This week the American Academy of Pediatrics (AAP) came out with a new recommendation that children under age one should not be offered juice as a part of their diet. They also recommend limiting juice to no more than 4 ounces per day in toddlers and young children up to age 6 years and to only 8 ounces per day for age 7 to 18 years. Instead parents should focus more on whole fruit. Previous recommendations from 2001 and 2006 were more liberal and recommended that children under age 6 months should not be offered juice, and recommended limiting intake to 4-6 ounces daily for children ages 1-6 years and 8-12 ounces for children 7 years and older.
As a pediatrician I am happy that these AAP recommendations are taking a harder line on juice consumption in kids. For years in my pediatrics practice I have been telling patients that they should not give their kids juice, and I’m definitely not the only pediatrician who feels that way. But full disclosure, when my kids were much younger I used to buy a bit of juice and I kept it in the house for when they had friends over. Although my kids were not too interested in drinking juice, some of their friends were, and would consume a lot of it when they visited. I finally came to the realization that I was offering pure sugar to kids and that I could hydrate these kids cheaply and and in a healthier way with plain water.
As a pediatrician and founder of the Doctor Yum Project, I have become more keenly focused on how to prevent diet-related illness in children, like obesity and tooth decay, I would take the AAP’s recommendations a step further and recommend that parents do not offer ANY juice at ANY age within their home. It may be fine to let a kid have a juice box at a birthday party, but I tell parents that should consider NOT buying juice or bring it in the home. Here are my reasons why:
- Excess sugar promotes obesity. According to the American Heart Association kids older than age 2 should have no more than 6 teaspoons of “added sugar” a day but note that kids of all ages are consuming many times more than this. Although the sugar in juice is technically naturally occurring, juice is a processed food and there is nothing natural about a toddler drinking the equivalent of 12 apples-worth of sugar in one day. Although the AAP reports no direct correlation between fruit juice and obesity, in my practice I have collected growth curves of overweight children before and after I advise the parents to stop offering juice. These curves show a dramatic normalization of weight once juice is eliminated.
- Bathing the teeth in fruit juice causes tooth decay. Kids who are regularly consuming sweet beverages are at more risk of dental cavities. My messaging about no juice and other oral hygiene habits as resulted in startlingly low rates of tooth decay in my practice. Doctor Yum’s “No Cavity Club” is growing strong because parents know juice should be off limits at home.
- Fruit juice starts a pattern of craving sugary drinks. Get kids used to plain water and milk so they don’t look for the next sweet drink like sports drinks or soda. As an alternative in the Doctor Yum Project Cooking Camps we let kids drink fruit water. Kids can slice up the herbs and fruits they love and place them in a pitcher of water to give it some flavor, (without all the sugar).
- Parenting around juice can be challenging: Consider that toddlers are probably the most manipulative people the world. Their tactics of auditory assault, public humiliation, and pure persistence can break even the strongest of parents. If you bring juice into the home, the chances are your toddler will want more than four ounces of it, and in a weak moment you may give in. Why take the chance? Water is free or low cost, and you don’t need to worry about how much of it they drink. Instead of juice, offer whole fruit regularly to get key nutrients and fiber.
Here are recommendations I give my patients’ families when it comes to juice:
- Do not introduce juice to babies or kids of any age within your home. Once they are over a year, an occasional juice offered outside of the home is okay, and should be considered a “treat.”
- Avoid juice to avoid tooth decay. Teach kids to drink lots of water, especially between meals and keep your dentist bills to a minimum. Grazing on drinks other than water (even milk) can predispose kids to tooth decay. For sipping between meals, water is the best choice. Many parents ask about watering down juice but still has sugar and teaches kids to crave sweet beverages.
- In select instances juice can be medicine. For kids with constipation, fruit juice or a fruit puree may be appropriate to help manage constipation naturally. In that instance, treat it like medicine and give a limited amount according to your pediatrician’s recommendations. To help kids learn the distinction between juice for constipation and regular drinks like water, (and avoid any juice meltdowns,) place juice in a different cup and offer it at the same time each day like you would offer a medication.
- Whole fruit is superior to juice. Juicing a fruit can remove key phytonutrients (plant nutrients) including antioxidants that repair cell damage. In addition, so much or our health is controlled by our microbiome, the important world of microbes that resides inside us. When we eat whole, the fiber left behind fuels that microbiome, allowing us to stay healthy. Processed juices do not contain fiber, and therefore do not help sustain our microbiome like whole fruit does.
