• Vitamin D

    As many of you have heard from me before, I tend to be a minimalist when it comes to vitamins and supplements. These are big business (we’re talking billions of dollars a year in the US), with lots of big claims about benefits and necessity, but often not a whole lot of evidence to back those claims up.

    Of course, sometimes we have to use our judgment and expertise, because especially when it comes to kids, and non-pharmaceutical therapies, there simply may not be the research for us to know one way or another. But one question that comes up a lot this time of year is: should my kids be taking any extra vitamin D supplementation?

    Vitamin D (“calciferol”) is an interesting topic. It’s a fat-soluble vitamin that humans obtain by eating foods that contain it, but which we can also produce ourselves when UV light from the sun reaches our skin and triggers vitamin D production.

    Vitamin D does a lot of things: it’s very important for bone health in both children and adults, and it also plays a role in inflammation reduction, modulation of certain neuromuscular and immune functions, and glucose metabolism, as well as modulation of critical cellular functions such as cell proliferation and differentiation. 

    For a while, the idea that vitamin D supplementation would be a panacea for all sorts of things was all the rage - that it would help with not just bone health in adults but also with reducing the risk of cardiovascular disease (e.g. heart attacks and stroke), cancer, and depression. Unfortunately, many of these possible connections have been extremely well investigated, and have just not turned out to be true. 

    And on the other end of the spectrum, excessively high levels of vitamin D can lead to serious harm as well. It’s a fat-soluble vitamin, so when you take too much, the body can’t easily get rid of it the way it can excrete extra water-soluble vitamins like vitamin C out through the urine.

    We do see plenty of true vitamin D deficiency in our northern climes. But what’s tricky is that no one’s entirely sure what the “ideal” vitamin D level is; many professional guidelines suggest 20 ng/mL and above as sufficient, while some argue that higher (e.g. 30 ng/mL and above) may be more optimal. But again, we also know that too high can cause harm as well. 

    So, what to do? Here’s what I recommend: 

    • Breastfed babies (and any baby who is not receiving 100% formula) should be supplemented with 400 IU vitamin D daily, or their moms should take high-dose vitamin D supplementation while breastfeeding (4000-6400 IU/day) to ensure excretion of adequate vitamin D in breastmilk.

    • For everyone else: we generally do not need to be checking labs routinely, but when we do, I generally look for it to be about 30 ng/mL - though again, some argue that 20 (or even lower) may actually be sufficient!

    • As with everything else, it’s best to get our vitamins and other nutrients through real foods. Here’s one source that shows some of the highest vitamin D foods.

    • If you think that between sun exposure and diet, your child really isn’t getting the recommended amount (600 IU per day), then I think it’s fine to supplement with 400-600 IU daily or every other day; some families choose to do this just during the winter where we truly don’t get much sun exposure during some intervals. 

    If you’re interested in reading more, I found this article a nice overview. Though not a scientific article, it’s well-researched.

  • Thoughts on Omega-3 Supplementation

    I read an interesting article about omega-3 supplementation recently, which prompted me to do some digging into the current research on whether omega-3 supplementation is beneficial or not. 

    As most of you probably know by now, I am not big on vitamins and supplements unless there’s a very compelling reason. As with so many things in the health/wellness industry, there’s just so much marketing, so many exaggerated or frankly false claims, and huge amounts money to be made from selling these products, so I tend to be pretty skeptical unless there’s really clear evidence of benefit and safety. 

    There’s been a lot of buzz about omega-3 fatty acids, so here’s a brief overview: omega-3 fatty acids are a type of “healthy” (polyunsaturated) fatty acids that can be found from some main dietary sources. The long-chain omega-3 fatty acids EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) are found mainly in cold-water fatty fish like salmon, herring, tuna, etc. ALA (alpha-lineolenic acid), on the other hand, is found in plant oils, e.g. flaxseed, chia seeds, and walnuts. 

    There are other types of omega fatty acids as well, like omega-6 fatty acids, which are also important and come primarily from vegetable oils, but generally the desirable ratio of omega-3 to omega-6 seems to be between 2:1 and 4:1 (i.e. you want more omega-3 than omega-6). 

    Omega-3 fatty acids have a lot of important functions in the body. They’re components of the cell membrane and participate in a huge range of functions, including brain growth and development, the eye/vision, cardiovascular health, and more.

