To pediatricians, gun control is a public health issue, not a political one. But they're treading a fine line, and they know it.

The American Academy of Pediatrics has begun a renewed push to try to get Congress to pass gun control measures, sending more than 100 pediatricians to Capitol Hill earlier this month. But others who have taken on the issue over the past decade have a warning for them: they can run afoul of the National Rifle Association and other pro-gun groups that are quick to paint anyone who advocates for gun control as a political extremist.

What the doctors want is an assault weapon ban, mandatory background checks and waiting periods before all firearm purchases, a ban on high-capacity magazines, handgun regulations and requirements for safe firearm storage under federal law.

“I think we can be honest brokers,” says Dr. Lolita McDavid, medical director for child advocacy and protection at University Hospitals, part of Case Western Reserve University’s school of medicine in Cleveland.

Johnny Hanson / AP file

With a little help, a child shoots an Airsoft gun at a target during NRA Youth Day events at the National Rifle Association's 142 Annual Meetings and Exhibits in Houston on Sunday, May 5, 2013..

“We have to have a collectively louder voice,” Dr. Danielle Laraque, who chairs the pediatrics department at Maimonides Infants and Children’s Hospital in Brooklyn, told a meeting of the Pediatric Academic Societies in Washington, D.C., earlier this month. “What we need is a call to action, to really look at how we can change public policy that is not often affected by data.”

They don't always get a friendly reception. Just two weeks before the doctors arrived, Congress had scuttled what gun-control advocates had considered a modest bill to expand background checks for gun sales.

Congress had already dropped a wider measure pushed by President Barack Obama and Vice President Joe Biden after the December shootings of 20 schoolchildren and six adults in Newtown, Conn.

Obama has been trying to roll back some of the restrictions placed on gun research by Congress. He’s issued an executive order specifically directing the Centers for Disease Control and Prevention to conduct research into gun injuries. While the CDC was never banned from doing so, Congress had specifically cut precisely the amount CDC spent on firearms violence research, sending a clear message.

“If you think that Congress has sort of been asleep…you are wrong,” said Dr. Daniel Webster of Johns Hopkins University, one of the few academic experts who has continued research on gun violence despite efforts to divert funding. “They have been doing a very good job of weakening the laws to make it easier for gun dealers to have the least amount of responsibility. They have made it harder to sue dealers and made it harder to access data on … which dealers are pumping out guns to criminals. They’ve made it almost impossible to prosecute a gun dealer.”

Pediatricians are puzzled that the statistics aren’t speaking for themselves.

“Where there are more guns in the United States, there are more people dying,” Dr. Matthew Miller of the Harvard Injury Control Research Center told the meeting in Washington, D.C. “There are more women dying, there are more men dying, and there are more children dying. We are talking about a lot of people who are dying when they live in places with a lot of guns and homes with guns.”

Miller’s done research on gun deaths using what CDC data he could get -- dating from before Congress cut its funding.

He divided the U.S. population in half, classifying half as living in high-gun-ownership states and half in low-gun-ownership states. In the “high gun states,” 21,148 people were murdered between 1988 and 1997, compared with 7,266 in the “low gun states”.  He found 369 kids up to 14 of age who were murdered using guns in states with high rates of gun ownership; 97 were killed deliberately with guns in low-ownership states.

And there were more murders overall, even using weapons other than guns in the high-gun-ownership states, Miller found. Other research finds kids and adults alike are more likely to commit suicide if they have access to a gun.

Miller hopes that pediatricians can change the tone of the argument, making it about safety.

“Here we are talking about children. We can’t gun-proof a child. We have to childproof our homes,” he said. “It is a leading argument that hopefully will change the way people think about guns generally.”

“Can we reframe the conversation so that it is about data, not about political beliefs?” Dr. Barbara Stoll of Emory University asked the meeting.

That might not be easy.  

“I am widely known as the ‘widely discredited Dr. Arthur Kellermann’,” Dr. Arthur Kellermann of the RAND Corporation, a think-tank, told the pediatrics meeting in D.C. Kellermann, who established the Emory Center for Injury Control, has spoken out about gun-injury and death rates that are almost 20 times higher in the U.S. than those in other high-income nations with populations of more than 1 million.

He’s also done research showing that people are 2.7 times more likely to be murdered if they have firearms in their homes – research challenged by guns-rights advocates. Kellermann says he’s not an advocate for gun control and cautioned the pediatricians to pursue changes that gun owners are comfortable with. 

