Peanuts again. When? Why? Are they safe?

Nuts have once again made headlines. The good news is that not much has changed over the past few years. These newer guidelines simply give a more active recommendation to go ahead and feed peanuts to higher risk babies, whereas prior statements were more lukewarm, advising that there is no need to delay introduction of nuts.

Here is a summary of the new guidelines by the National Institute for Allergy and Infectious Diseases. These are based on the LEAP trial, a randomized, controlled study that showed a significantly reduced risk of peanut allergy at age 5 in high risk babies who were regularly given peanuts starting between 4 and 11 months of age, compared to babies in whom peanut introduction was withheld.

So what should you do for your child? It depends on your child’s risk, as determined by the LEAP trial:

Babies with a history of egg allergy AND/OR eczema requiring regular topical steroids or immune modulators:  You should consider blood or skin prick testing for peanut allergy. Discuss with your healthcare provider. He or she may (or may not) recommend blood and/or skin testing for allergies.  As long as your provider considers it safe, start peanuts between ages 4 and 6 months. This is based on our current understanding of the immune system. It seems that when the gut encounters a food, it teaches your body to tolerate it. When the skin or lungs encounter that same allergen, the immune system is triggered in a more hostile fashion, sensitizing your body against the proteins in these foods. It makes sense then that babies with significant eczema may “see” a food through the breaks in their skin (food proteins are all around us) and trigger an allergic pathway. Feeding them the allergenic food before their skin can start an immune reaction may teach the immune system to more calmly react to the food.

Babies with mild to moderate eczema (not needing topical steroid or immune modulator use for an extended period): Start peanuts around age 6 months.

Babies without eczema or food allergy: Start anytime that the family desires. Of note, these low risk babies—which refers to most babies out there—have not actually been well studied. This recommendation is based on what we know from observational studies and from applying what we learned about higher risk babies in the LEAP trial.

How to feed a baby peanuts, since they are a choking hazard: Smooth peanut butter can be mixed with breastmilk, formula, food, or water to create a less sticky puree. You can also crush or powder the nut to feed your child a non-choking-hazard form of peanut. In the study, parents were given Bamba, a popular puffed corn and peanut snack eaten by infants in Israel. Personally, I like real peanut butter (not palm oil and sugar, flavored with peanuts) which means you have to read your labels.

Safety: Peanut allergy can be life-threatening, but the vast majority of these deaths occur in older people, like teens and young adults who may take risks with food consumption and may not carry epi-pens. There were no deaths in the LEAP trial.

For curious people or clinicians, I provide some more details:

Let’s summarize why nuts make headlines every few years: Back in 2008, the American Academy of Pediatrics (AAP) came out with a statement that said that we should not avoid introduction of peanuts or allergenic foods as had been previously recommended. This was based on observational data comparing genetically similar kids with a 10-fold difference in peanut allergy. The group with more peanut allergy was given peanuts at age 3 (as per UK guidelines at the time) whereas the group with less allergy was given peanuts at age 6 months (as per cultural norms in Israel). In 2013, the American Academy of Allergy, Asthma and Immunology came out with their guidelines recommending introduction of all foods, including allergenic foods, at age 4-6 months.

Meanwhile, this striking difference in the development of peanut allergy among Jewish children got people thinking and resulted in the LEAP study, a randomized-controlled trial (these are considered higher caliber studies than the aforementioned observational study) on kids considered high risk for peanut allergy. It turns out that kids who were given peanuts as early as 4 to 11 months had a hugely reduced risk of peanut allergy (as much as 86% relative reduction) at age 5 years compared to the kids who were not exposed to peanuts at all. As a result, the AAP came out with an interim statement advising introduction of peanuts to high-risk infants at age 4-11 months. Now, the National Institute for Allergy and Infectious Diseases released its statement and again headlines are made. The actual differences, in my practice, are subtle.

Of note, the LEAP trial did not include “super” high risk babies. All babies included had eczema and/or egg allergy, but at the study onset, the children were skin tested with peanut allergen and grouped based on these results. Those that showed more significant sensitization (based on the size of the skin test reaction), were not included in the study. So for these kids, we are still not sure about the optimal approach.

For more on starting solids, see a previous post. It is a few years old, but I will update it soon. The only major change is my recommendation on gluten introduction. Gluten can be introduced any time after 4-6 months, but it should not be given frequently.



Stop for a Minute: Making Mindfulness and Gratitude Part of You

I recently worked with a most excellent medical student, Karinne Van Groningen. She is the kind of student that practicing physicians love to work with: enthusiastic, bright, and a self-starter. During her rotation with us, she chose a topic and wrote a guest post featured below:

“Good morning my Karina!”

