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First Years Pregnancy Sep 19, 2019
19 Minutes

Ask the expert: We talk to top paediatrician on the big themes and what as parents/parents-to-be we can do to be as healthy as possible!

We are always looking for leading experts in their fields who approach having and raising children in our modern world in a proactive, open minded, big picture way. Most crucially, we want to speak to those who dont just treat symptoms when they arise but who really want to get ahead and take prevention as seriously as possible. Lucky for us, our special guest for this article and podcast takes exactly this approach!

We have been lucky enough to chat with leading US based paediatrician Dr Mona Amin (aka @pedsdoctalk). We talk to her about everything from what she is seeing more in her practise (autism, allergies and ADHD), to the gut, to screen time, to breastfeeding and most importantly what are the evidence based things that you as a parent or parent to be can do to maximise the chances of having healthy babies. We also ask Dr Mona herself (who is expecting her first baby) what she does as part of her own routine.

Click here for the podcast version or search ‘The Journey’ on all major podcast providers: below are the key highlights/what you need to know from our chat:

First and foremost: what was it that first inspired you to get involved in Pediatrics and why?

I had dreams of becoming a paediatrician since I was little, I was always fascinated by medicine from an early age, my mother was in the healthcare field and I saw first hand what it was like was to help people. So, I knew early on that medicine was my path. Then as I went through medical school, and the different rotations, I fell in love with Pediatrics. I am very into preventative medicine and I thought what better avenue to do that through than Pediatrics. Starting children and their families young with good habits and healthy choices is one way you can can really truly help with long term health health.

The world looks very different to the one that existed even a few years ago, what are some of the trends you’re seeing more of now in your practise vs when you first started? 

I am seeing a lot more of three things in particular:

There is a debate here as to whether some of this is better diagnosis or are we actually seeing greater incidence of this. What is your view? 

I do think there is a case for better screening vs decades ago, autism is one for example particularly regarding some of the higher functioning parts of the spectrum that may not have been diagnosed in the past. However, on the flip side there may also actually just be more incidence alongside this driven by a number of different factors.

Ok, so outside of better screening, what do you think is driving some of this increase? 

Ok so at the moment there is a lot of research and debate on autism. Personally, I am seeing a few trends, related to genetics. Firstly, I certainly see that link between siblings or first degree relatives and I do see it running in families. The question is however: where is that gene(s)? As it stands we have not pinpointed this – it could be from a mutation, it could be from the egg/sperm, at this stage we are not sure. People want a simple blood test of course, but the reality is that so much of medicine is just not that simple and when it comes to autism for example it is truly multifactorial (meaning many potential causes). What we do know is that statistically boys are 4x more likely than girls and very preterm babies are also increasingly predisposed. The big area of interest for me is advanced paternal and maternal age which I am seeing. It may well be impacting eggs/sperm and is an area under a lot of research currently, so watch this space. I certainly will be keeping my followers up with the latest goings on.

You talk about genetics and lifestyle change, are you referring to epigenetics here (the science behind how our environment impacts gene expression) as a potential cause? 

Yes, I think it has a huge effect, our genes control so much of who we are and it is an area of a lot of research. Click here for more.

What do you say to parents who may perceive an increased risk, what (if anything) can you do to reduce your risks? 

At the moment there just isn’t enough information, the unknown is a difficult reality, there is unfortunately a lot of our minds and bodies that unfortunately we can’t actually control. It is hard as a go-getter and with a lot of information out there to accept but for now this (and other cases) is where all we can do is to live our best healthiest lives and hope for the best.

You also said you were seeing a greater incidence of allergy? Why do you think this is? 

These are my theories, and this is just based on what I see, my research and what comes into the office. Firstly, once again there is incidence of family history/genetics, but I also see where there is none. My main theory here is the germ hypothesis (click here for more). My sense is that somewhere along the way we have become fearful of germs. We don’t want our kids to get sick, we overwash, sanitise, bleach etc and I see a lot of this. A kid drops a pacifier on the ground and immediately we have to wash it. We have this terror around germs. However, a lot of our immune health and system comes from our guts. When babies and kids swallow germs it can actually have a big effect, it creates antibodies and it helps develop immunity. I always joke with my families let them eat germs, let them play, get dirty and be kids. In a way it can help. However, it also applies to the parents too. The whole microbiome is the mother too – so it has to be parents who adopt this approach too – it is all connected. Antibiotic overuse has become part of that theory and many people ask for and push antibiotics which is another huge issue.

It does seem as though we have become conditioned to want a ‘pill’ to fix everything especially with antibiotics: is that what you’re seeing? 

