah share some of the same ingredients, they likely share the same health risks. Specific studies on hookah are limited at this time. What we know for sure is that the smoke from one hookah session (which may be 60 minutes or more) contains up to 40 times the tar, 30-50 times the carcinogenic polycyclic aromatic hydrocarbons, two times the nicotine, and 10 times the carbon monoxide as the smoke from a single cigarette. The burning charcoal that heats the tobacco is the source of carbon monoxide.

Is there a link to smoking cigarettes, using alcohol, smoking marijuana, or other illegal substances and using hookahs?

Most children begin smoking cigarettes prior to age 18. The current increasing trend of hookah use is predominantly based among high school seniors, college students, and other young adults. Since current and former cigarette users are those most likely to use hookah, the link may simply be tobacco in an alternative form that is perceived to be less harmful and part of a more mature social setting. The link also may relate to the neurobiologic role of “reward” in the brain, to which the adolescent brain is very sensitized. This may account for increased hookah use among users of alcohol and marijuana.

What is otherwise fueling the initiation and use of hookah?

Hookah bars have popped up in cities and near college campuses around the U.S. since smoke-free laws have not been extended to hookah lounges. Hookah use increases in communities with an increased number of hookah lounges. Hookah tobacco also appeals to young people due to its lower cost and fruity or candy flavoring. Since shisha is considered pipe, rather than cigarette, tobacco per the Food and Drug Administration, it has escaped the 2009 ban against flavored cigarettes as well as the higher taxation of cigarette tobacco.

What should parents do?

Remember that initiation and early patterns of tobacco use are strongly influenced by family and social factors, said Dr. Bokor.

  • Set a good example. Don’t personally use hookah or any other form of tobacco, as that sends a message of acceptability to children and teenagers. Parental effort to cut down and quit any form of tobacco (and the challenges incurred) sends another powerful message that helps keep minors from tobacco initiation or use.
  • Correct myths. Using tobacco via hookah exposes them to more addictive nicotine and toxic smoke than cigarettes, despite use of water filtration or flavoring.
  • Communicate early and often. Open communication with children and teenagers about the risks of all forms of tobacco is the best prevention strategy against tobacco addiction.

Since hookah use increases with age, make sure to talk with high school seniors prior to attending college.

If a child or teenager makes it to age 21 without ever using tobacco, they have very little likelihood of becoming addicted.

Dr. Bokor said hookah produces 40 times the amount of smoke for equal time spent smoking hookah or cigarettes.

“Patrons of hookah bars are exposed to a very high level of secondhand smoke (containing carbon monoxide and toxicants) and third-hand smoke, for example, soot on the walls that contributes to poor air quality,” she said. “The air quality in hookah bars, per one study, regularly reached ‘hazardous’ Environmental Protection Agency levels. This impacts smoking and non-smoking patrons alike, especially those with asthma or other respiratory limitations.”


D. Camenga. “The New Cigs on the Block”: An Update on Conventional and Novel Tobacco Products.” Adolescent Medicine: State of the Art Reviews. 2014; 25:33-49.

Monday, August 25, 2014

Teens Need More Sleep: The AAP Releases Guidelines to Delay School Start Times

The American Academy of Pediatrics (AAP) has just released guidelines urging middle schools and high schools to delay start times to 8:30 am or later.

According to research, only about 15 percent of U.S. schools start at 8:30 am or later, with 40 percent of schools starting before 8 am.

The lead author of the policy statement, Children’s National Health System’s Director of Sleep Medicine, Judith Owens, MD, said that the chronic sleep loss suffered by teens is one of the most common and easily fixable public health issues we have today.

“Sleep tends to get relegated to the bottom of the pile and the more activities that kids are involved in, social networking, after school employment, homework, all of these other priories take precedence over sleep,” Dr. Owens says. “Delaying high school start times is a necessary step. One of the most important messages parents can give, is to take sleep seriously themselves.”

Learn more about the recommendations and how sleep deprivation affects teens in the video below.