That was the typical greeting I got from one of my patients during my rotation on the Hematology-Oncology service at Washington Hospital Center as a third year medical student. Ms. S was a vibrant woman with AIDS and newly diagnosed lymphoma. Her prognosis was poor — at the time of diagnosis the cancer had spread throughout her body. I made it a point to stop by her room throughout the day and met a handful of her family and friends. We shared stories of our backgrounds and plans for the future. One afternoon, before leaving the hospital, I stopped by her room to say goodbye. She wasn’t her normal bright self; she didn’t instantly give me her warm smile or call out her nickname for me, “Karina.” Instead, she moved around her IV cords and looked at me with a somber face. She leaned in and said, “I just wish I were like you, able to get out of bed and walk around…. I just wish I could have my health back.”

Earlier that morning, I wanted nothing more than to lie in bed and get more sleep. The thought hadn’t crossed my mind that I was, in fact, incredibly lucky to be able to get out of bed, round on patients, and meet people like Ms. S. This happens to all of us. On so many days we’re tired, rushing from point A to B, preoccupied with what’s to come, oblivious to the subtleties of our environment. It’s rare that we stop during our busy days to notice our surroundings, acknowledge our gratitude for the blessings in our lives, or take time to breathe. But considering the many ways that practicing mindfulness has been shown to improve health, maybe we should.

What is mindfulness? It has been described as the practice of purposeful, nonjudgmental attention to the events of the present moment. It is incredibly easy to practice, and takes virtually no time. For example, the next time you’re outside, think about how the cold air feels on your face. When you take your next bite of food, notice the texture and the taste you sense. Upon waking up in the morning, try to list three things you’re thankful for. These simple mindfulness exercises could improve your health, and here’s how:

It lowers stress: A UC Davis study found that mindfulness can lower levels of cortisol, a substance released by our body in response to stress, which at high levels has been associated with hypertension, bone loss, and hyperglycemia. The study sent 57 people to a 3-month retreat where they practiced compassion, meditation, and mindful breathing. Their saliva cortisol levels were measured both before and after the retreat. After the retreat, participants were less stressed, had an increased propensity to let go of distressing thoughts, and had decreased levels of evening cortisol associated with reported increases in mindfulness.

It makes us more compassionate: Harvard and Northeastern University researchers showed that mindful meditation can improve compassion and do-good behavior. They divided participants into two groups: one group underwent 3 weeks of mindfulness meditation online self-study, and the active control group underwent a 3-week online cognitive skills self-study. At the end of the training period, participants were placed in a staged waiting room with only one empty chair left, and were asked to take a seat. Then an actor, appearing to be in great distress, entered the room with a set of crutches. In the control group, only 14% of people got up and offered the pained person his or her chair. In the meditation group this number increased to 37%. This supported previous findings by the same group in which 50% of the meditation group gave up their seats compared to 15% in the control group. It appears that mindfulness made participants more willing to act altruistically and help another in need.

It’s good for our hearts: A study in April 2015 found that gratefulness can lower inflammatory biomarkers associated with adverse cardiovascular events. The study involved 186 men and women who had longstanding cardiac disease. Patients were asked to complete a questionnaire that would measure their level of gratefulness. They found that patients who were, at baseline, more grateful, had lower levels of inflammatory biomarkers that predispose a patient to adverse outcomes. The more grateful patients also had better sleep, less fatigue, and less depressed mood. The same researchers then conducted a follow-up study to further look at the beneficial effects of gratefulness on cardiac health. They asked 40 patients with heart disease to write down three things they were grateful for on most days of the week for 8 weeks. At the end of the trial researchers found that patients who kept a gratitude journal showed reduced levels of inflammatory biomarkers and had an improved heart rate variability, which is associated with reduced cardiac risk.

It helps us view ourselves more positively: A 2012 study published in Frontiers in Human Neuroscience found that mindfulness-based stress reduction techniques can lead us to view ourselves more positively. The study analyzed 56 patients with social anxiety who were randomly divided into two groups: one that focused on mindfulness-based stress reduction through yoga and meditation, and another that focused on aerobic exercise. After 8 weeks, the group that practiced mindfulness had a greater decrease in negative self-views, an equivalent increase in positive self-views, and decreased social anxiety as compared to the aerobic exercise group.

It can improve overall quality of life: A January 2016 study published in Pediatrics studied the utility of mindfulness exercises in socioeconomically marginalized urban youth. Researches took 300 students in fifth through eighth grades from Baltimore urban elementary and middle schools and divided them into two groups. The experimental group underwent a 12-week mindfulness program that consisted of didactic sessions in yoga and meditation, group and individual practice of meditation and yoga, and group discussion focused on the application of mindfulness activities. The control group underwent a general health program that covered topics such as nutrition, exercise, and puberty. At the end of the study, those in the mindfulness group reported lower levels of depressive symptoms, self-hostility, negative affect, negative coping, and rumination. The mindfulness participants also showed significantly lower levels of posttraumatic stress symptoms.

A wealth of recent evidence strongly suggests that practicing mindfulness can improve both physical and mental health. Better yet, there are zero known side effects of this practice. So the next time you get a chance, why not take a minute to take a deep breath, give thanks, and observe where you are in the moment?