Yes I am seeing this. When I work in Urgent Care in particular, when people come in later after work and are tired, they often don’t want to hear you have to ‘wait it out’. Often people want something to be prescribed. However, I still have a lot of integrity and I find it hard to prescribe something that is not necessary. However, unfortunately medicine is increasingly becoming ‘customer service’ based which basically means do what the family wants, however I want to practise ‘clean medicine’, when I say that I mean evidence based and what is needed and not overuse/prescribe. It is hard and there can be a disappointment, many patients say that the antibiotic makes the child feel better. However, much of what I see in terms of minor childhood illness is viral so the effect that they see is either placebo or anti inflammatory (some antibiotics have anti inflammatory priorities). Children’s bodies are amazing and can recover fast. There are some situations of course when antibiotics are needed and I find it unfortunate to see overprescribing.

As you say, the majority of minor childhood illness is viral: there does seem to be misunderstanding around this: 

Honestly, 90% of the common illnesses are actually viral which an antibiotic won’t cure. The trouble is that Viruses can take from 3 days to 4 weeks to break (coughs/diarrhoea symptoms for example) unfortunately though there is little patience these days and that applies to waiting for the doctor and treating the illness, people want something to take home. However, my big focus as a doctor is understanding when to be concerned – it is always on my mind to ascertain if i need to treat or can I monitor.

So, the key message: a lot of these things are viral and trust if a doctor is not prescribing an antibiotic, then it is a good thing. Is it not the case that overuse of antibiotics too much use not make you more susceptible to further infections? 

Yes, I see this. Ear infections are a good example of this. The guidelines keep changing and now a lot of doctors recommend ‘watchful waiting’ for ear infections meaning a long time ago when we were children, you would get one ear infection and immediately you would be prescribed an antibiotic. However, now, I am heavily (not just me) doing watchful waiting which means we don’t start it unless it persists, heavy persistent fever and intolerable pain. I see it. Once you get one antibiotic round, that cycle starts, and it often follows with back to back viral infections that keep coming because they got treated once. Antibiotics will depress your immune system as will a viral infection so then it becomes a double whammy, you get sick an antibiotic gets put on and the more we keep putting antibiotics on to delicate young immune systems for children they are more likely and can be to keep getting sick until their gut health and flora comes back.

You also mentioned that it matters what the parents do when it comes to immunity. We have become a generation to reach for the hand sanitisers. The research is more that the immune system of the child begins to build in utero. What other factors impact this? More C-Sections, Breastfeeding etc? What are some of the things as parents/parents-to-be we can do to preserve gut health and long term immunity:

I went to a lecture with a GI doctor in the states which I am fascinated by. A few of the things we spoke about is how complex the microbiome is, genetics plays a part but we also talked about ‘what nature intended’ – ie. vaginal birth, non sterile and breastfed. This is the trifecta as to what is expected to be ‘perfect’ however it is also not that simple as genetics also plays a role. However, the mother’s microbiome also matters. I am pregnant myself: I was born via C-Section, was formula fed, I didn’t receive antibiotics however but my microbiome is different to my sister’s who was breastfed so you as a mother will be influenced by that. One piece of advice however is if a C-Section has to happen or formula has to be given I never want a mother to feel like that was a negative thing as sometimes for safety of mum and baby it is necessary. There is an area of understanding that it could impact the baby’s gut. Can probiotics help? There is some research coming out that it may help, but at this stage it is selective, and not enough to suggest that all mothers and all babies should take them. Click here for more. 

As you say, the research is still rapidly evolving, what is your view however regarding eating probiotic foods and how as a mother your diet can influence the microbiome vs taking OTC probiotics? 

I am a big believer in this. Even prior to conception and during pregnancy: diet, stress reduction, nutrition and exercise are so important for a woman. You’re right the foods that we eat have a huge impact. I eat a lot of yogurt with probiotics, Kefir and Kimchi. I agree that is what we should be doing we should go to nature rather than supplements.

You also talked about breastfeeding, we know the benefits, but you made a good point about how difficult this can be for a mother. What’s your view as a paediatrician?

I always wonder how much, particularly in the US, we do a good job of supporting breastfeeding mothers. For several reasons. Firstly: the maternity leave policy is not the best and some mothers find this highly stressful, even for me, when I go back I will have to pump between my patient load and I see 40 patients a day. I do believe that stress has a huge effect on a lot of things, including breastfeeding. That can have an effect on production. I am big on support if you want to breastfeed. It is an individual choice and for the mother’s that actually want to I will work with them very closely. Putting them in touch with a lactation consultant and do breastfeeding classes alongside a specialist consultant in my practise because I am so fascinated and I want to maximise it for women and for babies as it does have a lot of benefits. Understanding what the barriers are is important: the two big issues are often the production and the latch – we then work with that issue and then track the weight to give reassurance. Sometimes we supplement with formula. When you are breastfeeding you need a cheerleader – postpartum is tough, the hormones, the sleep deprivation is tough so I am passionate about supporting women do this.

