April 2008

When and what is appropriate for a snack

Spring is a great time to get moving

Family participation plays key role in success

Slipped capital femoral epiphysis

West Suburban YMCA Transformation

When and what is appropriate for a snack?

By Heather Fortin, RD, CD, CSCS, CLC, dietitian

Many parents want to know what to give their kids for a snack. This is a great question, but another question that needs to be answered is if the child needs a snack.

The first step is to look at the time between meals. A snack may be appropriate if it has been more than four hours since the last meal. The snack also should be more than an hour before their next meal; otherwise the child may not eat as well during the meal. Watch in between meals for cues that they need a snack. Are they complaining of hunger? Does he or she eat very large or double portions at the next meal? Is he or she more irritable? If so, they probably need a snack.

When deciding what snack to give, encourage parents or caregivers to look at the complete day and see what food groups are lacking. Great snack ideas incorporate fruits, vegetables or dairy, as those food groups usually are lacking in a child's typical daily intake. A great snack combination incorporates a protein source (peanut butter, cheese, yogurt, milk, meat, nuts, etc.) with a carbohydrate source (whole grain starches, fruits, vegetables). Make sure parents are sticking to the serving size listed on the package. There is a tendency to make snacks into meals and the calorie levels quickly get too high. An ideal snack should have less than 150 calories and more than 3 grams of fiber per serving.

Use the attached handout with your patient families in guiding snack choices.

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Spring is a great time to get moving

By Stacy Stolzman, MPT, physical therapist and Margaret Morrissy, exercise science student intern

Spring is a great time to ensure safety with all wheeled activity devices. Make sure that all children and adults have properly sized helmets and protective gear when riding bikes, rollerblading, skating, skateboarding, riding scooters and wearing Heelys¨ (tennis shoes with wheels in the heels). Tell families that a good rule to follow is if you are moving faster than running, you should always wear protective helmets and gear. Get more safety tips here.

In the Milwaukee area, bike helmets can be professionally fitted and obtained at several locations.

• Bike helmets may be purchased and fitted at Children's Hospital of Wisconsin's Emergency Department/Trauma Center. Helmets are sold for $10-15 and the fitting is free. No appointment is necessary.
• Helmets also may be obtained at Children's Health Education Center. Helmets are sold for $10 and the fitting is free. Call (414) 390-2186 to make an appointment.

As spring approaches, aerobic activities available to children vastly expand. Children interested in sports can look to recreational centers in their city or county. These departments often have sports teams and clinics open to various skill levels and ages. The activities offered at recreation centers can vary from basketball and softball to broomball and kickball. Swimming is another popular physical activity that children enjoy with warmer temperatures. Tip: Ask your local recreation department for copies of its activity guide to share with families.

As the weather improves, children are able to better utilize outdoor recreation areas.  They can play games such as tag, Frisbee and touch football with their siblings and friends in backyards, neighborhood parks and school playgrounds.

Suggest families designate family walk time several times per week. The walks can vary from walking the dog in the neighborhood, hiking on a nature trail or going on a scavenger hunt at a park. Children and adults of any age can participate in a family walk. Put smaller children in a stroller, bring along bikes for older ones and start walking.

Other ideas for spring activities include:

• Badminton.
• Kickball.
• Riding bikes.
• Tag games.
• Racing games.
• Flying a kite.
• Shooting hoops at a park.
• Canoeing.
• Nature hikes.
• Roller skating/blading.
• Taking a dance class.
• Recreational sports teams.
• Mowing the lawn.
• Gardening.
• Washing the car.
• Frisbee golf.
• Jumping rope.

Use this list to get families started and encourage them to add additional activities that they enjoy.

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Family participation plays key role in success

By Brian Fidlin, PsyD, program director, NEW Kids

It goes without saying, parents have a profound impact on virtually every aspect of their child's life. All of the following have an impact on a child's weight status:

• A caregiver's knowledge of what they view as "proper" nutrition.
• The caregivers' influence over food selection, access to foods, meal structure and eating patterns.
• The caregivers' modeling of healthy eating practices and levels of physical and sedentary activity.

The entire family needs to be involved when addressing a child's weight problem. Leonard Epstein, a pioneer in the area of weight management, offers three reasons for involving parents in lifestyle change behaviors:

1. Obesity has a genetic as well as a behavioral component. It is unrealistic to intervene with one member of a family while other members are modeling and supporting behaviors that run counter to the intervention goals.
2. Parents serve as role models and reinforce and support the acquisition and maintenance of eating and exercise behaviors.
3. It may be necessary to instruct parents to use specific behavior-change strategies such as positive reinforcement, to produce maximal behavior change.

While this may appear to be common sense, it can become incredibly difficult for a family to completely embrace. Parents and siblings often will state that they want to support the child who is struggling with his or her weight. If this means that some of their favorite foods or television watching may be limited, he or she may not be so cooperative.

Examine the principles of the 3-2-1-0-Blast Off to a Healthier Family and use them as a way to help families integrate healthy lifestyle changes. Children's Health Education Center offers fun tools for families to use in between office visits at www.bluekids.org.