Gun advocacy groups have moved to discredit the AAP, which represents 60,000 doctors who have voted overwhelmingly to support some gun measures. One was set up specifically to do this – the Doctors for Responsible Gun Ownership (DRGO).  “DRGO is a nationwide network of 1,400 medical doctors, other health care professionals, scientists, and others who support the safe and lawful use of firearms for any legitimate purpose,” the group says on its website.

Founded by the pro-gun-ownership Second Amendment Foundation, DRGO says the the AAP and the American Medical Association are “motivated by deep-seated prejudice against gun owners.” “DRGO’s mission is to expose the poor medical scholarship -- and the anti-gun bias behind it -- held out as truth by organized medicine and medical journalism,” the group says.

The NRA has sponsored legislation to stop pediatricians from asking parents about guns in the home -- something that really puzzles doctors who routinely ask about other safety issues, such as using car seats and wearing helmets while riding bikes.

A federal judge struck down Florida’s 2011 law that forbade doctors to ask about guns in the home, but the NRA has sponsored similar legislation in Alabama, North Carolina, West Virginia, Minnesota, and Oklahoma.

“The chilling effect persists,” Miller said.

Related:

• Slideshow: Faces of the NRA
• 'I am a mom with a gun': Why I'll teach my girls to shoot
• Kids at risk of suicide can get guns, study finds

As many as one in five children who are at risk of suicide live in homes where they can get hold of guns -- the single most effective means to killing themselves -- researchers reported on Monday.

They said their findings show it’s extremely important to screen children for suicide risk, and to educate parents about how to keep guns out of their hands if they are. And early treatment is also vital.

The researchers, who presented their findings at the Pediatric Academic Societies meeting in Washington, D.C., say they don’t want their results to get mixed up in the current debate over firearms regulation. They just want to keep kids safe.

“A lot of kids, surprisingly, don’t have a history of mental illness but they attempt suicide,” says Dr. Stephen Teach, an emergency room doctor at Children’s National Medical Center in Washington, D.C.

Suicide is the No. 3 cause of death for children and youths aged 10 to 24, according to the Centers for Disease Control and Prevention. About 4,600 kids and young adults kill themselves each year, and 45 percent of them use guns. Another 40 percent suffocate or strangle themselves and 8 percent poison themselves.

Don't look for testing of the anthrax vaccine to begin in children any time soon. 

Controversy arose last year as experts debated whether such studies should be done to learn how to treat children in case of a bioterror attack.

But a presidential commission says the government would have to take multiple steps — including more safety research in young adults — before it would be ethical to consider tests in children.

"The safety of our children is paramount, and we have to get this precisely right," said Dr. Amy Gutmann, who chairs the Presidential Commission for the Study of Bioethical Issues, which released its report Tuesday.

More than a decade after the anthrax attacks, the government has a multibillion-dollar stockpile of drugs and vaccines to fight an array of threats. There's no information on whether those so-called countermeasures would work in children like they're expected to help their parents, or even what dose to use. Yet if a large attack were to occur, children undoubtedly would receive those untested products.

Worried about how to handle an emergency, a government advisory group recommended studying the anthrax vaccine in children if independent ethics experts agreed it could be done appropriately. The Obama administration put that question to the panel.

Tuesday's answer: Children don't gain any benefit from pre-attack research with the anthrax vaccine or other countermeasures. So the panel said such studies would be ethical only if they presented no more than minimal risk to participants — like the risk from a routine medical check-up. Determining that would require, among other things, more testing in adults, the panel added. Something that proved safe in 18-year-olds, for example, might be a candidate to study next in 16- and 17-year-olds.

However, the government should plan now for how it would study children who receive those treatments in the event of an attack, the panel said.

The Health and Human Services Department, which requested the advice, said it would review the findings.

Related story: 

• Bioethicist: No chance of anthrax vaccine trials in kids

Codeine can kill some children when it is used to help with pain after tonsil and adenoid surgery, and it shouldn’t be used any more, the Food and Drug Administration cautioned on Wednesday.

The FDA said it was adding a strong warning, called a boxed warning, to the label of the drug, and also will warn that it is not to be used in certain patients – especially children after tonsil or adenoid surgery.

“Health care professionals should prescribe an alternate analgesic for post-operative pain control in children who are undergoing tonsillectomy and/or adenoidectomy. Codeine should not be used for pain in children following these procedures,” the FDA says in a statement.

