Monday, July 23, 2012

the vitamin racket

I try hard not to substitute my medical judgement for that of a pediatrician. Even though I know it's probably a virus and I don't want my kid on antibiotics unnecessarily, when my little mom voice whispers "oh but wouldn't it be nice to just check in with the pediatrician....?" I listen, and usually give the office a call.

The balance between mom and momMD can be difficult to maintain. When my son was 22 days old he developed a low grade fever for which we sought care in our local ER. Two failed LPs and countless futile attempts at IV placement later, the little mom voice that usually serves me so well was screaming Grab your son and get the (expletive) out of here NOW. But I didn't. I thought of countless febrile-but-stable patients I had met in my short training. How, in the span of a few short hours, some of them would be actively dying in the ICU with clear plastic tubes coming out of every natural and man-made orifice. I thought of the two people I knew who had suffered the sequelae of childhood meningitis - one was almost deaf, the other had had partial amputations of all four of her limbs. I ended this internal debate by breaking into loud, messy tears. At one point I started choking on my own snot. For better or worse (and to this day I'm not sure I made the right decision) we stayed and were admitted to the hospital. And my son is fine. 

I tell that rather unpleasant story to make a point - I try to be a good patient. A good mother-of-the-patient. Even when it conflicts with my own instinct. But there is one thing I don't understand - vitamins. My 3 year old daughter was never on infant vitamins. But my six months son has two different vitamin prescriptions. Two. Our first pediatrician told me it was mostly for "vitamin D supplementation". Perhaps I am prejudiced, but as an internal medicine resident who dutifully checked vitamin D levels on most of her patients, I came believe there was something wrong with the test because every single patient had a low or undetectable level. My husband - a healthy 32 year old who eats a balanced diet and works out in the garden - has an almost undetectable level. I guess I'm saying I don't know what to make of the vitamin D hysteria, so I didn't prioritize (or really, remember), my son's infant drops. When my husband admitted to the second pediatrician that we hadn't been very dutiful vis a vis the infant drops,  she appeared quite taken aback. And then wrote a new prescription, this one for infant vitamin drops with fluoride. I hope "poor compliance with medical therapy" wasn't entered into the medical record. In my defense, we've been very compliant with use of iron fortified cereals - an enthusiasm directly attributable to my hematology training. 

I am all for prenatal vitamins and fluoride supplementation in the water, but my son? He doesn't even have teeth yet. 

15 comments:

  1. Ah, but he does have tooth buds.

    I'm cautious about fluoride because as an infant and toddler, I was overexposed and have significant staining on my adult teeth from it. We are on well water, though, and my kids have inherited my poorly enameled teeth, so I've considered fluoride drops for that reason. Still debating it, though.

    Been curious about those vitamin D tests myself. Seems like absolutely everyone is deficient, even my husband who works twelve hours a day outside and drinks far more milk than a lactose intolerant person should.

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  2. Hilarious! I think the vit D thing may be overblown as well... but my child gets basically no sun, so we do the drops pretty religiously. And iron fortified cereal.

    However we completely blew off the recommendation to wait until 6 months before starting solids because our daughter seemed developmentally ready and because new research from a recent prospective cohort study seems to indicate that food allergies are actually reduced if you introduce solids earlier rather than later.

    See, I'm even worse than a non-compliant patient. I'm that dreaded mom who tries to "educate" herself. Haha.

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  3. I'm going to second the "if there are tooth buds it isn't too early for fluoride" comment. Depends on the fluoride in your local water (or lack thereof) and how much (or little) of it your child gets, but starting early can really help down the road.

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  4. Hi.. I'm a dentist and first time poster - flouride and vit D are necessary for both teeth and bone calcification and tooth formation starts at 6 weeks in utero and continues till almost 12 years. Different teeth at different times. Normal water fluoridation levels of 1ppm prevent caries and actually make teeth resistant and more calcified. But for all this to happen, fluoride need to be present when the teeth are erupting. After they erupt topical fluorides maybe needed to get these benefits but its always better to start early. As regards to staining of teeth, well water has excess fluoride in it already and it will lead to a mottled appearance of the teeth. Adding fluoride drops on top of well water is not a good idea and you should talk to your pediatrician about this.

