If your daughter is anything like mine, seeing an article with this title will likely send her slinking to her room, cheeks flushed. Kinda like when my dog disappears the moment he catches onto the fact that a visit to the vet is in the works.

But the question of when to take your daughter to a gynecologist is an important one, and, like other discussions of puberty or the birds and the bees, the same teens who might redden and squirm will likely be very thankful (inside) that you asked.

The answer to this question will vary from pediatrician to pediatrician. But my short answer as to when to take her to the gynecologist is as follows:

1. If she has a breast/gynecologic issue your pediatrician feels would benefit from a gynecologist’s input
2. Possibly if she is thinking of becoming or has become sexually active, although talk to your pediatrician first
3. When she is 21, at the absolute latest

Let’s break this down.

1. If she has a breast/gynecologic issue your pediatrician feels would benefit from a gynecologist’s input

We pediatricians — according to the American Academy of Pediatrics— should be seeing your child or teen yearly for well-child checks. At these visits we will discuss many topics including puberty, menstruation, sexuality and contraception. Checkups also involve a physical exam of the entire body, including a look at an adolescent’s breasts and a brief external look at her genitalia (not a full, dreaded pelvic exam, mind you, but still rather unpopular) in order to check on pubertal development and to screen for any other issues or abnormalities in these areas. Adolescent visits often frequently include some time when it is just the doctor and nurse talking with your teen (with you out of the room). This separate time allows teens to begin taking some ownership of their health visits, gives them a chance to bring up whatever more delicate concerns they might have, and to perform those more private parts of the exam.

If issues come up at these visits or at any point — issues such as heavy or irregular periods or somewhat slow, fast, or atypical growth or puberty— your pediatrician will help determine next steps. Sometimes, worries can be normal variations and might need simply to be watched and followed for a while. Asymmetric breast development (even in boys) and mildly irregular cycles for the preteen (particularly those new to having periods) often get better on their own. Other times, issues may veer further from the norm, and your pediatrician may feel it necessary to order lab tests and/or imaging. Depending on how the evaluation goes, your doctor may refer you to Cook Endocrinology and/or Gynecology.

2. Possibly if she is thinking of becoming or has become sexually active, although it’s still good to talk to your pediatrician first

As discussed above, as per the American Academy of Pediatrics, we pediatricians should be seeing your daughter for yearly well-care visits, incorporating an assessment of growth and puberty, a full exam, and anticipatory guidance. Similarly, the American College of Gynecologists and Obstetricians recommends a first visit to the gynecologist for girls between age 13 and 15, in order for the ob-gyn to do much the same thing. So there is some overlap in the services and roles which pediatricians and gynecologists can provide for a young teen. Following the letter of the law (that is, seeing both doctors) is always an option, as our colleagues in ob-gyn can be a wonderful part of the village helping to care for your child. Some of them have contraception education down to an informative yet entertaining art! That said, if your daughter is already having regular care through the pediatric office, and if she is also getting detailed education about sexuality and contraception choices at home, school, church, or through other groups, she may not need to see a gynecologist for that first introductory visit in addition. I leave that choice to you.

After laying the groundwork for future well-woman care, however, the next time to consider taking your teen to the gynecologist is if she is thinking of becoming sexually active or — less ideally—has taken that action already. If we have indeed moved from the theoretical “here’s what a person needs to know about birth control” to the actual “here’s what YOU need to know and start doing NOW with regard to birth control,” it is still a good idea to begin the discussion with your pediatrician. Pediatricians want to be kept in the loop and can provide information about the risks and responsibilities of sexual activity, options for birth control, and guidance for next steps.

There is variability between pediatricians as to whether or not they prescribe birth control pills (or COCs, combined oral contraceptive pills), though many do. Even still, most pediatric offices do not provide the full gamut of contraceptive options (such as hormone injection, IUD, or implants) available through a gynecologist. If other contraceptive options might be better suited to your particular adolescent, it would be a good idea to see a gynecologist.