Last year, the FDA said it was investigating the deaths of three children. They died after getting their tonsils or adenoids removed, and had been given codeine to ease the pain. Codeine is turned into morphine in the liver, and morphine can suppress breathing.

“Many of the cases of serious adverse events or death occurred in children with obstructive sleep apnea who received codeine after a tonsillectomy and/or adenoidectomy,” the FDA said.

The children appeared to have metabolisms that natually converted codeine to morphine at an unusually high rate – meaning they got a higher-than-expected dose of the drug once the body processed it.

“Since these children already had underlying breathing problems, they may have been particularly sensitive to the breathing difficulties that can result when codeine is converted in the body to high levels of morphine. However, this contraindication applies to all children undergoing tonsillectomy and/or adenoidectomy because it is not easy to determine which children might be ultra-rapid metabolizers of codeine," the FDA says.

The FDA says between one and seven percent of people are “ultra-rapid metabolizers,” but people of North African, Ethiopian, Greek and African-American descent are especially likely to be.

The FDA says parents should call 911 if their children have been given codeine and show any of these signs:

• Unusual sleepiness, such as being difficult to wake up
• Disorientation or confusion
• Labored or noisy breathing, such as breathing shallowly with a “sighing” pattern of breathing or deep breaths separated by abnormally long pauses
• Blueness on the lips or around the mouth

Related stories:

• Nursing moms: Watch out for codeine
• Common pain meds don't always work, study finds
• Ibuprofen works best for kids' pain - study

Teaching parents to switch channels from violent shows to educational TV can improve preschoolers' behavior, even without getting them to watch less, a study found.

The results were modest and faded over time, but may hold promise for finding ways to help young children avoid aggressive, violent behavior, the study authors and other doctors said.

"It's not just about turning off the television. It's about changing the channel. What children watch is as important as how much they watch," said lead author Dr. Dimitri Christakis, a pediatrician and researcher at Seattle Children's Research Institute.

The research was published online Monday by the journal Pediatrics.

The study involved 565 Seattle parents, who periodically filled out TV-watching diaries and questionnaires measuring their child's behavior.

Half were coached for six months on getting their 3-to-5-year-old kids to watch shows like "Sesame Street" and "Dora the Explorer" rather than more violent programs like "Power Rangers." The results were compared with kids whose parents who got advice on healthy eating instead.

At six months, children in both groups showed improved behavior, but there was a little bit more improvement in the group that was coached on their TV watching.

By one year, there was no meaningful difference between the two groups overall. Low-income boys appeared to get the most short-term benefit.

"That's important because they are at the greatest risk, both for being perpetrators of aggression in real life, but also being victims of aggression," Christakis said.

The study has some flaws. The parents weren't told the purpose of the study, but the authors concede they probably figured it out and that might have affected the results.

Before the study, the children averaged about 1½ hours of TV, video and computer game watching a day, with violent content making up about a quarter of that time. By the end of the study, that increased by up to 10 minutes. Those in the TV coaching group increased their time with positive shows; the healthy eating group watched more violent TV.

Nancy Jensen, who took part with her now 6-year-old daughter, said the study was a wake-up call.

"I didn't realize how much Elizabeth was watching and how much she was watching on her own," she said.

Jensen said her daughter's behavior improved after making changes, and she continues to control what Elizabeth and her 2-year-old brother, Joe, watch. She also decided to replace most of Elizabeth's TV time with games, art and outdoor fun.

During a recent visit to their Seattle home, the children seemed more interested in playing with blocks and running around outside than watching TV.

Another researcher who was not involved in this study but also focuses his work on kids and television commended Christakis for taking a look at the influence of positive TV programs, instead of focusing on the impact of violent TV.

"I think it's fabulous that people are looking on the positive side. Because no one's going to stop watching TV, we have to have viable alternatives for kids," said Dr. Michael Rich, director of the Center on Media and Child Health at Children's Hospital Boston.

In just 10 years the number of children diagnosed with attention deficit/hyperactivity disorder, or ADHD, rose dramatically, a  large new study suggests.

Overall, about 5 percent of nearly 843,000 kids ages 5 to 11 were diagnosed between 2001 and 2010 with the condition that can cause impulsive behavior and trouble concentrating. But during that time, rates of new ADHD diagnoses skyrocketed 24 percent – jumping from 2.5 percent in 2001 to 3.1 percent in 2010.