And while we definitely encourage joining mindfulness programs or reading books on the topic, we want to add a few simple techniques that are easy to add to your daily life. They can even be taught to children. These ideas are from The Mayo Clinic’s Guide to Stress Free Living:

Every morning, think of five people with whom you can share your gratitude. Instead of letting your mind think about what needs to get done or if you are late or what you should wear, let your first thoughts be Thank Yous for the people who make your life greater. This could be your friends, partner, parents, neighbors, teachers, children, or pets.

 Involve children. Tell your children or your nieces and nephews that you are thankful for them. Allow them to enjoy the practice of gratitude. They can give thanks with you (my kids practice gratitude at bedtime nightly. I was surprised when my 2 year old started chiming in along with his older sister. He started naming people he enjoys in his life… as early as age 2, kids can pick up on and participate in the circulating theme). You can also allow kids to deliver Thank You cards to a friend or teacher (or doctor!). This leaves a lasting positive effect on children.

Look at the bright side. This sounds easy but it can be difficult. Choosing to look at circumstances from the positive perspective can strain the mind. Mundane examples include paying taxes (hey, you earned money) or having to take care of your yard (hey, you have a home). But you can see how this is more difficult in heavier situations like personal illness or illness in a loved one (focusing on what you do have, rather than what the illness has taken from you). Regular practice can make this an automatic part of your overall attitude and view on life.

Keep a gratitude journal. Write down things (or one thing) that you are grateful for at the end of the day (or week). My husband and I keep a shared journal. On rough days when one or both of us needs a little reminder, we can look back on some of our entries and remember fun(ny) experiences or quotes from our kids or loved ones.



  1. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York, NY: Dell Publishing; 1990
  2. Jacobs, T.L., Shaver, P.R., Zanesco, A.P., et al. Self-reported mindfulness and cortisol during a shamatha meditation retreat. Health Psychol. 2013;32(10)1104-1109.
  3. Condon, P., Desbordes, G., Miller, and W., DeSteno, D. Meditation increases compassionate responses to suffering. Psychological Science. 2013;24:2125-2127
  4. Mills, P., Chopra, D., Redwine, L., et al. The role of gratitude in spiritual well-being in asymptomatic heart failure patients. Spiritual in Clin Pract. 2015;2(1)5-17.
  5. Goldin, P., Ziv, M., Jazaieri, H., and Gross, J.J. Randomized controlled trial of mindfulness-based stress reduction versus aerobic exercise: effects on the self-referential brain network in social anxiety disorder. Font Hum Neurosci. 2012;(6)295
  6. Sibinga, E., Webb, L., Ghazarin, S.R., and Ellen, J.M. School-based mindfulness instruction: an RTC. Pediatrics. 2016;137(1):1-8.

My Love-Hate Relationship with Antibiotics

Antibiotics are amazing. They can save lives. They can prevent horrible complications of infections, like rheumatic heart disease as a complication of strep infection. I prescribe antibiotics regularly. However, I also have many conversations about why I do not recommend antibiotics for various illnesses. I have to say, these conversations are generally longer and more difficult than writing a simple prescription for antibiotics. And when patients or parents (or my own parents!) give me confused or frustrated looks, I remind myself that my job is to do no harm and more and more we are learning that antibiotics are doing harm.

As you have no doubt heard, our use of antibiotics has swung to an unforeseen level. Our animals are fed antibiotics and this enters our food supply. Patients and parents feel like they need antibiotics to “get better faster” or “just in case.” Doctors fear they will lose patient satisfaction if they do not give prescriptions.

I am not against antibiotics. I just think that we all need to consider when antibiotics are truly necessary and when a tincture of time might do the trick. Here are a few things to consider next time you or your child or your parent feels under the weather:

Antibiotics kill the good along with the bad. When you take antibiotics to kill off unhealthy bacteria, your gut’s healthy bacteria suffers collateral damage. We rely on these bacteria for more than simple gut health—our gut microbiome shapes our immune system, effects mental health, obesity, and heart health. Recent data suggests autoimmune illnesses such at inflammatory bowel disease and juvenile idiopathic arthritis are related to antibiotic exposure in childhood. In extreme cases, the balance is so upset that secondary infections like C. difficile aka C. diff can arise from antibiotic use. The importance of healthy gut bacteria is so great that treatment for C. diff infections now includes fecal transplant, ingesting another person’s healthy microbiome to restore the healthy balance. Fecal transplant is now being studied for all sorts of ailments, from metabolic syndrome/obesity to cancer to resistant infection.

Resistance. I will not go into this too much as most people are familiar with this concept. Simply stated, bacteria can develop properties to resist the antibiotics used against them. When our bodies are exposed to antibiotics, we then harbor antibiotic-resistant bacteria, at least for transient periods of time. We have antibiotics that can defeat some of the known resistant bacteria but certainly not all. This is especially problematic in older patients or people with chronic illnesses who are repeatedly exposed to antibiotics. In cases when antibiotics are a must, consider discussing course duration (more and more we are learning that we can do shorter courses) may help minimize exposure.