Thursday, August 21, 2014

Innovating the Future of Surgery

Medical researchers and engineers in the Sheikh Zayed Institute for Pediatric Surgical Innovation at Children’s National Health System craft high-tech tools for the next generation of procedures.

The goal for both of these high-tech tools is to make procedures minimally invasive, which means a faster recovery time, less pain, and smaller scars, if any at all.

Smart Tissue Anastomosis Robot (STAR)

The first tool, STAR, represents a paradigm shift from current robotic surgical systems, which act as functional extensions of surgeons, to a “smart” system that can be programmed with a surgeon’s best practices to enhance a surgeon’s skills rather than perform entire operations.

“I compare STAR to smart power tools – it’s meant to be used only when it augments one’s ability to perform a task better,” says Peter Kim, MD, CM, PhD, Vice President of the Sheikh Zayed Institute. “STAR allows surgeons to perform safer operations, and because it’s programmable, share their best techniques with other surgeons.”

STAR also features a versatile adapter device for modifying minimally invasive surgery tools and a user interface with three degrees of functionality: standard master-slave, supervised autonomy and automation with a “stop” option.

EndoPyloric Tool

The second high-tech tool treats children with hypertrophic pyloric stenosis, a condition that occurs in infants that is defined by the thickening of a valve in the small intestine, preventing food from passing from the stomach. This condition is currently treated with open abdominal or laparoscopic surgery.

 The EndoPyloric tool is an inventive double-balloon catheter placed inside a patient’s body through an endoscope without an incision.

“The device enlarges the intestinal channel by approximately 30 percent,” Dr. Kim -says. “The goal is to stretch the obstruction just enough so food can pass through until the child outgrows the condition without exposing him or her to the potential complications of an invasive procedure.”

These two tools are slated to begin clinical trials within two years.

Read more from past issues of Advancing Pediatrics.

Monday, August 18, 2014

HPV Vaccine: Why is the US Lagging Behind?

Despite the preventative benefits of the vaccine in preventing cancer, the United States lags behind much of the developed world in immunization rates for human papillomavirus (HPV).

According to U.S.News & World Report, countries such as Canada and the United Kingdom have an HPV vaccination rate of up to 85 percent and 70 percent, respectively, (of girls who received all three doses), nearly double that of the U.S.

Recent numbers from the Centers for Disease Control and Prevention (CDC) show that about 57 percent of girls and 34 percent of boys ages 13-17 receive the first dose of the HPV vaccine.

About HPV

HPV is a sexually transmitted infection (STI), carried by both males and females, which can lead to genital warts and cervical cancer. Genital HPV is the most widespread STI: the CDC estimates about 20 million people in the U.S. are infected with HPV at any given time. , The American Social Health Association estimates three fourths of sexually active men and women between the ages of 15 and 49 have been infected at some point in their lives.

Because the virus is preventative, Children’s National’s Infectious Disease Specialist David Hyun, MD, recommends vaccinating children beginning at ages 11 or 12, before they become sexually active. While the vaccine can protect from up to 70 percent of HPV variants causing cervical cancer and 90 percent causing genital warts, as well as numerous head and neck cancers, there is still a great deal of controversy surrounding it throughout the U.S., according to the CDC. A study published in the journal Pediatrics found that the vaccine is effective for at least eight years.

The Stigma Behind HPV Vaccination

In 2012, a CDC survey asking parents of adolescents and teens whether they intended to vaccinate their daughters found that of the 23 percent who stated their daughters would remain unvaccinated, three of the top responses were: “vaccine safety concerns,” “vaccine not needed,” and “daughter is not sexually active.”

According to Dr. Hyun, this reluctance of parents to vaccinate their children stems from the fact that HPV is a sexually transmitted virus.

“Some parents view it as a green light for their kids to have sex, which gives it a stigma,” he said.
A study published in Pediatrics found no connection between the HPV vaccine and an increase of sexual activity for up to three years after vaccination.