That’s according to a comprehensive review of medical records for children who were covered by the Kaiser Permanente Southern California health plan.  Rates rose most among minority kids during the study period, climbing nearly 70 percent overall in black children, and 60 percent among Hispanic youngsters, according the study published in JAMA Pediatrics. Among black girls, ADHD rates jumped 90 percent.

Rates remained highest in white children, climbing from 4.7 percent to 5.6 percent during the study period.

The biggest factor driving this increase may be the heightened awareness of ADHD among parents, teachers, and pediatricians, says the study’s lead author Dr. Darios Getahun, a scientist with Kaiser Permanente. For kids who need help, that’s a good thing, Getahun says.

“The earlier a diagnosis is made, the earlier we can initiate treatment which leads to a better outcome for the child,” he says.

Unlike previous studies in which researchers relied on reports from parents and teachers to say whether a child had ADHD, the new study tracked kids who were diagnosed according to ADHD medical codes entered by child and adolescent psychiatrists, developmental and behavioral pediatricians, child psychologists and neurologists.

ADHD is one of the most commonly diagnosed childhood disorders. Experts estimate that anywhere from 4 percent to 12 percent of school-age children are affected, many of whom continue to suffer from the disorder into adulthood.

Rates of diagnosis in the new study were greater in families with higher incomes, with nearly three-quarters of kids with ADHD coming from families that earned more than $50,000 a year.

“Higher rates of ADHD observed in affluent, white families likely represent an effort by these highly educated parents to seek help for their children who may not be fulfilling their expectations for schoolwork,” Getahun and his co-workers write.

Boys still outnumber girls 3 to 1 in ADHD diagnoses, but the gap appears to be closing among black girls.

“The increasing rate of ADHD among girls is an interesting finding and could represent an effort by parents to get more help for their daughters,” the authors say.

There was no change in the rate among Asian kids, but Getahun suspects this may have something to do with culture. Asians, as a rule, have been less likely to use mental health services and are more likely to discontinue therapy despite having equal access to care, Getahun says.

A child development specialist unaffiliated with the new study says he suspects that increased awareness of ADHD may have contributed to the increasing rate of diagnosis.

“Heightened professional awareness in general and improved efforts to detect ADHD exert an influence, but we cannot tell the magnitude of that,” says Alan Kazdin, the John M. Musser Professor of Psychology and Child Psychiatry at Yale University.

With all the coverage of the condition in the media, parents and teachers now have a better sense of what signs to look for, Kazdin says.

“Heightened awareness in the media, by parents and by teachers, too, may play a role. A child who in previous years just was said not to be able to control himself might now be more finely described.”

Related stories: 

• Childhood ADHD may limit adult achievements
• ADHD overdiagnosed in youngest kids in class
• Number of women on ADHD meds soars

By Kerry Grens
Reuters.com

While parents may sometimes despair of their children getting enough shut-eye, especially with age-old stalling tactics of another story or another glass of water, children in the United States do appear to be getting the recommended amount of sleep.

According to a U.S. study published in the Archives of Pediatric and Adolescent Medicine, there has been concern that U.S. children are getting too little sleep, with insufficient sleep tied to issues ranging from behavior problems to heart health risks.

But there hasn't been much hard evidence on how much sleep children typically get, so a group led by Jessica Williams, a graduate student at the University of California Los Angeles, set out to get estimates of sleep times from birth to age 18.

"These estimates are consistent with the amount of sleep recommended for children, and no evidence was found of racial/ethnic differences," the group wrote in its report.

The researchers gathered data from a nationwide survey that has tracked families for decades, focusing on parents' reports of their children's sleep, beginning in 1997.

At that time, 2,832 children were included, In 2002 and 2007 the families were surveyed again and 2,520 and 1,424 children were included, respectively.

Williams's team found that until their second birthday, babies in the study slept an average of 12 to 14 hours during each 24-hour period.

By age four it had dropped to about 11 hours of sleep and by age 10, to 10 hours. By age 16, kids were getting an average of about nine hours of sleep per night.

The U.S. Centers for Disease Control and Prevention recommends that toddlers get 12 to 14 hours of sleep, preschoolers 11 to 13 hours, and adolescents aged 10 to 17 from 8.5 to 9.5 hours.

One of the big strengths of this study is that it tracked changes in sleep among the same children as they aged, said Maurice Ohayon, director of the Stanford Sleep Epidemiology Research Center in Palo Alto, California.