Viruses are normal. Most illnesses, adult and pediatric, are viral. Viruses help develop our immune systems, which is especially important for children. Antibiotics will have no effect on a viral infection since antibiotics work against bacteria, not viruses.

Time can heal many things. Ear infections, for example. We know that we over treat ear infections. Data shows that many ear infections are viral. Even pneumonias appear to be mostly viral. However, as physicians, we cannot always distinguish between viral and bacterial infections. As a patient or a parent, you can ask your doctor or health care provider about “watch and wait” options. You can also read about home remedies and ideas for prevention for common cold symptoms.

Prevent illness. Vaccinate your child. The most important reason we can offer more antibiotic-free options for kids is because of vaccines. Many of the bacteria (like pneumococcus in the Prevnar vaccine), that caused more significant ear infections and complications of ear infections, are just not around thanks to the vaccines.

Tell your doctor you would like to avoid antibiotics if possible. It is fast and easy to write a prescription and many doctors feel that patients come expecting antibiotics. In my own practice, parents often come in saying their doctor gave them antibiotics, implying that the child has the same need. This is a very difficult situation. Data on over-prescription of antibiotics, especially in the adult population, is frightening. Over-prescription in pediatrics seems to be improving (though I only found data from 2002). Perhaps because parents worry more about their children’s gut health and immune health than their own. Or perhaps it is because of adult doctors’ perceptions of their patient satisfaction. In pediatrics, an old but nice study involving kids with upper respiratory infections (colds) reveals that parents actually leave more satisfied without a prescription for antibiotics, as long as the doctor outlined a contingency plan. I think an open and educated discussion with your health care provider is always worth the extra few minute.

Replenish your gut. If exposed to antibiotics, our gut can restore itself. It takes time (1 month to 2 years). Eating fresh foods, high fiber foods (natural fiber, like vegetables, fruits), cultured foods (like yogurt), and fermented foods (like kimchee, sauerkraut) can help keep your gut fill itself with a variety of species. Exposure to animals and dirt probably helps as well. I generally recommend taking probiotics when on antibiotics. Lactobacillus rhamnosus aka LGG is readily available over the counter. In studies, it seems to help some people with antibiotic-associated diarrhea and stomach upset. For patients taking multiple courses of antibiotics or very strong antibiotics, I may recommend a blend of probiotics to help prevent C. diff. For those of you interested in more on the gut and microbiome, try The Good Gut.

Getting Your Kid to Eat Your Food (assuming you eat healthy food)

Multiple times a day I hear stories of picky eaters, battles over food, and the resultant parental stress. There are books and articles galore on the subject, but for those of you who just want a quick read, here are some thoughts and strategies. If any of you have ideas to add, please feel free to post them!

And don’t feel bad for minor indiscretions here and there… it is the everyday that counts. Once in awhile treats and slip-ups are normal. How you approach food everyday and what is available for us to eat everyday in our homes is what matters most.

Have kids help you in the kitchen. Kids can do many things with you in the kitchen: pull leaves of greens off stems, break  apart broccoli florets, pour spices, grind spices or nuts using a mortar and pestle, transfer chopped veggies into a (not hot) pot, and cut. For smaller kids, you can use cookie cutters or purchase kiddie choppers that are smaller variants of cookie cutters. Let them taste the foods—even the spices. Or better yet, watch them slyly as they sample the food they are responsible for preparing.

Show them where food comes from. Maybe a little garden? Data (mostly from school and community based nutrition programs) suggest that kids may try more new foods if they grow it. This is also a fun project for a parent and child to work on together. It does not have to be extensive… even just some basil, mint, garlic chives, or oregano. They are full of delicious phytonutrients, grow fairly easily, and kids will learn about food growth. They may even pick some while playing in the yard and chew on it. Yay!

Picking and eating your fruits or veggies (which includes herbs!) when they are ripe adds nutritional value as well. Store-bought goods are often plucked prior to ripening for hardiness during transport. (note: I must give my husband full credit for creating and running with our garden project over the last few years. Our kids love it. I love it. And in case you are looking for an “urban garden,” I have one and it is awesome. This one is particularly expensive. I received it as a gift, and our gardening experience literally blossomed.)

Have one meal for everyone. I mean, for the most part. Kids should not be served mac and cheese or hot dogs or even “healthy” chicken nuggets while parents are eating salmon and broccoli. One, this is way too much work for the person creating the meals at home, and two, this teaches kids that their food is somehow different from that stuff that grownups eat. The whole point is to eat real food. Obviously, this is easier if you start during infancy, but even if you don’t, you just have to go through a painful cleansing of the pantry/freezer and then stick with it. Once you make the decision, you hold a family meeting, list the things that will not be replenished once they run out, and tell the kids to prepare themselves. It may be a week or two of annoyed looks and angry demands, but eventually your child will learn that you mean business. You are the boss of your child, as it turns out.