Rumors of the vaccine’s alleged harmful side effects have been bolstered by media personalities such as journalist and author Katie Couric, who publicized rare reports of vaccinated individuals who became ill or died, despite no evidence connecting their deaths to the vaccine. Although scientists were concerned about the risk of blood clots, a massive study involving half a million Danish women, published by the American Medical Association, revealed no association between blood clots and the HPV vaccine.

Numerous studies point to the effectiveness of the vaccine. One in particular, published in The Journal of Infectious Disease found “within four years of vaccine introduction, the vaccine-type HPV prevalence decreased among females aged 14 - 19 years despite low vaccine uptake. The estimated vaccine effectiveness was high.”

Dr. Hyun reports that, of the strains of HPV that Gardasil, a vaccine brand, protects against, the vaccine “has a 98 percent efficacy rate in preventing cervical cancer.”

Children’s National Division Chief of Adolescent and Young Adult Medicine, Lawrence D’Angelo, MD, has seen the stigma play out with his own patient families.

“It’s so important for primary care physicians to emphasize this is a cancer prevention vaccine,” Dr. D’Angelo said.

Ask your child’s pediatrician for more information on HPV vaccination.

Friday, August 15, 2014

Get Psyched Friday: How to Prepare Your Child for Transitions

In her latest Get Psyched Friday, psychologist Eleanor Mackey, PhD, gives advice on how to handle transitions throughout the year.

Transitions, regardless of whether they are wanted or not, are challenging! Following summer comes the transition back to school, which for some years (for example, starting kindergarten, middle school, or high school) marks a huge transition.

Although almost every child will say that they enjoy these transitions, they can bring about stress that parents might not expect. For instance, kids might become clingy, moody, or irritable as they have anxiety about leaving a school or teacher or starting something new in the fall.

So, how can you help your kids with these transitions?
  1. Talk with your child. Your child may appreciate that you recognize that these transitions, even if welcome, are not easy. It might also help them to identify from where some of their negative feelings are coming. For younger kids, read books about ending or starting school (for example, Franklin, Berenstain Bears, etc) or let them draw pictures about their experience or feelings or act out scenarios with toys/dolls. For older kids, listen carefully without judging or trying to solve the problem. If your child does not want to discuss it, don’t force them to, but let them know you are ready to listen anytime they want to talk.
  2. Identify stressors and make small changes to help. For example, if your child is bored by the slower pace of summer, schedule some activities or find a way to create more structure. If your child is anxious about leaving old friends behind or making new friends, set up social activities with friends from a previous class or a new class.
  3. Try a “dress rehearsal” to get them used to the routine or the new location, building, or classroom by letting them check it out ahead of time. Talk about what it will be like. Remind them it can be hard at first but that it will get easier and you will be there to help them. Remind them of how nervous they were the previous year and praise them for how they adjusted then.

As with so many issues, listening openly and warmly to your child’s concerns without making them feel bad, embarrassed, or that they are complaining too much is important. Although some of these issues may seem small to parents, they feel very big to kids.

Monday, August 11, 2014

How to Sneak Nutrition into Any Meal

Getting kids to eat healthy can sometimes feel like “Mission: Impossible.” According to the American Academy of Pediatrics dietary recommendations, children from the ages of 9-13 should be eating:

  • 5 ounces of protein 
  • 1.5 cups of fruit 
  • 1.5-3.5 cups of vegetables 
  • 5-6 ounces of grains 
  • 3 cups of dairy daily 

 It can be hard to pack all this into one day, especially with picky eaters.

With more finicky eaters, Children’s National Health System dietitian Erika Davies recommends parents resist offering their children special meals on a repeat basis, as “it gives them no motivation to try something new.”

To encourage kids to reach for healthy snacks instead of chips or cookies, she advises always having nutritious foods easily available, while also eliminating junky snacks.

“Parents  also should be sure to model good eating behaviors” Davies said, noting kids often take after what they see.