3. When she is 21, at the absolute latest.

This AGE 21 bit is going to be for some girls and their parents the best news all day! In fact, let’s all do a little happy dance, as it is a fairly recent and welcome change (through the recommendations of ACOG, the American College of Obstetricians and Gynecologists), that a girl/woman’s first pap smear (for cervical cancer screening) does not have to be until age 21. What this means is that for a lot of girls (those who are without gynecologic symptoms, problems, or infections), the much despised first full pelvic exam (with stirrups and speculum— yeah that!) can be delayed to age 21. Hooray!

The recommendations used to be for earlier pelvic exams, pelvic exams at least within three years of sexual activity, and for pelvic exams prior to starting birth control, but things have changed. Internal pelvic exams are in most cases not needed before the initiation of pills or any other contraception with the exception of IUDs. So — big sigh of relief all around!

Of note, an important exception to the age 21 pap smear rule is that girls who have HIV or are immune-compromised need to start seeing a gynecologist regularly and getting pelvic exams when they become sexually active.

Well, that’s all, folks! Hope this gives some insight into when to take your child to the gynecologist. Now, come to think of it, when DOES the dog need his next vet visit, and where did he go?

So Your Child/Teen Wants To Be a Vegetarian: Ventures into Vegetarianism/Veganism

One of my favorite movie moments is when Aunt Voula in My Big, Fat Greek Wedding learns that Ian Miller, the non-Greek protagonist soon to join the family, is a vegetarian. She asks, “What do you mean he don’t eat no meat?” and the hoopla of the engagement party falls to a stunned silence. The festivity only resumes with her reassurance, “That’s okay, that’s okay—I make lamb!”

I laugh at this scene because for me it hits home. You see, when my younger sister was eight years old, she announced to my family that she intended never, ever to eat meat again. My usually well-spoken Texan grandparents, who expressed their love for us (at least in part) by buying us kids barbeque, could only stand there and say, “Huh?” And my Italian grandmother and extended family on the other side— well, they acted like Aunt Voula. My grandma would say she understood the vegetarian thing and then would proudly present my sister with an aromatic vegetable dish that was exquisitely seasoned and essentially perfect except that it was decorated with bits of …were those bits of ground beef? Let’s just say my sister’s vegetarianism, which often has edged into veganism, has been an education for my entire family over decades. And my sister, as per her promise, truly has never eaten meat again.

What did my parents do, after a short period of puzzlement? And —more to the point—what should YOU do, should your child or teen make a similar declaration? Here are a few tips I hope you will find helpful.

1. Consider the reasons behind the choice. My funny and, yes, perhaps dated movie reference for this section is a scene from Notting Hill, when Hugh Grant’s character, William Thacker, has a dinner date with a fruitarian woman who says she believes “fruits and vegetables have feelings, so we think cooking is cruel.” Hugh listens attentively and non-judgmentally as she clarifies her position. He starts, “So these carrots,’ and she cuts in, “have been murdered, yes.” “Murdered,” he says sensitively, “Poor carrots—that’s beastly.” In all seriousness, however—and with all due respect to fruitarian Steve Jobs, listening is important. My parents listened carefully to my sister’s reasons in accordance with their goal of rearing a self-assured, independent thinker. Like many school-aged children, she expressed her horror on learning that beef, pork, poultry, and seafood were cows, pigs, chickens, and fish. She became a fervent spokeswoman for animal protection and for humane farms. Inspired by a recent school unit on the environment, she — like Dr. Seuss’s Lorax— also spoke for the trees. She listed ecological concerns about large food industry’s destruction of the rainforest and the need to share earth’s resources responsibly. My sister’s heartfelt explanation helped my parents arrive at acquiescence and ultimately support of her decision.

Indeed, there are many very good reasons people have in choosing vegetarianism (eating no meat) and/or veganism (eating no meat, dairy products or eggs). Aside from the environmental and ecological arguments, it is a decision that for many is tied to cultural or religious beliefs. Teens who are trying to define themselves and formulate their own beliefs may want to back their newly-stated opinions with actions.