For babies, give them real food real early. That is, transition between 6 and 9 months to table foods. I always say that by 9 months, your kids should be eating a non-choking hazard version of whatever you are eating (which is hopefully healthy. And if it is not, well, kids are the great motivator to clean up your own diet!).  At this age, kids are curious. Food is exciting. And if you capitalize on their curiosity, you may get a kid who enjoys spices (yes, spices are healthy: turmeric, black pepper, cilantro, parsley, thyme, oregano). If you are worried about salt, just under-salt the food a bit. I was happy to see a recent study that supported my recommendation of feeding your kid all sorts of foods (I mean, I say go for it. Indian food, Thai food, Ethiopian food… after all, that’s what kids in those countries are eating! And veggies with flavor taste so much better than steamed-pureed mush!). Don’t worry about your child’s expression. Just keep offering and feeding.

Role Model. This is known. You can’t be eating chips and drinking soda and then say no when your kid asks for some. Parents must avoid the junk, and they must eat (and enjoy) the fruits and vegetables themselves, just like they have to wear helmets, seat belts, and all those other things that are good for prolonged health and life.

For toddlers, give them some independence. They may not want to be stuck in a highchair. You may have to negotiate a little. Let them eat at their own little table. Put a blanket or towel underneath so you are less worried about the mess.

Please no TVs/iPads/screens. It is known in adults that watching TV while you eat really blunts the brain’s ability to acknowledge satiety. Hence the term  couch potato. You just keep eating. We want kids to learn to listen to their hunger cues. Kids need to stop eating when they feel full and eat when they are hungry—not  just because they get to watch a screen while a parent shovels food into their mouths!

Options are ok, but they should be equally attractive/healthy options. For example, if tonight’s dinner is not suitable, how about last night’s? The major point here is that if a kid knows that his parent will make him a “kiddie” alternative, then he or she will more easily say no to a meal. However, if kiddie alternatives simply do not exist after aforementioned pantry/freezer cleanout, then food refusal will be less common. Or it may be because he is actually not hungry. And that is fine too, as long as he knows that if he gets hungry, that meal will be waiting for him—not an alternative.

For those interested in further information:

Sick of Being Sick – Home Cold and Flu remedies

My husband keeps complaining that he is sick of being sick… well, winter is here, and as I keep telling my patients, it is the Venn diagram season of viruses. We are still seeing summer viruses and the winter viruses seem to be in full force.

There is not one surefire method of preventing or treating viruses, but here are some tips (aka phrases I repeat to patients, friends and family!):

Wash your hands. Hand washing is clearly critical. When you cannot wash well with soap and water, use a hand sanitizer. There is no need to use harsh anti-microbial soaps like those containing triclosan. They are not superior, and they can irritate skin (as a side note, they are bad for the environment).

Don’t touch your face. If you touch your face, those germs on your hands (from the keyboard, the phone, the last doorknob you touched), are now near your eyes, nose and mouth. You just brought the enemy to your doorstep.

Cough into your elbow. This way, the viral particles you are coughing are less likely to be on your hands, so when you go to the water cooler, remote control, grocery cart… you will be less likely to leave behind a viral load for the next guy.

Sleep. Chill for a minute. Sleep boosts your immune system. Stress is hard on your immune system. Couples who fight more tend to get more colds. Med students’ immune marker levels go down during exam time.

Zinc. Zinc helps boost the immune system. Studies suggest that zinc lozenges, if taken at the onset of symptoms,  may reduce the duration of colds. In adults, about 30 mg a day of zinc may do the trick (that would be six 5mg lozenges). There is not really good data on kids. If your child is old enough to take lozenges (since they are a choking hazard), I would try 15-30 mg a day, depending on the age. Zinc can upset the stomach, and too much zinc can be harmful, so please talk with your doc if you are going to try this.

Echinacea, vitamin C. No good data to support this.

Vicks VapoRub. The menthol in it does something. Parents give improved cough ratings when they use this on their kids. I always remind parents to use menthol rubs under clothes to prevent a child from getting it anywhere near his eye, nose or mouth.

Elderberry. Now this is my new favorite. There are a few studies, (even a double-blinded, controlled one!) that show really remarkable effectiveness of elderberry, especially when it comes to fighting influenza.  In vitro, it appears that elderberry has anti-viral and anti-oxidant properties. I cannot offer a standard dose, but based on the one small study, an adult could take elderberry syrup, about 15 ml, four times a day for 5 days.  Again, talk to your doctor about this, especially if you are giving this to a child. There are lozenges that contain both elderberry and zinc. That is what I keep at home. Please note that elderberry comes from a plant, Sambucus. Eating the plant parts can be toxic, so don’t try to make your own elderberry supplements at home!

Honey. Buckwheat honey in particular has been shown to reduce cough and night time cough. The studies were done with just eating the honey. I tell parents they can spoon feed it or mix it in warm water and make a little “tea” for their kids. Remember kids under age 1 are advised to avoid honey consumption.