Pediatricians need to keep educating our patients about juice consumption, especially our higher risk patients. Some of my patients who receive WIC benefits are able to access juice using their benefits, which can be confusing for families. Knowing this, I take the time to educate them on why bringing juice into the home may put their children at risk for obesity and tooth decay and encourage them to teach their kids to drink plain water. As a community we need to look more systematically on how juice is offered at gatherings, schools, daycare camps and other programs and realize that water and whole fruit are better alternatives. Educating those who influence kids about this new recommendation may help us to keep juice consumption to a minimum.
Dear Yum Pediatrics Families,
For the past two and a half years I have enjoyed the privilege of taking care of so many lovely patients in this practice. Getting to know my young patients and their families is something I cherish, and I am grateful to all of you for allowing me to be part of your children’s young lives.
As many of you know I am also extremely passionate about my work with The Doctor Yum Project, a nonprofit organization I founded in 2012. Our mission is to teach families the connection between good food and good health with nutrition education and cooking instruction. Being able to learn from my patients in the exam rooms at Yum Pediatrics allows me a unique insight into how to help our greater community become healthy with good food.
Many of you also know that I am a wife and mother to two young boys. My husband and two sons have been incredibly supportive and understanding of the time and energy I put into my patients and my nonprofit work.
Managing my responsibilities as a physician and nonprofit director along with spending time with my family is challenging. As our practice has grown, I have been looking for ways to be able to give more time to my family and nonprofit work while still taking excellent care of my Yum Pediatrics patients.
It is for this reason all of us at Yum Pediatrics have decided to close the practice each Thursday starting September 22nd.
We feel that this is the best decision for all of us, our staff included, to find the balance we need to continue to take care of our patients in the best way we know how.
While we are closed on Thursdays, our phones will be answered by the Mary Washington Healthlink nurses as they are on the weekends. If you have urgent needs you may reach them at our usual phone number. You may send non-urgent messages through the portal, which will be checked once during the day. If you feel your child needs to be seen, we recommend the Peds Xpress on Salem Church Rd or the emergency room for more urgent needs.
We hope that you will not be inconvenienced by our new schedule and that you understand how dedicated we are to provide you the best care possible.
Dr. Fernando and the Yum Pediatrics Staff
At Yum Pediatrics we have made the decision that we are no longer able to provide injection visits for alternative vaccine schedules. We have accommodated some alternative vaccine schedules in the past, but as our practice is growing and changing it is no longer possible for us to do so.
Here are a few of the reasons for this decision:
- I am the only physician here at Yum Pediatrics. Many of you have chosen this practice because you want your family to know one physician and for that physician to know your family well. However, accommodating alternative vaccine schedules takes an enormous amount of my time and resources, which makes me less available to my patients. I love to be able to see patients for same-day sick appointments when they need me. However if many families request to receive shots over 2-4 visits when they can be done in one visit, it leaves less time in my schedule to see necessary same day appointments.
- Offering vaccines is incredibly costly. It is by far my biggest monthly expense. While most plans will cover the cost of the vaccines, it is never a guarantee and the reimbursement does not cover the specialized staff I need to administer vaccines safely, the price of the equipment, the upkeep to store and monitor vaccines, or the supplies to administer them. We also spend an enormous amount of unreimbursed time doing paperwork and site visits so that we can be certified to deliver vaccines to families who self pay or have state insurance. Offering alternative vaccine schedules multiplies these expenses, making the cost of providing vaccines unaffordable.
- By far the most important reason for this decision is that I feel I am not providing the best care for my patients when I agree to alternative vaccines schedules. The vaccine schedule endorsed by the American Academy of Pediatrics and the CDC is the most well studied way of providing vaccines and is proven to be safe. I would not recommend this schedule to my patients if I did not have overwhelming evidence that it was in their best interest. It is the reason that my own children are vaccinated according to the AAP approved schedule. My experience and training have proven to me that the recommended schedule is safe and provides vaccines in a way that minimizes vaccine visits, which are often a fearful experience for children. We have put a lot of thought into making this practice a fun place for kids and feel that increasing shot visits makes kids more scared to visit us. Also, when we delay key vaccines we leave unnecessary gaps in immunity to vaccine-preventable illnesses. As a physician I have a duty to provide the best medical care that I can, and when I use vaccine schedules that are not studied I don’t feel like I’m doing my best job for my patients.