Words of warning:  While I strongly advocate really listening to your child’s reasons, as a physician I am also on the alert for a teen who does NOT seem to have well-thought-out positions. Beware of kids and teens who choose veganism for the WRONG reason, such as using it as a cover for excessive or unhealthy caloric restriction and eating disorders.

2. Make a general team strategy. Something as big as dietary change is best done as a family unit. It is too big a project, with too much potential for family dissension, for poor, dear Mom or Dad to tackle alone or for the child to manage without help. In the movie Everything is Illuminated, Elijah Woods’s character visits Ukraine and explains to utterly baffled companions at a restaurant that he eats no meat. When he is told that there is nothing available without meat, he asks if he can have just one of the potatoes that would otherwise be served with meat. The scene’s ending is poignantly and amusingly pathetic, as he is presented with a single, peeled baked potato on a plate, without even a sprinkle of chives … only to then roll onto the floor. Poor guy— oh, the plight of the unaided vegetarian! Honestly, that simply should NOT be how it is, for a good vegetarian effort takes teamwork. Meal-planning, grocery shopping, and cooking are all affected. In fact, if you have been a family of omnivores all along, it may be wise to take baby steps into vegetarianism or veganism. After all, it is truly daunting for a parent who knows how to cook a certain repertoire of meat-based meals to face the task of relearning a vegetarian selection (and as a pediatrician, I do recommend home-cooked meals as often as possible). To borrow Sheryl Sandberg’s phrase, you might consider “leaning-in” to a change—in this case, changed dietary habits— by instituting Meatless Mondays, or Meatless Mondays, Wednesdays, and Fridays! After all, cutting out half the meat still makes a positive impact on animals and on the environment.

My sister would consider nothing other than being a full-on vegetarian, while the rest of us still enjoyed our brisket and Chicken Marsala. However, we omnivores did slowly learn to cook more vegetarian dishes, to modify the ones that had dashes of bacon bits to include the veggie mock-bacon bits or perhaps sesame sprinkles instead, and to cook the vegetable dishes that we already knew more frequently than before. We cooked things that had vegetarian versions, like pasta that she could eat with straight red sauce, though we added meatballs. Many Sundays, my mom cooked a big pot of some variation of vegetable/bean soup, made with vegetable broth, NOT chicken broth! We often enjoyed it that first night as our family dinner entree, after which it made for great vegetarian left-overs for my sister throughout the week.

3. Be Smart about Nutrition. There is a classic scene from I Love Lucy in which Lucille Ball does a commercial for a syrup called “Vitameatavegamin” that is supposed to provide everything needed for good health. The scene is a riot, as Lucy endures its foul-taste for many repeated filming takes until she becomes drunk on the concoction. For a wonderful laugh—check it out! But, seriously, back to your vegetarian child, there is not one simple formula to ensure good nutrition. ANY restricted diet means more potential for nutritional deficiency, and that means more of a need for planning. To begin with, be sure calories are sufficient. I recommend the website choosemyplate.gov, which also includes a tracking feature called supertracker.usda.gov that can help in following calories and nutrients in a child’s diet. If your family is new to vegetarianism/veganism, it might be a good idea to have your child take a multivitamin. Truth be told, however, if your child is a non-picky vegetarian who eats milk and eggs and a pretty wide variety of vegetarian foods, he/she is probably getting all the nutrients needed without said vitamin. Similarly, if your child or teen has chosen to be a vegan but consumes a varied diet including fats and protein as well as a fortified milk substitute (like fortified soy/almond/cashew/coconut milk), then he/she is also probably set on nutritional requirements (due to supplementation in these dairy replacements). Without milk substitutes, though, I do worry about your child’s not meeting nutritional needs and would definitely recommend a multivitamin, particularly for Vitamin B12, calcium, Vitamin D and zinc. If in doubt, I recommend meeting with a nutritionist (Cook Children’s has a wonderful nutrition department).