Saline. Huge fan. I recommend a sterile mist-spray  with “normal saline,” or 0.9% saline. This is well-tolerated by small kids and adults alike. Use this as often as needed. Spray and blow. If your child will not blow, just spray it up there (and you do not need to stick the nozzle up your child’s nose. Just place it underneath his nose and spray. It will shoot up into his nostril and if he shakes his head in violent protest, you will not have ripped a nostril). I recommend one separate canister for each person in the house. During dry East Coast winters, I use this even when we are healthy. Just to keep the nares moist—especially for small kids who do not blow as well and who may stick a finger up there to get the dried, crusted booger. Then you get yourself a nosebleed. Note: read the ingredients to ensure it is preservative free. The preservatives can hinder your body’s natural ability to clear mucous.

Oscillococcinum . I have not tried this myself, but a recent-ish (2009) review found that its use may reduce flu symptoms by 0.28 days.

Probiotics. Lactobacillus and bifidobacter may help out… more and more data on probiotics. Difficult to say how much or which type since there are so many different ones out there. My general advice is: if you are going to take a probiotic, make sure you buy it from a place with high turnover. These are live organisms, and if they have been sitting at your local drug store for 2 years, you may be better off going to a health or natural foods store.


Stop bugging me

With warm weather come mosquitos and ticks and reports of various vector-borne illnesses like West Nile virus, Chikungunya, Dengue,  and Lyme disease. You West Coasters are lucky to have fewer of these pests but the rest of us need to keep up with our bug spray trivia in order to best protect ourselves and our children.  Here are some basic facts and resources on insect repellents that I hope you will find helpful:

DEET? Or Picaridin? Depends on how long you need it and what pests you are aiming to repel. Both have excellent safety profiles. DEET has been around for 50 years, and the cases of bad outcomes are almost always associated with improper use (ingestion, over-application). DEET products have a longer duration and are more effective against ticks.  However, picaridin goes on more easily, does not damage plastics or synthetic clothing, and is equally effective against mosquitos (keep in mind it has shorter duration). The EPA has a fantastic search tool that will help you pick the best option for your needs. For example, if you are looking for a picaridin product that is effective against mosquitos and ticks for a 4 hour period, you will find several options. However, if you decide you want a picaridin product lasting for 12 hours, you may find only 1 option.

There are also other EPA registered products but DEET and picaridin are the most common and most effective when it comes to efficacy and duration.

Citronella and other more natural products. Unfortunately, citronella-based products have a very short duration of efficacy against mosquitos (i.e. less than 20 minutes) and they are not effective against ticks. I do keep the citronella sprays around if they are needed for a short duration, keeping in mind that if you really want to protect against mosquito-borne illnesses, you should pick a DEET or picaridin product. The New England Journal did a comparison study several years ago. At that time, the best natural product was a soybean oil preparation. It lasted for a mean time of an hour and a half. The DEET-based products lasted approximately 90-300 minutes, depending on concentration. Wrist bands… pretty dismal results. At best they lasted a few minutes. So far, there is no good evidence for the electronic devices either.

Oil of Lemon Eucalyptus (chemical name P-menthane-3,8-diol aka PMD) products. These are also very effective in higher concentrations. They have not been tested in small children and thus should not be used in kids under age3. Also avoid contact with eyes and face, especially in children.

Combination Products. It is best to use a separate sunscreen and mosquito repellent. This is mostly because sunscreens need to be pre-applied and frequently reapplied , whereas repellents, especially DEET-based products, should be used when needed and then washed off. For those interested, here is my refresher on sunscreen use.

Ticks. Best to use a DEET product. If you live in a tick-infested area, de-tick yourself and your kids every evening. If the ticks are removed in a timely fashion (generally, less than 36 hours), you have minimized any chance that the tick will transmit disease.

For the hardcore. If you are traveling to the Amazon or live in a heavily tick-infested area, you may want to look into permethrin-treated clothing. Permethrin is an insecticide and repellent. You can purchase clothing that is treated or buy treatments that you can apply to clothing. These treatments can last through several wash cycles.

You may already know these tidbits but just in case… For application to the face, spray repellent onto hands and then dab onto face and ears. Wash your hands and kids’ hands after application of insect repellents to avoid contact with mouth and eyes. Avoid use on cuts or broken skin. Do not use under clothing. Wash off after use. For mosquitos, avoid the dawn and dusk hours outside. Dress in full-coverage clothing. DEET should not be used in kids under 2 months of age.


The latest on how to start solid foods

One of the most common discussions I have with patients revolves around starting solid foods. Given the many changes recommended over the years, I would like to give my basic suggestions and some of the logic behind them. For more information regarding the timing of solids, see my prior post on introducing nuts and wheat (also, stay tuned for a new post with specific timings for certain foods). As is always the case, recommendations may differ for individual circumstances. These recommendations are in general accordance with the American
Academy of Allergy, Asthma & Immunology

Step-by-step basics:

  • Start between the ages of 4 and 6 months.
  • All foods should be pureed. As your baby can handle more textures, you can advance from purees.
  • You may introduce water from a cup (not from a bottle). Babies can and should have small amounts of water with their solid food meals. This is usually only a few sips at a time which is why you should not use a bottle. There is no need to introduce juice to your baby.
  • Start with any pureed food. I generally recommend avocados (for their healthy fat and ease of preparation), lentils (for their iron and protein) or a grain (also has some iron and protein when given in its whole grain form). You can make your own pureed wheat or oatmeal cereal. Click on those links to see how I make mine.
  • Start with a tablespoon or 2. Feed your baby until he seems to lose interest. It may take a few attempts for your baby to learn how to use a spoon. If your baby uses a pacifier, you can use it to teach your baby to eat (that is a video of my first child learning to eat). After the first one or two attempts at feeding, you should no longer need to use the pacifier to help.
  • Add one new food every 2-4 days. Remember your baby’s gut will be adapting to new compounds as new foods are introduced, and even though this is a good thing, your baby may need a little time to adjust.
  • I recommend offering pureed foods in between milk feedings. A breakfast feeding may be at 8:30 or 9 am if your baby has milk at 7am and then again around 10 or 11. This way, the baby is not super hungry and frantic, looking for what he really wants (milk). But he also is not stuffed from a recent feeding.
  • At first, your baby may appear to eat solids while drinking just as much milk as before. This is normal. As your baby develops, he will eat more volumes of solids and advance to table foods. This will naturally bring down his milk intake.
  • Once your baby tolerates some less allergenic foods, like grains and vegetables, you can introduce any food, including the highly allergenic foods, like eggs, nuts, dairy, soy and fish. Keep in mind that nuts pose a choking risk, but nut butters are generally ok. For some babies, however, they are very sticky. It may be helpful to offer them in small amounts on a grain, like a finger-food cereal or small pieces of toast or cracker.
  • Some foods, like citrus and berries, may cause a little redness around the mouth or even hives. Reactions like this may not be true allergic reactions. However, if your child reacts to any food, discuss it with your health care provider before trying it again.
  • Don’t forget to advance your baby’s schedule. Offer purees once or twice a day at first. By 9 months, most babies are eating 3 meals a day, including finger foods.
  • The consistency of foods also should be advanced. With time, sometimes even just a few weeks, babies may be able to handle thicker textures and eventually table foods.


  • Please make sure your baby is getting iron-rich foods. This is an essential nutrient, and after age 4-6 months, babies rely on solid foods or iron supplements to maintain adequate iron stores.  Commercially prepared cereals offer a convenient source of iron. They may be nice to have around to mix with other foods if your baby is not eating naturally occurring sources of iron, like meats, legumes, or dark leafy greens.
  • Remember healthy fats, especially in formula-fed babies.
  • The only foods you must avoid are choking hazards (e.g. nuts, hard carrots, whole grapes, popcorn, hot dogs—everyone should avoid hot dogs, if you ask me).
  • If your child has an adverse reaction to any food, discuss it with your health care provider before trying it again.
  • If your child is at high risk for a peanut allergy (sibling with peanut allergy), talk with your pediatrician about it. In general, you can probably still introduce peanuts at home, but some situations may warrant a visit to the allergist prior to introduction.
  • Try new foods at home, especially highly allergenic foods. You don’t want to be at a restaurant if your child has anadverse reaction!

Wheat cereal

What you need:                                                                                                                                       Cracked wheat… 1 cup                                                                                                                            Water… 3-4 cups                                                                                                                                             A pot                                                                                                                                                   Immersion blender or blender

What to do:                                                                                                                                                  Rinse 1 cup of cracked wheat with water. Then place it in 3-4 cups of water. Bring to a boil. Bring it to a simmer and cover for 25-40 minutes. Let cool. With an immersion blender or food processor, puree the cereal. If necessary, add water, breast milk, or formula to reach desired consistency.

Unused cereal can be stored in the refrigerator.                                                                                    As kids get older, wheat cereal may be cooked in milk rather than water.

Makes approximately 2 ½ cups.

Oatmeal cereal

What you need:                                                                                                                                       Steel cut oats… 1 cup                                                                                                                            Water… 3-4 cups                                                                                                                                             A pot                                                                                                                                                   Immersion blender or blender

Option 1… prepare and serve: Rinse 1 cup of steel cut oats with water. Then place it in 3-4 cups of water. Bring to a boil and then a simmer. Cover for 25-40 minutes or until it reaches desired texture. Let cool.

Option 2… soak the night before: Rinse 1 cup of steel cut oats with water. Bring 3-4 cups water to a boil. Then turn off stove and add the rinsed oats. Cover. The following morning, bring the pot to a boil and then a simmer. Cover for 10-20 minutes or until it reaches desired texture. Let cool.

With an immersion blender or food processor, puree the cereal. If necessary, add water, breast milk, or formula to reach desired consistency.

Unused cereal can be stored in the refrigerator.                                                                                    As kids get older, oatmeal cereal may be cooked in milk rather than water.

Makes approximately 2 ½ cups.

So How do I Eat a Mediterranean Diet (and do I really need to)?

Study after study supports the benefits of the so-called Mediterranean Diet (MeDiet),  but most of us do not know exactly what that means—or what key changes we can make to move from the Standard American Diet to this mysterious and wholesome MeDiet.