The United States Department of Agriculture (USDA) Food and Nutrition Service provides a database of easy, healthy recipes, tips, and nutrition information for parents to help families eat healthier, and their Choose my Plate page provides tips for making healthy food fun and appetizing to even the pickiest of eaters. Sneaking in healthy alternatives and nutritious substitutions has never been easier.

  • Replace junk food: Try replacing junk food with more healthful versions of the snacks your kids already enjoy: 
    • Replace buttered popcorn loaded with fats and sodium with air popped popcorn. 
    • Make your own trail mix with dried fruits and nuts instead of store-bought trail mix, which is filled with refined sugars and preservatives. 
  • Be sneaky: Slip in nutritious foods and alternatives into meals. 
    • Add fruits and fruit purees to baked goods, cereals, and pancakes 
    • Prepare homemade goodies with whole grain flour or a gluten-free substitute such as rolled oats Add vegetables to homemade pizza 
    • Replace mayo with avocado, which is full of good fats, and try Greek yogurt, which is packed with protein, instead of sour cream 
    • Substitute leaner meats such as ground turkey instead of beef 
  • Find low fat, high fiber alternatives 
    • Try reduced fat or skim milk instead of whole milk 
    • Replace white bread with whole wheat 
  • Emphasize a “rainbow” plate: Encourage kids to include a variety of colors on their plates, for example: 
    • Green broccoli and spinach 
    • Yellow squash 
    • Orange and red peppers 

The USDA advises parents to encourage children to eat more fruits and vegetables by making it fun. Allowing kids to be actively involved in making and preparing food makes them more likely to eat it and be more mindful about the ingredients involved. Here are some of the USDA’s tips to making nutritious eating fun for kids and parents.

Wednesday, August 6, 2014

How to Talk To Your Children about the Ebola Outbreak

The Ebola outbreak is all over the news as the media focuses on the status of infected Americans. According to the World Health Organization (WHO), the outbreak in West Africa has infected more than 1,300 people and killed more than 900, making it one of the largest Ebola outbreaks in history. Two American missionaries who worked in West Africa have been stricken with Ebola and transported to the United States for treatment.

Infectious disease experts say there is little danger of an outbreak in the United States. While the public health risk is low to U.S. residents at this time, it is possible that patients traveling from affected areas may receive medical treatment at U.S. hospitals. Given the news coverage, children may ask questions or worry that they or their loved ones, too, might be adversely affected.

We reached out to Children’s National’s Division Chief of Psychiatry and Behavioral Medicine, Paramjit Joshi, MD, to find out ways that parents can talk to their children about Ebola.

Parents should allow children to express their concerns and ask questions about the disease, according to Dr. Joshi.

“Acknowledge, listen, and reassure children,” she advised.

Dr. Joshi also suggested one of the most important steps parents should take is limit mediacoverage and monitor their children’s behavior – their emotional and physical state – to determine if they’re worried or anxious.

Below is a list of symptoms in how children express their worries depending upon their age and developmental level:

Infants and Toddlers (Birth to age 2): 

  • This age group may demonstrate fears of separation, become fussy 
  •  Infants may develop feeding and sleeping problems, and become easily startled.

Preschoolers (Age 2-6): 

  • This age group may develop fears of separation and rejection, and regressive behaviors 
  •  Preschoolers may cry uncontrollably, run aimlessly, and cling excessively because they’re afraid to be alone 
  • They may develop eating problems and exhibit confusion and irritability

School-age (Age 7-12): 

  • School-age children may display inappropriate or unpredictable behavior, deny affect (feelings) and focus on details 
  • This age group may also complain of physical symptoms, show regressive behaviors (i.e., acting younger than their age) and withdraw 
  • Whining, clinging (reluctance to leave parent or teacher)

Teenagers (age 13-18): 

  • Teens may seek a time alone and may occasionally isolate themselves from their family
  • This age group may exhibit non-specific physical problems (aches and pains) and sleep changes (nightmares, trouble falling asleep) 
  • They may also demonstrate sadness, withdrawal and isolation, and excessive fears and worry