4. WILL MY VEGETARIAN CHILD GET ENOUGH PROTEIN?

For lacto-ovo vegetarians, those who are not vegan and therefore consume both milk and eggs (both good sources of protein)—the answer is most likely YES, without even much forethought. Vegans, however, might not be getting enough protein and will need to strategize. The take-home message for them is that they need to eat a VARIETY of protein-sources each day and enough of them to meet requirements. I suggest counting protein grams for a few days, and—once you get the idea of what you need—then go for gestalt.

As an overview, animal-based foods (like meats, fish, dairy and eggs) are considered “complete proteins,” containing all 9 essential amino acids in a quite digestible form. On the other hand, plant-based foods are generally deficient in at least one amino acid, so— in order to get all 9—you need to eat a variety of different plant-based foods with “complementary proteins.” For example, legumes (beans) are low in methionine but high in lysine, while grains are the reverse. If you eat both legumes and grains in one day, you get them all. Also, plant-based protein is less easily-digestible than animal —based, so you need to consume more protein daily as compared to a carnivore, to get the same benefit. Do note that there ARE a few plant based proteins which are becoming more popular and which are complete, including quinoa, hempseed and chia seeds—hooray!

If vegans drink soy milk as their milk-substitute, they will get nearly as much protein from it as someone drinking milk (6-7g per cup as compared to the 8g in milk). However, there are some concerns about the relationship between soy and estrogens and the potential impact on children’s endocrine/hormonal systems (endocrine-disruptors). If you would like to limit soy milk, another option for a milk-alternative is Ripple Pea Milk, made from peas and containing just as much protein (8g/cup) as regular milk. Simple almond, cashew, and coconut milks do not typically contain any protein, but there are starting to be some nut milks on the market that are fortified with pea protein (check out Silk Protein Nutmilk container 10g of protein—woo-hoo!).

To touch on details, people generally need around 1 gram of protein per kilogram per day ( just over 1 g for toddlers, and 0.85-0.95 for kids/teens, but requirements can be 20% higher if protein is from harder-to-digest vegetable sources). Let’s consider a young teen who is 100 pounds, or 45 kilograms. That teen needs 43 grams of protein per day, which is pretty easily achieved if the child eats milk and eggs. In breakfast alone, she can get 17 grams, with her cup of milk and cup of bran flakes (8 g plus 3 g respectively) plus one boiled egg (6 g). Not bad for one meal alone! If that teen is a vegan, though, she may need as many as 51 grams of protein daily, since her proteins will be harder to digest. Tofu faux-eggs scrambled in the morning could help reach that goal (5g/oz), along with a cup of Ripple Pea milk (8g). Beans are a great go-to (8 g per half-cup), as are broccoli (4 g per stalk), spinach (5g per half-cup), and artichokes (4g per one medium-sized). Expand into ancient grains such as quinoa and amaranth, the latter which can be made into breakfast porridge and sprinkled with hemp or chia seeds for even more protein. And don’t forget peanut-butter sandwiches—they have 13 grams each!

Pearls of Protein Wisdom:

1. It helps to eat dairy and eggs, which are protein-rich.
2. Soy milk and pea milk (Ripple) are protein-rich milk-alternatives.
3. Nut milks like almond, cashed and coconut milks do NOT USUALLY contain protein, but there are some high-protein varieties fortified with pea protein.
4. Eat beans, hummus, soybeans/tofu, spinach and peas.
5. Sprinkle hemp or chia seeds over salads or smoothies, and try the ancient grains like quinoa or amaranth (which you can make into a breakfast porridge).

5. WILL MY VEGETARIAN/VEGAN GET ENOUGH FAT? Omega-3s?

It is absolutely possible and important to do so, but it is not a given! Keep in mind that people of all diets can make healthy or unhealthy choices even within their dietary restrictions. If your child vegetarian leans toward a diet heavy on the grilled cheese sandwiches and macaroni and cheese, not to mention donuts and cookies, while perhaps tending away from as wide a variety of vegetables as you would like, he/she may actually have a high-fat diet. Many teens, however, go the opposite direction and eat overflowing and deceptively- filling plates of vegetables that do not have enough fat. Fat is important and should make up approximately 30% of the energy a child/teen consumes in a day. Since fat provides 9 kcal per gram, teens consuming 2000 - 2600 kcal per day need around 75g of fat per day.