    One of the main things that has been studied over the years is the role of omega-3 fatty acids - from dietary sources versus from supplements - in reducing the risk of cardiovascular disease (e.g. heart attacks, strokes). While diets higher in omega-3 fatty acids do appear to be associated with lower risk of heart disease, the research on omega-3 supplements has been pretty underwhelming. This study, for example, pooled results from 10 different large, well-designed trials, and no benefit was found. 

    One thing that interests me is the potential neurobiological role of omega-3s in behavioral/psychological conditions like ADHD and depression. The research in this area is much more preliminary, and the results are pretty mixed. Some well-regarded clinicians, however, like Sanford Newmark at UCSF, do recommend the use of high-dose omega-3 supplementation for children with ADHD. 

    The bottom line seems to be that there are no hugely magical benefits of omega-3 supplementation, and in adults there is some concerning evidence that high-dose supplementation may actually be associated with the development of atrial fibrillation, a type of heart arrhythmia.

    So my recommendation is to skip the supplements and focus instead on good dietary intake of omega-3 fatty acids. For kids, this means 1-2 servings per week of fish or another source like flaxseed. My kids all enjoy salmon and whitefish in particular, and we are huge flax fans in my house - we put ground flaxseed into smoothies and oatmeal and muffins. Flax also has a lot of fiber so it can be great for healthy bowel function (as long as you’re drinking enough fluids to go along with it)!

  • Measles

    As most of you have probably heard, there have been a number of cases (9) of measles identified recently in Michigan. So far there have been none in Leelanau, Grand Traverse, or Benzie counties, but given the rising number of cases nationally (884 confirmed cases, so likely a much larger number of total cases), we may be at the tip of the iceberg in terms of measles losing its status as “eliminated” in the United States and returning to endemic (that is, regularly occurring) status. 

    Measles scares me. In the United States, about one in every 5 people who develops measles becomes sick enough to require hospitalization. About one in every 20 children with measles develops pneumonia (which can’t be treated with antibiotics, because measles is caused by a virus, not a bacteria).

    And there are two really significant possible long-term complications of measles. The first is SSPE (subacute sclerosing panencephalitis), which on average occurs a few years after recovery from a bout of measles, and it causes progressive brain inflammation that is fatal. Thankfully, SSPE is pretty rare - it occurs in about one out of every 50,000 cases of measles, but you can’t predict who will develop it. This is what Roald Dahl’s daughter Olivia died of at age 7.

    The second is immune amnesia: measles essentially wipes out your body’s immune memory. It happens in pretty much all cases of measles, though to differing degrees for different people. It can last for a few years and means that you need to rebuild immunity to various things (by vaccination or natural exposure) all over again. 

    There’s been talk of the role of vitamin A in measles, and the most important thing to know about this is that while there may be a role for vitamin A in the treatment of hospitalized measles patients, this really has to be done under medical oversight in the hospital setting because vitamin A is a fat-soluble vitamin that can cause toxicity if not dosed properly. It’s really not helpful for prevention of measles in the United States.

    We routinely vaccinate for measles with the MMR vaccine at 12 months of age, and then again at age 4. The MMR vaccine is safe, and doesn’t cause autism or neurodevelopmental problems. The second dose of the vaccine isn’t used as a “booster” like with some other vaccines. After the first dose, about 93% of children will develop immunity; the second dose is meant to catch those children who did not develop immunity after the first dose. 

    If you’re wondering about vaccine status for yourself or your own parents:

    • People born before 1957 are presumed to have been exposed to measles because it was endemic then and there was no vaccine, so they are presumed to have lifelong immunity. 

    • For people who may have received one dose of the original measles vaccine between 1963 and 1967, it’s recommended that they receive a dose of the current MMR vaccine because the original one wasn’t as effective as the one we have now, so they may not have immunity. 

    • If you were vaccinated after 1967 and received two doses, then you are considered immune!

    The recommendations may change as the outbreak grows, but currently it is recommended to give infants an early dose of MMR between ages 6-12 months only if they are traveling internationally or to an area with an active outbreak. Then, they would still receive the regular doses at 12 months and 4 years. 

    For children younger than 4, if they have received their first dose, they are eligible to receive their second dose as soon as 28 days after dose #1.