"We have an evolution of the sleep during the childhood. That is the unique thing," said Ohayon, who was not involved in the study.

The researchers didn't find any differences in the amount of sleep between boys and girls, and only a slight gap between white and Hispanic children.

Hispanic kids tended to sleep 19 minutes longer than white children after age nine, but Williams said that difference is too small to matter for individual kids.

It’s a tragic sign of spring: Two young children have died this month in Texas and Missouri after their parents accidentally left them all day in hot vehicles.

Although such deaths occur in nearly every month of the year, records show that warmer weather typically heralds a seasonal spike in fatalities from hyperthermia, or heat stroke, among children left in cars and trucks.

Worse, experts add, such calamities don’t have to happen.

“It’s a totally preventable occurrence,” said Kate Carr, president and chief executive of Safe Kids Worldwide, which recently launched a new campaign to raise awareness about the problem. “Our hearts go out to the parents and families of these children.”

In the most recent cases, a 7-month-old boy from the Sugar Land area of Houston died May 3 after the child’s father, Leland Jacobson, 41, left the baby for hours in the backseat of a pickup truck in 89-degree weather. Jacobson wasn't normally the parent who took his children to day care and became distracted after dropping off the older kids, police said.

On the same day, a 13-month-old boy from Lee’s Summit, Mo., died after his mother, a teacher, mistakenly believed she’d already left the child at day care that morning. Temperatures reached 83 degrees that afternoon.

“The investigation has revealed no signs of foul play and at this time it appears that the death was a tragic accident,” said Sgt. Chris Depue, spokesman for the Lee’s Summit Police Department.

That’s true of most cases in which children die after being left in hot vehicles. At least 529 such deaths have been recorded since 1998, including the two logged in the past week, according to figures from the Department of Geosciences at San Francisco State University, which tracks reports.

On average, 38 children die each year in hot cars, reports show. The numbers typically begin to climb in May, with an average of three deaths per month. They spike in July and August, when nine deaths, on average, are recorded, the figures show.

Overall, more than half of the deaths -- 52 percent -- occur when a child is mistakenly left in a vehicle, typically by a parent or caregiver who is rushed or stressed, said Carr.

“That’s a story we’ve heard first-hand,” she said. “The baby falls asleep in the back and mom or dad gets distracted. You can get in the car headed to work and absolutely forget.”

More precisely, a distracted brain can get stuck on autopilot, allowing parents to believe they actually have left the child, said Janette E. Fennell, founder and president of KidsAndCars.org,which has been focused on the problem for a dozen years. Her agency has counted 620 child deaths from hyperthermia since 1990.

Frequently, the accidents occur when there’s a deviation from the normal routine. Dad is handling the drop-off instead of mom, or there’s been some other change in schedule.

"The parents are absolutely certain that their children are in a verysafe place," Fennell added. It's only later, at the end of the work day, for instance, that they realize what's happened. 

About 30 percent of the deaths occur when a child is playing in an unattended vehicle and becomes trapped inside -- or in the trunk, reports show. Another 17 percent of deaths occur when a child is intentionally left alone, for instance, when a parent went shopping.

Once inside, the babies and children face temperatures that soar quickly to lethal heights. It takes only 10 minutes for the temperature to jump 20 degrees; within 30 minutes, it can climb by 34 degrees, according to a vehicle heat study sponsored by General Motors, which helps fund Safe Kids Worldwide.

Under that scenario, even a mild day -- 70 degrees -- can quickly become deadly.

“Cracking the window doesn’t help,” Carr said. “If you’ve ever been in a hot car that’s parked on an asphalt parking lot, you know how quickly that car heats up, even if your windows are down.”

Child's body heats five times faster
Regardless of how or why a child is left behind, the effect is swift and devastating, said Dr. Leticia Ryan, researcher and clinician at Children’s National Medical Center in Washington D.C.

“The child’s body heats up three to five times faster than an adult’s,” she said. “Their internal systems are not fully developed.”

Kids don’t sweat as efficiently as adults and their bodies absorb heat faster. It can take as little as 15 minutes in an overheated vehicle for a child to begin to suffer life-threatening brain or kidney injuries. When body temperature reaches 104 degrees, internal organs begin to shut down. At 107 degrees, children die. 

“It’s the double whammy of being more vulnerable to the heat illness in a short amount of time,” said Ryan, a pediatric emergency medicine expert who has seen many young victims of heat stroke. “In most cases, they’re usually too young to get themselves out of the car seat or to alert people outside of the car to their predicament.”