Good sources of fat include avocados (32 g each!), peanut butter, nuts, seeds, and oils (including olive, canola, and coconut oil). A cup of milk contains 2.5 g of fat, and fortified substitute milks have about that much or more. You will have to read labels on them, as there is some variability—Silk Coconut milk and Ripple Pea Milk top the charts with 5 g and 4.5 g per cup, respectively.

And, while we are on the subject of fats, what about those Omega-3 fatty acids (DHA, EPA, and the precursor called ALA) that everyone is always talking about, the ones that help for eye and brain development and also for heart health? The main sources of omega-3s are fish, eggs, and algae, but how much algae is your vegetarian/vegan eating? Indeed, vegetarians and vegans have been shown to have generally lower levels of omega-3s than omnivores and would likely benefit from more, though as of yet there are no officially recommended daily allowances for omega-3s for children (or adults). For adults, there is a suggestion that 250-500mg of combined DHA and EPA is a minimum goal. Kids/teens can get one of the omega-3s, alpha- linoleic acid (ALA), through flaxseeds and hempseed (which can be added to pancake mix or oatmeal), chia seeds (which can be added to smoothies), soy, and canola oil. Kids can also get omega-3s (DHA) from Ripple Pea milk, the milk substitute made from peas.

A WORD ABOUT PERCENTAGES ON FOOD LABELS

When you look at food labels to see how much of many of our next nutrients are in foods, sometimes instead of a number of units, it will list a percentage. That percentage is telling you what percentage of Daily Value is provided, but Daily Value is NOT the best guide when thinking about your child’s nutritional needs. Daily Value (DV) is a single number issued by the FDA for labeling purposes and is different from the more precise and age-specific Recommended Daily Allowances (RDA), which is what we pediatricians recommend parents follow. RDAs are determined by the Institute of Medicine and can differ from DVs— so get wise to it! In the case of Vitamin B12, for example, younger children have an RDA of 1.2-1.8 mcg, while teens have an RDA of 2.4 mcg. On labels, however, packaging will list a percentage of the Daily Value (DV), which for Vitamin B12 is 6 mcg. If, for example, the label says a serving of your coconut milk has 50% the DV, it has 3 mcg, which is great and exceeds the RDA for your child (it’s not just half of what he/she needs!). In some cases, like for Vitamin D, on the other hand, the DV is less than the RDA, so you can get misled into thinking you are getting enough Vitamin D, when you are not.

6. WILL MY VEGETARIAN/VEGAN GET ENOUGH IRON?

They can if they plan! It is certainly easier for meat and fish eaters to get enough iron, and—unlike the protein situation—milk and eggs are not too helpful as iron sources. Consequently, vegetarians and vegans are both in the same boat. There is a lot of iron in meat, and that “heme-iron” is more easily absorbed than “non-heme iron” in vegetables. So vegetarians and vegans alike will need to eat more of their iron-containing vegetable-based foods to get the necessary protein. It is also important to note that some foods can help or hurt you in your efforts to get iron. Legumes (which have phytates) or coffees and teas (which have tannins) decrease iron absorption from other foods, while your friend Vitamin C —think oranges, strawberries, tomatoes—increases iron absorption.

Toddlers and school kids need between 7-10 mg of iron daily, whereas teens need more, 11mg for boys and a whopping 15mg for girls (who lose iron with their periods). One cup of kale or collard greens has just 1mg, so you can see that you will need quite a bit to approach the daily requirement. Remember oatmeal as a great source of iron—13 mg in one cup! Dried fruits can be helpful to have around (1.75mg in 1/2 cup of dried apricots), as can peas and pistachios (2mg in 1/2 cup peas, 1.2 mg in 1/4 cup of pistachios). Ripple pea milk, a milk substitute made of peas, has quite a bit of iron—2.7 mg per cup (on the label it says 15% of the 18 mg/day Daily Value)! Soy and nut milks do not have nearly that, but some have 0.75-1mg (Chocolate Silk Cashew Milk has just over 1mg, or 8% of the DV), and every little bit helps!