    However, this is not routinely recommended, but can be considered if traveling internationally or to an area with an active outbreak. They would also still receive a dose at age 4. I will be monitoring the recommendations closely in the event that the guidelines are revised. 

    Even if you are not choosing to vaccinate against other things, I would strongly recommend at least considering MMR vaccine in light of all of this. I’m always happy to talk through it in as much detail as might be helpful, and to support your family in making these decisions.  

  • Elderberry

    A lot of families have asked me whether elderberry really is helpful this time of year. It’s often talked about as a good way to “boost” the immune system and help prevent illness, but do we actually have any evidence that this is true? Yes and no.

    Black elderberry (sambucus nigra) is the most commonly used species for this purpose, and elderberry contains flavonoids called anthocyanins that can have immunomodulatory effects. One neat things that anthocyanins can do is to attach to the glycoproteins on viruses and make it harder for them to enter host cells to cause infection.

    One not-so-neat thing about elderberry is that it is extremely toxic if it is raw/uncooked: the raw plant and berries contain sambunigrin, a cyanide-producing chemical. When cooked and properly prepared, though, it is quite safe, but you should always check with your own healthcare provider before using any new supplements/medications.

    There have been a few studies trying to dig into the question of whether elderberry actually makes a clinical difference in real life. A systematic review of studies that had been performed investigating elderberry as a prevention or treatment strategy for viral respiratory illnesses found that elderberry may a) reduce the duration and severity of colds, b) may reduce the duration of influenza, and c) compared to Tamiflu, an influenza antiviral treatment, elderberry products may be associated with a lower risk of influenza-related complications. However, this was based on only 5 randomized controlled trials that had been performed, so the authors couldn’t draw any definitive conclusions. 

    A different study (a double-blinded, randomized controlled trial, which is the highest quality kind of research study) that specifically included pediatric patients ages 5 and above found, on the other hand, that elderberry didn’t reduce influenza duration or severity. 

    One of the challenges with studying medicinal plants and herbs, and other holistic or alternative remedies, is that we often lack high-quality, large-scale research studies from which to draw solid conclusions about whether something is effective, whether it is safe, and so on. So to some extent, a lack of evidence doesn’t necessarily mean that something isn’t beneficial, it may just mean that it hasn’t been studied in a formal scientific way.

    On the other hand, just because something is herbal or plant-derived doesn’t necessarily mean that it is safe or that it works, so I think it’s always worth being curious and questioning, and seeking out unbiased sources and evidence! 

    The bottom line with elderberry seems to be: we’re not totally sure if it helps, but it might, and it tastes good, and it’s generally safe if prepared and used properly. 

    One of my favorite integrative medicine physicians is Dr. Anne Kenard, who is an obstetrician-gynecologist out in California. She has two great elderberry recipes, which I am sharing below. Both contain honey, so should not be given to children under age 1. 

    Elderberry syrup

    INGREDIENTS

    4 cups water

    1 cup dried elderberries (Mountain Rose Herbs)

    2 Tbsp grated fresh ginger or 2 tsp dried ginger

    1 cinnamon stick

    1 star anise

    4-6 cardamom pods

    3 Tbsp orange zest

    1 cup honey

    INSTRUCTIONS

    Add all ingredients except honey to saucepan and bring to a boil.

    Simmer for approximately 20-25 minutes, until the volume has reduced by half.

    Strain out the herbs and return to the saucepan

    Stir in honey until dissolved.

    Keep refrigerated for 3 months.

    Eat with pancakes or drizzled on ice cream, or take at the first sign of a cold or influenza (1 teaspoon 3 times daily for children ages 2-6, 1 tablespoon 3 times daily for children ages 7-12, and 2 tablespoons three times daily for ages 13 and older).


    Elderberry Popsicles

    1 cup dried or fresh elderberries


    2 cups water

    1 cups raw honey

    Squeeze of lemon juice

    2 cups water or apple juice

    8 Popsicle molds

    Bring elderberries and water to a boil.  Gently bruise the berries, encouraging more dark purple color into the syrup.  Reduce heat and boil down until it has a thick, syrup like consistency.  Strain out elderberries.  Return to heat source and add honey and lemon juice.  Heat and stir until combined.  

    For popsicles, add additional water or apple juice.  Stir to combine and place in Popsicle molds.  Freeze.