Because we realize that parents have a lot of questions we have gathered information about vaccines from The Children’s Hospital of Philadelphia, a center that is a leader in information about vaccine safety. If you are interested in reviewing that informational packet give our office a call and we would be happy to provide it to you. If you decide that you would still like to pursue an alternative schedule then we may be able to suggest other practices that have the ability to provide that service.
Thanks for your understanding.
Nimali Fernando, MD, MPH
As a pediatrician I’ve enjoyed the power that social media has given me in communicating information to my patients and my community. However, recently I have been dismayed by the number of articles and videos I see shared on social media involving vaccines and vaccine safety. Many of these are videos and articles that discuss half-truths and even made up information about vaccines.
As the founder of The Doctor Yum Project I spend a lot of my time helping families prevent illness with a whole food diet. But as solo practitioner I have also made the decision to prevent illness by providing vaccines to my patients. I am comfortable with this decision because my training and experience has provided me too many opportunities to witness the consequences of contracting a vaccine preventable illness. I have seen first-hand the devastation of pneumococcal meningitis, cervical cancer, dehydration from rotavirus, and pertussis, just to name a few. I have also heard the stories from my older colleagues of much worse times when other infectious diseases took even more lives before new vaccines were developed.
This decision to provide vaccines is not easy from a personal and financial standpoint. The upfront cost to stock vaccines is staggering, and is the single largest cost to my practice. The slim profit margin that insurance provides does not cover the staffing, administration, refrigeration and infrastructure needed to provide those vaccines. And yet, many of us physicians are still hanging in there, bearing the burden and doing what we can to protect our patients. To make things even worse, steady increase in social media postings has made this job seem insurmountable. It’s rare for me to meet young parents that don’t ask about “mercury” in vaccines or whether they can do a “delayed vaccine schedule.” This extra counseling is time-consuming, but entirely worth it in my opinion. I understand their trepidation, and so I have spent a lot of time compiling information from credible sources so families can make informed decisions. After reviewing this information and consulting with me, most of these families have been able to come up with a vaccine plan that is comfortable for them.
However, every day I see people posting information on social media that works against my efforts. I understand that families may have concerns about vaccines. I understand that parents may have hesitation and may want more answers so they can do their best to protect their children. But conversations about these concerns should, in my opinion, be kept PRIVATE. When people publically post pseudo-scientific articles and personal opinions about vaccinations, it can be very easy for other parents to get spooked. It is only because of herd immunity that children who are not vaccinated can be protected. This herd immunity is established by hard working physicians who make sure that most of the community is vaccinated. Parents who choose not to vaccinate are only putting their own children at risk by breaking down that herd immunity with the flood of vaccine hysteria on social media. This is happening slowly and steadily with every article and video posted. As a pediatrician I ask that all parents keep their decision to vaccinate or not vaccinate a PRIVATE conversation within their family and with their physicians, so that other parents can be open to the peer-reviewed articles, scientific data and professional experience that their own medical providers can offer them. Let other parents make their OWN informed decisions. It would certainly make physicians’ lives a little less complicated as we strive to protect our communities.
Kids making Fritattas in their PJ’s
Zane heads up the Smoothie Station
This past weekend our the staff of Yum Pediatrics volunteered for the Doctor Yum Project’s first cooking class in our new Instructional Kitchen. Doctor Yum’s Pajama Party was cooking class for kids age 7-12 to learn the importance of a healthy breakfast and to learn some cooking skills and recipes to make a great breakfast at home.
Using our new Multimedia set up, we first discussed the pitfalls of of most breakfast choices:
- Not enough protein
- Too much sugar
- Not enough fruits and veggies
The kids learned about how eating breakfast can make them perform better in school. They learned about how protein is a great source of energy and helps every cell in our body to repair and function. They then learned about how most kids get 2-3 times the recommended amount of sugar in a day, and how breakfast can be a large contributor to excess sugar. We discussed how important fruits and veggies are, how many servings are recommened and how easy it is to get some of those servings in at breakfast.
We made 4 recipes with the help of our Yum Pediatrics staff (all of us in matching mushroom pajamas!) Zane headed up the breakfast smoothies station, showing kids how to add veggies and like kale and carrots to a fruit smoothie. I made mini fritattas packed full of veggies and Carmen made kiwi strawberry fruit pizzas. Kids samples a crockpot oatmeal with apples and cinnamon, too.
Nurse Carmen and Cindy with Dr. Fernando
Preparing veggies for the Fritattas
Our first class was a great sucess and we are hoping to offer more classes in the future. Visit doctoryum.com to find out about more classes and camps at the new kitchen!