You mention that production can be an issue. Is there anything you’ve found from your observation. You mention stress: what else have you picked up that can help a mother who isn’t producing enough?

My classes are usually with women in their third trimester and stress is definitely a real issue. I say to these mothers: whatever you can do to reduce stress can have a huge effect, meditation for example. Stress as we know however is a hard thing to eliminate and is something hard to teach someone! I am very aware of that. The other thing is to stay very hydrated and eating – I know that sounds a little silly but what happens is that if a breastfed baby is initially a bit colicky the mother may start to restrict certain foods from the diet but my goal in the initial period is to have the mother eat and drink a lot. You need a lot of calories to breastfeed and that is important to eat and drink well. It is a basic thing but if that means having family members help out with food it is worth doing. You need to be fed so that you can feed your baby. We also talk about establishing a feeding routine which can help with production. Breastfeeding in the end is very physiologic, but there are barriers that come up – hormone release, skin to skin, sucking reflex that all helps the feedback mechanisms that says produce the milk and doing this more really can help. The more we feed the better. So, I usually have my mothers on an hour and a half, two and a half schedule so even if it means waking the baby up at night in the early stages it all helps establish production at least initially. A schedule can help build that initial production.

How long do you think it usually takes on average for production to kick in and get established?

That is a great question, I see babies from anywhere from 1-3 days old and I see the panic on the mother’s faces. At this point the mother is only producing colostrum and the baby’s tummies are very tiny at this point and they don’t need a lot to be ‘full’. I remind them that it can take even as much as day 5-8 for the milk to come in fully and it can even be later. Monitoring weight and being patient is a good start here.

We were discussing allergies before, some people may worry that their baby is not responding as they thought when it comes to breastfeeding and sometimes this may be due to allergies. What are some of the signs to watch for if you are concerned?

One common allergy in the very early days of course is a milk protein allergy (as obviously this is the only source of nutrition in the early days). It does exist and I do see it in patients, it is not super common. The tricky thing here is that there is not one exact/single symptom so when I talk about this allergy – one tell tale sign is bloody/mucusy poop and you need to share this with your paediatrician. If this is the case and there is suspicion your doctor may put you on formula free from milk protein and you as the mother will have to eliminate from your diet. That is a discussion that has to happen with the Pediatrician however. That being said there is not always this symptom and there are others to watch for:

If there are 1-3 of these things happening together you should speak to your doctor and investigate the cause. There isn’t always a blood/stool test so it is something we need to investigate alongside your doctor.

What about if you take something out diet-wise from an early age and you take it out can you make this a problem long term?

This is exactly why I like my families to ask about food removal from a diet before they actually do it. Like I said earlier, not all colic/reflux etc is milk protein allergy and if you remove and it wasn’t that then you can have issues further down the line. The good news is that with true milk protein allergy we are usually able to reintroduce it slowly further down the line, depending on the severity it can happen from 6mnths to a year. Starting with a small amount of yogurt/milk initially. I do see a lot of children outgrow this. It’s about working with your doctor to slowly reintroduce it over time. Communication is key. Talk to your doctor before removal of foods because so much of a baby’s GI health is not from the food that the mother eats it is a baby learning how to deal with gas/digestion, many mothers/parents want to remove things from their diet when it may not be necessary and could even do more harm than good.

You also mentioned that you are seeing more ADHD. As a society we also have anxiety around parenting and this seems to be rife too. Do you think there is more awareness/it is more acceptable to talk about it and why do you think it is happening more? 

So I agree that like the conversation around autism that it is probably a bit of both: more incidence and we are picking it up more. I go back to when I was a kid and when I was in school there was the ‘class clown’, they didn’t have a label of ADHD, the parents and teachers dealt with it and we didn’t have that diagnosis. People are more tuned to it, however, there is a lot of ADHD over diagnosed too. A lot of ADHD is being diagnosed as an intellectual disability and delay and it could even be a child who is struggling in their current school system and for whatever reason not understanding the material that is being discussed so is not focused. We are not really assessing this properly on occasions before medicating. Do we need more resources or a tutor for the child vs a label/medication. The other issue is I see a lot of poor boundaries with sleep. I talk to families whose kids have ADHD and I see sometimes that a child of 5 or 6 years old has no set bedtime, no boundaries and the child could be going to bed as late as midnight there is no bedtime and children need to sleep. If a child is not sleeping their attention span will be limited. That may lead to an overdiagnosis.