Norman Collins Sr.

Three-month-old "Bishop" Collins died on May 29, 2011 after he was accidentally left in a car in a church parking lot in Clarksdale, Miss., on a 93-degree day. His grandfather, Norman Lee Van Collins Sr., has become an advocate for car safety.

Such deaths leave the families devastated, too. The shock, grief and guilt are overwhelming, said Norman Van Lee Collins Sr., whose 3-month-old grandson, Norman Van Lee Collins III, known as “Bishop,” died last May 29 a hot car in a Mississippi church parking lot.

The child was accidentally left behind as his family hurried into a church service. The child’s father was the minister of music, so he was retrieving his keyboard from the car. He asked another church member to get the baby and take him to the nursery. But the church member didn’t hear him.

“There was just this miscommunication,” the grandfather recalled sadly. “I lost my grandson.”

To compound the tragedy, when Norman Collins Jr. reported the accident to the police, he was arrested for negligent manslaughter.

Nineteen states have laws that address leaving a child unattended in a vehicle. Thirty-one states have no specific laws, according to San Francisco State reports. An Associated Press investigation in 2007 found that charges were filed in about half of cases in which children died of heat stroke in vehicles; more than 80 percent were convicted.

In Collins’ case, the grand jury didn’t choose to indict him. “I did not even explore why,” the senior Collins said. “I was just so glad they didn’t.”

The bereaved grandfather now speaks publicly about Bishop's death in order to warn other families about the danger.

Airbags put babies in backseat
In one of the ironies of vehicle safety, the number of hyperthermia deaths in cars has skyrocketed since the early 1990s, when the advent of airbags led to directives that young children be placed in the back seats of cars and in rear-facing car seats for infants.

That position makes it easier to overlook babies, even for the most conscientious parent, said Carr, who recalled nearly forgetting to drop her own 2-year-old at day care -- until the child spoke up.

“Thankfully, my daughter was not a small baby who fell asleep,” she said. “From my own personal place in my heart, I have a great deal of empathy for these parents.”

Safety advocates such as Fennell, of KidsAndCars.org, have lobbied for years for technical solutions to the problem of leaving babies behind. Some private firms have come up with various devices, monitors and other alerts that can be purchased online, but none is available off the shelf, Fennell said.

Better, she said, would be a required sensor that could alert drivers that someone is still in the vehicle when they’re locking the car.

“We feel this is a good strategy because we know that many people feel that this ‘could never happen to them’ and may not think they need to purchase aftermarket technology,” she added.

Meantime, KidsAndCars advises all parents to institute an “iron-clad” rule with day care providers to contact parents if a child has not arrived as scheduled.

Safe Kids also advises that parents put back-up systems in place to prevent tragedy: Set up a “peace of mind plan” in which it’s routine to call or text a partner or other caregivers so that everyone knows when a child has been dropped off.

Place a purse, briefcase, gym bag, cell phone or other object needed at the destination in the backseat with the child. Set an alarm on a cell phone or computer calendar as a reminder to drop a child at care.

Though the number of child deaths from hyperthermia in cars is small, the actual number of incidents in which kids are endangered is likely much larger.

In Palm Beach County, Fla., there were 500 near-misses last year in which kids were retrieved from cars before they were seriously hurt, Carr said. The actual number of close calls is unknown.

“Never leave a child alone, even for a minute,” she said.  “It can and it does and it might happen to you.”

Related stories: 

• Hurt on the stairs: A child is injured every 6 minutes on the stairs
• CDC: Kids' accidental deaths down 30 percent
• Bioethicist: Youth hockey borders on child abuse
• VIDEO: Stairs in the home pose a hazard to kids

Nacho Doce / Reuters

Rychard Barboso, 5, looks at his physical therapist during a session at the Association for the Aid of Disabled Children (AACD) in Sao Paulo on March 19. All images captured by Nacho Doce of Reuters.

A disabled girl embraces a doll during a session of physical therapy at the AACD on March 19.

The Association for the Aid of Disabled Children (AACD) in Sao Paulo is a non-profit organization that began in 1950 with just 14 patients. It now works with some 8,000 young victims of disabling conditions and diseases such as cerebral palsy, and most of the patients come from impoverished or broken homes.