In this post, I hope to summarize the New England Journal of Medicine (NEJM) study, and then give some tips on incorporating a Mediterranean lifestyle. Feel free to jump to the Take Away Points if you are short on time.

First off, this study is fascinating. For those more geekily inclined, please have a look. For the rest of you, let me briefly summarize. This was a prospective, randomized, single-blinded study. The study enrolled about 7500 participants between the ages of 55 and 80 who were considered high-risk for cardiovascular disease. The enrollees were divided into 3 legs: The first group was advised to eat a MeDiet and incorporate olive oil; the second group was advised to eat a Mediterranean Diet and incorporate tree nuts; and the third group was told to eat a low-fat diet. This study looked at the number of major cardiovascular events (i.e. heart attacks and strokes) in each group. As it turned out, both MeDiet groups fared better than the control, low-fat group. In fact, the nut group fared better than the olive oil group. Below are the lessons I learned from this and similar studies.

Take Away Points:

Spend money on olive oil. The MeDiet is a high fat diet, with something like 40% of calories coming from fat. However, these are healthy fats and the majority of this fat comes from olive oil. But olive oil is more than just healthy fats. Unrefined, first cold pressed olive oil is rich in polyphenols and other antioxidants, whereas refined oils lose these healthy chemicals. In this study, the olive oil group was given olive oil and told to eat 4 tablespoons (yes FOUR tablespoons!) per day (they even checked the participants’ urine to make sure they were actually eating the olive oil).

Nuts are the best snack, especially walnuts. Filled with healthy fats (omega-6 and omega-3 in walnuts), some protein, and micronutrients, nuts have been known to increase longevity and can replace less healthy snacks. In this study, participants were asked to eat 30 grams (about an ounce) of nuts a day: 15 grams of walnuts, 7.5 grams of almonds, and 7.5 grams of hazelnuts. Three types of nuts were given due to nuances in funding/donations, but more walnuts were given due to the previously recognized benefits of walnuts. Keep in mind that this is not a large volume. Nuts are very calorie dense—a small handful goes a long way. You can eat nuts solo as a snack or put them in foods, like walnuts in salads or pine nuts in pasta.

Eat more legumes. What are legumes, you ask? Legumes are a family including beans, lentils, alfalfa, soy, peanuts. Most of us do not think of a typical Mediterranean Diet to include beans, but in fact it does! This makes vegetarians like me very happy, since legumes are high in protein and iron, and probably provide various phytonutrients. Regular consumption is a healthy alternative to meat-heavy diets. The MeDiet group was asked to eat at least 3 servings of legumes per week.

Eat more fish. The healthy fats in fish, omega-3 polyunsaturated fatty acids, have been studied for their cardiovascular benefits as well as mental health, obstetric health, and anti-inflammatory benefits. The results are mixed, but it seems, at least for cardiovascular benefits, that consuming only the isolated fish oil is not the same as eating fish. It is probably the combination of all the nutrients in the fish that portends benefit. The NEJM study advised at least 3 servings of fish per week.

Have that glass of wine. Drink it with a meal. Binge drinking does not count.

Avoid dairy-based spreads. Yes that means butter and cream cheese. Eat dairy in moderation.

Make your own salad dressing. No need for low-fat dressings when real unrefined olive oil is where the nutritional value rests. My mother-in-law gave me a great and simple recipe: ½ cup olive oil, ½ cup vinegar (red wine, balsamic or otherwise), ¼ tsp of salt. Then add pepper, mustard ,  garlic, or herbs to flavor. You can vary the acidic content with lemon juice or flavored vinegars.  It can be stored in the frig for weeks.

Eat less red and processed meats. There is a wealth of literature supporting limited consumption of red and processed meats. Everything from reduced cancer risk to reduced cardiovascular mortality. New research suggests that red meat eaters harbor gut bacteria that produce a pro-atherosclerotic (i.e. bad for your arteries) chemical. This study recommended eating white meat instead of red meat to the MeDiet groups.

Obviously, eat lots of fruits and veggies. This is a crucial part of the MeDiet and hopefully an accepted, though probably not practiced, aspect of the Standard American Diet. The study advised at least 3 servings of fruit at least 2 servings of vegetables daily.

Why does this matter for kids? Start with the good habits early, including an anti-inflammatory diet from a young age. And kids will eat more veggies if they taste good, so cook them in olive oil rather than steaming. Healthier and tastier. Another recommendation given to the MeDiet groups in this study was to eat sofrito. Sofrito is a base used in Mediterranean cooking, usually consisting of tomatoes and onions sautéed in olive oil over low heat. You can also add garlic, ginger, seeds, or spices. For example, the Indian version, tadka, usually contains cumin, mustard seeds, fenugreek seeds, and/or spices, all of which contain various phytonutrients.

(Just for those who were wondering, I am clearly not encouraging alcohol consumption in kids. That one is for parents, but do incorporate the rest for the entire family!)