Screen time is another and one of my biggest areas of frustration. I get it, I will be right there with everyone else, but a child needs to be engaged as much as they can outside of a device. It is ok to incorporate it if you have had other activities through the day, there is a time that is ok for screen. My concern is when there is more screen than human interaction and that has a huge impact on a child’s neurological development. Especially in the first four years of life, even in the first two years of life screens have become very prominent and it is important to try and do other things before the screen because their cognitive input actually slows down when the screen turns off. I actually did a big piece on my instagram about this (check out dr Mona @pedsdoctalk on instagram) but when a child is a year old and looks at a screen for a prolonged period of time and you then take away that screen their cognitive processing skills are delayed so that immediate period after they are not really getting that input as clearly as they would had there been no screen. I really wish there was a better balance, it can be a good thing and I do see it used in a healthy way for kids over five for example, and I’m all aboard, the trouble is when it becomes ‘all’ and that is when it is concerning to me.

You said you see some parents use screens in ‘a healthy way’ – other than moderation (and how do you define this) what do you classify as a healthy way to use it? 

So, healthy way in my view is if you are watching something together. An example would be watching something whether it be TV or an iPad and you are asking the child questions about what you are seeing. I like that as you are allowing a child to look at a screen but also make it a point of learning and a social activity. Younger kids it is a bit more difficult ie. under 2 as you cant have that back and forth. If you are using for a younger child, using it sparingly, setting boundaries and ensuring you are prioritising far more human to human interaction. Using screen for 15 minutes a day, when you do the dishes etc is a good example of a boundary and stick to it is a positive way to do it. Ideally everyone in the family needs to be on board with it and enforce it.

Congratulations, you are pregnant yourself: as a paediatrician and given all your knowledge, what are some of the things (ex eating probiotic food that you already mentioned) that you are doing yourself to put you and your baby in the best possible position? 

This is something that I think is important for pregnancy but I also teach my teenage patients and their parents. A lot of the medical issues that I see (and my husband is an ER doctor so he too sees a lot of the long term consequences of choices that we make when we are younger: heart attacks/diabetes etc) a lot of these can be impacted by how we choose to eat, how we approach stress and if we exercise. I talk about this with all of my families If you can focus on the four parameters of:

That is the best set up for a healthy future where you won’t need a lot of meds and is the basis of health. It is what I am doing for my life myself and in particular for my pregnancy. For eating clean: what I mean by this I don’t think we eliminate the treats, but yes it does mean probiotic foods, but it also means avoiding processed foods as much as we can, which in some areas is tough, but also focusing on portion control  (including stress eating) but focusing on a good relationship with food. Stress is another big one. For me personally it is meditation and yoga, I meditate thirty minutes in the morning, I used to do ten minutes but I have recently managed to increase this and yoga once/week and exercise. Everyone, depending on their pregnancy can do different things and ‘exercise’ is a broad term. I am happy to be able to do yoga, HITT, weights and cardio mix helps me stay healthy and feel good. I really think it has an effect on the health of the baby to have a good and healthy regimen with exercise and eating right.

The other question as parents-to-be: when it comes to parenting you deal with lots of families and see lots of approaches. One of our listeners asked how do you approach the balance between authoritative and a more gentle approach? What is your thesis/position on this?

Great question. I am also curating my own parenting style and we may well change this as our baby grows, but I like the idea of taking little portions of each parenting style to create your own. I practise a more authoritative style but it can mean many things, to me it does not mean there can be no gentleness, it is however about boundaries but also showing love and affection and having back and forth with your child. I believe a child needs boundaries: things like screen time when a parent decides, bedtime when a parent decides, but there is also the give and take, especially as the child gets older. Asking the question: why didn’t you like this/that? Being inquisitive as a parent. Having a conversation with them opens up a more gentle approach. Acknowledging their autonomy as they grow, suggesting alternatives and listening to the child but ultimately in my view the parent has to be the decision maker. I am big on this because there should be distinctive roles: the child being a child and the parent being responsible. Our job as parents is ‘to parent’ and not just to be their friend. A lot of our generation seem increasingly to want to be their child’s friend more than anything and not wanting them to ever be upset with us. The reality is however that even if we did everything perfectly gently and in accordance with what the child ‘wants’ they are likely to still find things to be upset with us about so it is important to understand that it is difficult to do, but as a parent you are doing right by the child to set healthy boundaries. Consistency and evaluating as a team if you are lucky enough to have a co-parent then it is also important to pull together. Kids thrive when there is a lack of unity and will exploit it so consistency and pulling together as a united front is really important as a parent.

If you’d like to hear more from Dr Mona please check her out on Instagram @pedsdoctalk.

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This article is for informational purposes only. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The information on this website has been developed following years of personal research and from referenced and sourced medical research. Before making any changes we strongly recommend you consult a healthcare professional before you begin.

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