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  5. I'm a physician at a large acad teaching hosp. I'm against universal vitamin supplementation in newborns/infants. Supplementation makes sense in those infants at risk. All our newborns are sent home on tri-vi-sol..even though many of them are on formula which contain vitamins. Those exclusively fed formula do not need extra vitamins. Moreover, the liquid vitamins are very expensive (covered by medicaid). Large studies in adults continue to show the harms associated with over supplementation of vitamins such as A and E. I'm wondering how this whole vitamin supplementation push became to prominent- is there some super pharma rep making the rounds?? I'm also super annoyed by the overuse and abuse of PPIs in infants....but that's for another time.

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  6. VIdhya, thank you. I'd been planning to discuss it with our paediatric dentist on my son's next visit, as I clearly didn't know whether our water had fluoride in it. It's about due for water testing anyway, so I may have that done just to know for sure how much is present.

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  7. I tend to be a non-compliant momMD for things I deem "unimportnat." Like, as Old MD Girl, mentioned, I completely ignore all instructions about when to introduce various food because I think that the delays are generally INCREASING food allergies.

    I also thought the vitamin stuff was a little over blown, and was very laid back about whether my daughter got her post 6 months poly-vi-sol with iron. Like, maybe once every few weeks laid back, because she HATES it. I figured she was OK since was getting about 12 ounces of formula supplementation a day and a variety of meats / veggies / cereals. Well, just got her 9 month CBC and she is totally anemic. So, feeling like a lousey momMD over here (and forcing a lot of poly-vi-sol with iron into a very angry baby...)

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  8. We were given those vitamin drops but couldn't get the baby to actually take them. One time I was attempting to get her to take it and she flung out her arm and the bottle spilled all over our covers. Multiple washes later, the covers are still stained, as are the sheets UNDER the covers, as is the mattress. Kind of made me wonder what I was putting in my baby's body. In any case, we stopped the drops shortly after that.

    I know the fluoride is important, but my baby is such a picky eater, it's hard to get her to take *food* so we're focusing on that.

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    Replies
    1. Will she drink them if you put the vitamins in her bottle?

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    2. We haven't tried. These days bottles are made quickly, with her screaming her head off, and the last thing I'm worried about is squeezing a dropper of fluoride in there.

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  9. Yeah, our entire last bottle spilled on the living room carpet, which was pretty much the end of vitamins for the baby -- at least until this recent CBC.

    Now, I am remembering why we'd stopped. We have stained clothes (hers and mine), a stained baby, and a stained highchair, as well as a baby who gags for the next 10-15 minutes after getting the vitamins, and who is going on an overall eating strike in protest.

    Good times.

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  10. Here in Canada the only vitamin we give, unless there is a good reason, is vitamin D to exclusively breast fed infants. It comes in a handy 1 drop 400 IU dose that can be put on the nipple and have the baby latch directly on top. We know that with limited sun exposure for other reasons and our northern climate, vitamin D deficiency is a reality here.

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  11. I remember giving my daughter one dose of poly-vi-sol when she was an infant. She promptly gagged it up and it went all over the place, staining any fabric it came into contact with. I didn't actually taste it, but it smelled like something that would taste terrible. Anyway, I held off and she came back anemic at one. Our pediatrician suggested that we crush a Flintstones vitamin and add it to some cereal every couple of days. We did that until she could chew half a tablet daily.

    With my second child, the only thing I gave him as an infant was the vitamin D drops medstudentitis mentioned. They are so easy!

    (I'm excited that I just found this blog! I'm starting med school next week at age 35 and with 2 kids.)

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  12. I don't know if anyone else is still reading this thread since we are all busy yelling at each other about formula, but I've starting give Wow his infant drops, like a good mother. Those little teeth buds deserve a chance...

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  13. Interesting that you noticed the overwhelming number of patients that we're Vitamin D deficient. The tests were accurate- we simply don't get the uvb exposure we need for adequate vitamin D levels, which acts like a steroid hormone more than a vitamin. www.vitamindcouncil.org

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