As I have warned before, don’t be misled by percentages of Daily Value on the food labels. The DV for iron is 18mg, but that is actually more than your child needs according to RDAs (even if your child is a female teen who needs 15 mg per day). So, if your oatmeal has 20% of the DV of iron, it has 3.6 mg. That is not just 20% but more like 33% of what your child needs.

Pearls of Iron Wisdom:

1. Eat iron-rich foods (oatmeal, leafy greens, legumes, dried fruit, soy products, etc)

2. Eat Vitamin C, to help iron absorption, along iron-containing foods (think

citrus, strawberries, broccoli or tomatoes)

3. Reduce your intake of tea/coffee with tannins (that reduce iron absorption)

4. Ripple Pea Milk is a very good source of iron!

7. WILL MY VEGETARIAN/VEGAN GET ENOUGH CALCIUM and VITAMIN D?

As Marisa Tomei’s character said in the movie My Cousin Vinny, “It is a trick question.” She also used other words not fit for this blog. Still, this question is tough because truthfully, many teens of even unrestricted diets seem to struggle these days to get enough calcium and Vitamin D, as many replace their milk-drinking habits with a sugary-beverage habit. However, if a teen (vegetarian or not) has about three servings of dairy a day plus vegetables that contain calcium, he or she can usually get the recommended 1300 mg of calcium (RDA is 1000 mg for kids 4-8 years old and 1300 mg for kids 9-18) and the 600-800 IU of Vitamin D recommended (600 for 1-9 year-olds and 800 for 9up). Vegan kids and teens also can get enough calcium these days, too, IF they drink a fortified milk substitute. This is a wonderful gift of the food industry to vegans, as they have added calcium and Vitamin D to their milk substitute drinks. Whereas regular unfortified soy milk has 6 times less calcium than regular milk, most soy, almond, coconut, cashew and even pea (Ripple) milk at grocery stores today are fortified and have ample calcium, even 1.5 to 2 times the amount in regular milk!

Many other foods have been fortified with calcium and sometimes Vitamin D as well, such as cereals, waffles, and orange juice (look for “Calcium added” in big letters on the packaging— but, remember that juice is sugary and not that healthy, so limit it!). Other good sources of calcium are spinach (240 mg per cup) and broccoli (180 mg per cup). Dark sugarcane-derived molasses has quite a bit, too (135 mg in 1 tbsp) — maybe put that over your fortified waffles? Also, mushrooms are your friend— they contain a lot of Vitamin D (634IU in 1 cup of portobello mushrooms)!

Note that for label-reading purposes, Daily Value for Calcium is 1000mg, which is LESS than the RDA for age 9+ of 1300 mg, and the Daily Value of Vitamin D is 400IU, also LESS than the RDA for kids 1year and older. So, when a label on your almond milk says it contains 45% of the DV of calcium, it means 45% of 1000, or 450mg. This is actually more like a third (33%) of what your child’s recommended Calcium intake should be.

Pearls of Calcium/Vit D Wisdom:

1. Drink milk or fortified milk substitutes or have other dairy 3 times a day
2. Enjoy calcium-rich greens like kale, bok choy, mustard greens
3. Look for other calcium-fortified foods like cereals, waffles, and orange juice
4. Molasses (dark, sugar-cane based) for calcium!
5. Mushrooms for Vitamin D!