Reuters photographer Nacho Doce became aware of the clinic through a close friend and was astonished at the range of disabilities the children faced and was impressed with their determination and resilience.

It was the children’s smiles and willpower that drew me to them from the start, as much to those who couldn’t move as to those who couldn’t speak or sense. The parents and even the therapists also showed incredible strength.

-- Nacho Doce

All photos were shot by Nacho Doce in March and April, and were made available to msnbc.com today.

A girl wearing a brace on her leg is assisted by a physical therapist during a hydrotherapy session at the AACD on April 3.

A physical therapist supports Luiza Ezaledo, 2, during a hydrotherapy session on April 2.

Luara Crystal, 5, who suffers from brittle bone disease, lifts a weight next to her physical therapist during a session at the AACD.

Ivan Bevenuto, 4, sits next to his skateboard after taking part in a Capoeira therapy session at the AACD on March 21.

Yara Santos, 9, talks with her mother before a session of physical therapy on March 21.

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Attention, germaphobes. Exposure to the microscopic bugs is crucial for keeping kids healthy, according to new research in the prestigious journal Science. The study strongly supports a growing body of evidence that you need to put away the disinfectant and expose children to the real world of germs and microbes. 

Getty Images stock

We're meant to encounter some microbes and dirt when we're young. It's how we build our immune systems.

Scientists Richard S. Blumberg and Dennis L. Kasper and a team of researchers at Harvard Medical School showed that in mice exposure to germs in early life helped reduce the body’s inventory of invariant natural killer T (iNKT) cells. These cells help protect us against diseases like inflammatory bowel disease and asthma. But, if there are too many of them with too much time on their hands, they can actually cause these conditions. By exposing young mice to common microbes the scientists saw that the animals were protected from accumulating T cells -- and were healthier than those who were not.  

The scientists reached an admittedly geeky conclusion: “These results indicate that age-sensitive contact with commensal microbes is critical for establishing mucosal iNKT cell tolerance to later environmental exposures,” they wrote in the journal Science. In other words, exposing baby mice to common germs got their immune systems appropriately busy and able to not over-react when encountering nasty bugs and other biological stuff later in life.

This is a big deal.

The rapid rise in food allergies, asthma and other immunological diseases is due, at least in part, to our modern obsession with cleanliness, scientists increasingly believe. The 'hygiene hypothesis', first advanced in 1989 by the British epidemiologist David Strachan, contends that these diseases are becoming more common because young children are not exposed to them at an early age. We spend so effort trying to prevent exposure to germs with antibiotics, antibacterials and soaps that letting kids get dirty seems like a violation of basic parental duty.

Parents are constantly being told to make their kitchens spotless, to kill 99.9 per cent of the germs lurking in their bathrooms and to wash themselves and their babies all the time.

This world of purity sounds good but it does not fit how we are designed. We are meant to encounter some microbes and dirt when we are young. It is how we built our immune systems. We need a certain amount of grunginess as kids to be healthy adults. 

As the Harvard study shows, filth can be good -- at least in tiny amounts when you are very young.

Arthur Caplan, Ph.D., is a Professor in the Department of Medical Ethics and Health Policy at the University of Pennsylvania

Ifp / featurepics.com

About 45 percent of parents give their children bottled water instead of tap water, a study found, which dentists say may leave them lacking fluoride that can prevent tooth decay.

When the dentist had to fill six cavities in her 4-year-old son’s baby teeth, Amy Wilson was shocked.

The New York City mother of three scanned her family’s habits, trying to figure how Seamus, now 7, could have developed such tooth decay so early.

“We said, 'No, no, no, they don’t have candy or gum or soda regularly,'” recalled Wilson, 42, an actress, author and blogger. For a while, she was stumped.

But then, at a party, a dentist friend posed a surprising question: Did Wilson’s children drink bottled water?

“I had a dentist tell me to make sure to give my kids tap water and not bottled because the latter isn’t fluoridated, and he’s seeing kids with more cavities,” said Wilson, who posted on the popular blog, Type A Parent. 

It turns out that many dentists and government health officials suspect that the practice of skipping tap water in favor of bottled water may be contributing to rising rates of tooth decay in young children.

Courtesy Amy Wilson

Amy Wilson, 42, of New York, was shocked when Seamus, far left, had to have six cavities filled at age 4. She now makes sure Seamus, now 7, as well as Connor, 9, and Maggie, 4, drink fluoridated filtered water from the family tap.