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Slipped capital femoral epiphysis

By Channing Tassone, MD, orthopedic surgeon

Slipped capital femoral epiphysis is a way of describing the pathology in which the femoral head seems to be slipping on the femoral neck. This is a condition that commonly occurs in teenagers and is highly associated with increased BMI. SCFE also can be found in other conditions unrelated to the teen years and increase in BMI such as hypothyroidism, renal failure and Down Syndrome.

The most important facet of SCFE relates to a heightened awareness of the pathology so that the diagnosis is not missed. Any time a teenager is being evaluated for knee pain, particular attention should be paid to knee pain that carries with it an external rotation deformity of the limb and pain that cannot be localized with palpation of the knee, but instead seems to be more related to the hip. Often kids with slipped epiphysis have no pain whatsoever at the hip and relate only pain at the knee. This pain often is exacerbated by gentle motion at the hip and not further elicited by any actual physical examination of the knee.

Other classic physical exam findings are decreased internal rotation of the hip as well as obligate external rotation of the hip. This obligate external rotation of the hip describes the situation in where gentle flexion of the hip actually causes obligatory external rotation of the limb as the hip is flexed. Forceful or vigorous internal rotation, or any rotation of the hip for that matter, is discouraged prior to obtaining radiographs to ensure that a slipped epiphysis is not present and you will not further the actual slip. Necessary radiographs to diagnose this condition are an AP as well as a lateral view. Either a cross table lateral view or frog lateral view is necessary. In a situation where there is an extremely painful or a question of an unstable condition, the cross table lateral is certainly warranted otherwise a frog lateral is reasonable.

Sometimes a patient presents after several months or even years of pain. He or she has had a full evaluation of the knee, including sometimes plain films, MRI and even surgical intervention to the knee such as arthroscopy, and yet the diagnosis of the slipped epiphysis was overlooked throughout. This is disappointing because over this duration the slip can further progress and even become unstable. The further progression of the hip carries with it a risk only in that the range of motion becomes worse and that there can be increased risk of joint degeneration in later years. An unstable slip is a much worse condition.

Historically, terms such as acute, acute on chronic and chronic slips were utilized. Those have largely fallen out of favor due to their lack of any real prognostic significance. Currently, the most pertinent diagnosis is either a stable or unstable slip. According to the literature, the true definition of an unstable slip is one in which the patient cannot ambulate even non-weight bearing with crutches. However, according to most pediatric orthopedic practitioners, a stable slip is one that can be walked on including weight bearing and an unstable slip cannot be walked on. The significance of this is that instability in the classification of slipped epiphysis has a significant increase in the risk of avascular necrosis, which is the most devastating complication of this condition. It is for that reason that once a slip is diagnosed then absolute maintenance of decreased activity to the point of non-weight bearing or bed rest. This ensures that a stable slip does not become an unstable slip and go on to AVN. There are anecdotal reports of kids with diagnosed stable slips falling in the bathroom and converting their stable slip to an unstable slip that went on to full head AVN. This turned what could have been a good long-term prognosis into an unsatisfactory outcome.

Once the slipped epiphysis is diagnosed, the next treatment necessity is surgical intervention with internal screw fixation of the hip. This is performed with one, or on rare instances two, percutaneously placed screws that cross the femoral neck into the epiphysis and hold it stable so that it can heal and the physis can go on to close. Complications of surgery are the previously described avascular necrosis, infections, progression of the slip, hardware failure or another uncommon complication of chondrolysis. Chondrolysis is a situation that can arise with or without surgical intervention to a slipped epiphysis in which the global articular cartilage of the femoral head actually deteriorates and it can be a very challenging condition to treat.

The most critical thing to remember is that our level of suspicion and awareness of slipped epiphysis in the adolescent population with increased bone body mass index has to be very high. These patients will not always present with a hip complaint. Often it is an isolated knee complaint that drives the diagnosis of the slipped epiphysis. Recommend that these children seek help from a specialist.

To refer a patient to Children's Hospital of Wisconsin's Orthopedic Center, call the Orthopedic Nurse Triage Line at (414) 266-2411.

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West Suburban YMCA Transformation

The West Suburban YMCA at 2420 N. 124^th St. in Wauwatosa is sporting a new look. The branch recently underwent an eight month renovation. The changes were made with families in mind.

The first thing members will notice is the bright and inviting welcome center. There's an area to sit and chat and also express lockers where you can stash your coat or gym bag without having to trek down to the locker rooms. The open concept is welcoming, making it easier for members to chat with staff and each other.

The first floor also features a reconfigured strength training and fitness area. This area was designed to help make people feel more comfortable and less intimidated. The cardio area features treadmills, ellipticals, stationary bikes, and cross trainers. All the equipment is surrounded by a new, two-lane indoor track.

More wellness coaches have been added to the staff. YMCA members can join the Commit to Be Fit program for free. Wellness coaches meet with an individual, give them a tour of the facility, sit down with the individual to find out their wellness needs, and the design a program tailored to that individual's goals. The coach will then check in with the member after several weeks and offer tips and advice. There are also fewer part-time staff members working more hours. This makes it easier for members to get to know the staff, making them more comfortable when they come to the Y.

Along with all these improvements, the West Suburban YMCA has a lot to offer kids and families. From youth sports, swimming lessons, and day camp to martial arts and dance classes, there's something for everyone. To check out, the West Suburban program guide, click here.

West Suburban YMCA
2420 W. 124^th St.
Wauwatosa
(414)302-9622

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