8. IS MY VEGETARIAN/VEGAN GETTING ENOUGH VITAMIN B12?

Similar to the calcium and Vitamin D discussion, this is an area in which we pediatricians USED to tell vegetarians who consumed milk and eggs that they would be fine, whereas we told vegans they were not getting enough Vitamin B12 and would need a supplement. However, the food industry has come to the rescue! Fortified milk substitutes like coconut, soy, and almond milk now are fortified with Vitamin B12. One cup of Silk Soy or Organics Plain Soy milk has the Vitamin B12 that you need in a day. Fantastic! So—you decide— you can take a multivitamin with Vitamin B12, or you can make a habit of drinking fortified milk substitutes. Without either of these things, though, a vegan may not get enough Vitamin B12.

Again, don’t be confused in reading labels. In the case of B12, Daily Value —which is what percentages are based on for food labels—is a lot higher than RDA, which is the vitamin recommendation for kids by age. Younger children have a Vitamin B12 RDA of 1.2-1.8 mcg, while teens have an RDA of 2.4 mcg. On labels, however, packaging will list a percentile of the Daily Value (DV), which for Vitamin B12 is 6 mcg. If, for example, the label says a serving of your coconut milk has 50% the DV, it has 3 mcg, which is great and exceeds the RDA for your child.

9. IS MY VEGETARIAN/VEGAN GETTING ENOUGH ZINC?

Lacto-ovo vegetarians who are good about drinking milk probably are, but vegans may not be. To make things even harder, zinc quantities are often not even listed on packaging. The RDA of zinc for kids 9-13 yrs is 8 mg/day, whereas girls and boys fourteen and up need 9 mg/day and 11 mg/day, respectively. The DV of zinc is 15 mg —quite a bit higher than these RDA recommendations—so remember that when reading packages!

The kings of zinc provision are oysters (74 mg/cup), which provide 70x the amount of zinc in servings of a lot of other foods, but that doesn’t help our vegetarians/vegans (or many of our omnivores who are texturally-challenged when it comes to oysters). Legumes, nuts and seeds, however, can help you get enough zinc. A half cup of baked beans has 2.9 mg of zinc, and an ounce of cashews or pumpkin seeds have 1.5-2 mg.

10. IS MY VEGETARIAN/VEGAN GETTING ENOUGH FIBER?

Vegetarians and vegans SHOULD be getting enough fiber if eating a varied diet with many types of vegetables. However, this is not a given! Some vegetarians subsist on breads and cheese and are not getting the fiber they need. Fiber is a challenge for many children and teens these days, as evidenced by our seeing a lot of constipation problems in the pediatric office. Look to whole grains, vegetables and fruits (with the exception of bananas) to be excellent fiber sources. Kids need about 25-30 grams of fiber daily, and they can get 5 grams in a serving of bran flakes alone. One rule of thumb is that for every 1000 kcal that a person eats, they should strive for 14g of fiber.

11. Make things delicious.

One of my sister’s biggest pieces of advice to other vegetarians/vegans and their families is to continue to expand your culinary and dietary horizons and not view the vegetarianism as an impediment to enjoyment. As a physician who wants people to strive for variety in even a restricted diet, I whole-heartedly agree. Take a world view. Asian food is great for vegans—the only big things to avoid are fish and oyster sauces, but many recipes and restaurants can make do with soy sauce alone. Curries often are made with coconut milk—perfect. Mexican food allows for many vegan options such as veggie tacos, guacamole and salsa, and black bean soup. Italian food with its pasta and tomato and pesto sauces, pizzas that can be made vegetarian, and risotto (great with mushrooms) offers great options, as does do Greek, Mediterranean, and Middle Eastern cuisines with their salads, hummus, and baba ganoush. Indian cuisine with its rice, naan, garbanzo beans, and spinach paneer (to name just a few things) is perfect. The list goes on. Often, the heart of a dish is really its seasoning and spices, and those can be enjoyed with just vegetables or a meat substitute!

There are so many options available at grocery stores now, too. Score! You can buy faux chicken fingers, veggie burgers, “meat”balls,” meatless-sausages and of all kinds, and even vegan hotdogs. And—from experience—they can taste pretty good!. Veggie bacon may not taste quite as amazing as real bacon, but it helps fulfill a craving, doesn’t allow for feeling deprived, and holds to your vegetarian choice. You can also learn to cook with meat-substitutes like tofu, tempeh, and seitan (contains gluten) that are now featured entrees of some world-class vegan restaurants. And, on the subject of dining out, we at the Cook Children’s Henderson office are extremely close to a great Fort Worth vegan establishment — Spiral Diner!