“You should brush twice a day with a fluoride toothpaste, see the dentist twice a year for fluoride treatment and get fluoride in your drinking water,” said Jonathan D. Shenkin, spokesman on pediatric dentistry for the American Dental Association. “If you’re not getting it in your drinking water, that takes out a component of the effectiveness of that triad.”

The Centers for Disease Control and Prevention, too, warns that “bottled water may not have a sufficient amount of fluoride, which is important for preventing tooth decay and promoting oral health.”

No question, many kids do drink bottled water. One recent study in the Archives of Pediatrics found that about 45 percent of parents give their kids only or primarily bottled water, while another in the journal Pediatric Dentistry found that nearly 70 percent of parents gave bottled water either alone or with tap water.

More than 65 percent of parents using bottled water did not know what levels of fluoride it contained, that study showed.

At the same time, tooth decay appears to affect a huge swath of the nation’s young children. About 42 percent of children ages 2 to 11 in the U.S. had cavities in their baby teeth, according to a 2007 prevalence study, the most recent data from the Centers for Disease Control and Prevention.

The study tracked rising decay from 1988 to 1994 and then from 1999 to 2004, when it was up overall about 2 percent. The data showed that decay affected not only more than half of children at the lowest income levels, but also nearly a third of kids in higher-income families.

That supports additional research by Bruce Dye, a dental epidemiology officer with the National Center for Health Statistics, which actually found that boys in higher income families had the greatest prevalence of decay. Whether that's because it's harder to get those boys to brush, or because parents in higher-income families are more likely to provide more beverages, such as juice, sports drinks -- and bottled water -- isn't clear.

“I look at that as choices being made,” Dye said. “Gatorade or bottled water could be part of that.”

To be clear, there are no studies to date that document a clear tie between bottled water and tooth decay. And the International Bottled Water Association, an industry trade group, notes that at least 20 of its roughly 125 bottlers do offer fluoridated bottled water -- and that water is a healthier option than other beverages.

“In fact, bottled water does not contain ingredients that cause cavities, such as sugar,” the IBWA said in a statement responding to a recent New York Times story about a rise in dental surgeries among tots.

But Shenkin and other dental experts say it’s actually not clear whether there’s a link between bottled water and tooth decay, mostly because the issue hasn’t been studied because of a lack of funding for oral health research. 

They contend that the continued popularity of bottled water in the U.S. -- about 8.4 million gallons a year or about 27.6 gallons per person in 2009, according to the Beverage Marketing Corp. -- fuels concern about kids’ consumption.

“I look at it as parents trying to do the right thing, trying to be healthy, but being healthy doesn’t prevent [cavities],” said Dye.

Fluoridation of public water supplies has been hailed as a public health victory, but in recent years, many U.S. communities have voted to stop adding it to local drinking water. Fluoride protects against tooth decay, but it also can cause tooth discoloration and bone weakness if ingested at too high levels for many years, experts agree. 

Federal regulators last year proposed setting recommended fluoride levels in drinking water to the lowest end of a range that permits between 0.7 and 1.2 milligrams of fluoride per liter of water, but officials are still wrestling with finding a balance between preventing decay without harming teeth and health.

Meanwhile, inadequate brushing habits, delayed dental visits, poor choices of foods and snacks and bad beverage selection -- in addition to spotty consumption of fluoride -- all likely contribute to tooth decay, Dye said.

No matter what causes it, the problem with decay that starts early is that it often gets worse.

“When you have tooth decay in your baby teeth, you will have tooth decay in your permanent teeth,” said Dye.

The problem may be particularly worrisome in minority families, who were three times more likely than others to give their kids only bottled water, usually because of concerns about the safety or taste of their home tap water.

Kids in minority families also are more likely to have tooth decay. The CDC data showed that 55 percent of Mexican-American kids ages 2 to 11 and 43 percent of black children had cavities in their baby teeth. For white youngsters, the figure was about 37 percent.

For all families, the key is to make dental health a priority, Shenkin said. Babies should see a dentist by age 1 and brushing twice a day with a fluoride-containing toothpaste should start at age 2.

“As soon as that first tooth comes through in the mouth, it’s susceptible to decay,” he said. “If you wait until kids are 3 or 4 years of age, it’s already happened.”

For Wilson, who admits tooth brushing is a struggle with kids now aged 4, 7 and 9, awareness has been a big part of changing her family’s habits.

“We live in New York City where the tap water tastes fine,” she said.

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