There is also the potential for amazing desserts. There are many vegan ice creams available now, including several options by Ben and Jerry that are incredibly tasty. You can also whip up cashew cream to use in place of real cream in cake and other recipes. My sister likes to slice bananas, freeze them, and then put them through the food processor with peanut-butter and/or chocolate syrup for a delicious and pretty healthy vegan dessert.

Best wishes for your ventures into vegetarianism and veganism. Who knows, dietary change that seems intimidating now may become second nature and a part of your child and your family’s identity. Think of Reese Witherspoon’s character in Legally Blonde, introducing herself to her Harvard Law School classmates. “Hi, I’m Elle Woods, and (holding up her chihuahua) this is Bruiser Woods,” she says, “and we are both Gemini vegetarians.”

Bon appetit to all, and many thanks to my awesome sister, Ariana Nizza-Chapman, for the inspiration and the many tips!

Let’s Not Send Zombies Off to School: Work on Sleep Schedules NOW

My kids are currently out of town for their annual summertime week with my mother, and that leaves us parents with some time to relax, eat out, watch Game of Thrones, and —drumroll—strategize about our parenting strategies. Yes, I know, that last bit sounds redundant and altogether less fun than the others. But —let’s face it—this parenting thing doesn't quite happen by itself—it takes total, multilevel “stategery.” This week, my husband and I must rethink the ever-changing and ever-challenging media rules in our household, reassess our approach to sibling tensions and our kids’ overly astute eye for even the slightest inequity between them, and, of course, discuss the sleep plan.

The sleep plan— OMG, I almost forgot! Yikes—we are just 3 weeks away from the start of school, and our kids are sleep-schedule disasters. We let it happen. We let them gradually follow their tween and teen circadian rhythms right into the swirly whirl of unstructured summer existence. We allowed for the full release of their inner night-owl. Recently in fact, our kids have tucked us parents into bed, they themselves dropping off much later (or sometimes really early the next morning), only to awaken around lunch-time the following day. Oh, Nellie.

So now, I’m calling on all parents with a sleep conundrum on their hands like we have. I’m calling on all parents who allowed their children to drift onto a late schedule. I’m also calling parents of rising kindergarteners, who up to now have let their job-schedule dictate family sleep patterns, but who now must have their kids alert and ready for circle time at 8am! I’m calling on all parents who perhaps have never had a good sleep schedule for their kids, or at least not as good a schedule as they would like. And I’m calling on the Sandman, that character of myth who sprinkles the gift of sleep and good dreams. Because, together, we have got to take action. We must rearrange the timing of our kids’ sleep, and we have no time to spare. The consequence of inaction is a big one, for without our intervention, school drop- off could look like a scene from the Thriller video, complete with the plodding, the stumbling, and the blank-eyed stares but without any good dancing. Let’s go.

1. Set a goal for optimal hours of sleep. First we must figure out just how much sleep to strive for. According to the American Academy of Sleep Medicine, whose guidelines are endorsed by the American Academy of Pediatrics, a grade-school child should sleep for 9-12 hours, while teens should sleep 8-10 hours at night. To know exactly how much our individual children need, however, we need to do a little observing and tweaking. Even if children have — (ahem)— less-ideal sleep habits this summer, it is helpful to calculate how many hours they have slept on the average, during periods when they have seemed well-rested overall, in order to awaken refreshed. My kids are ages 12 and 14, so they per the guidelines should sleep 8-10 hours. In fact, in watching them it does seem they awaken pretty chipper with 9-9.5 hours of sleep, provided they are not sleep-deprived to begin with (ie post- science project or sleepover), in which case they need 10 or 11. Of course, children’s needs can vary based also on the amount of exertion in a day, so be open for minor variations— they (and you) will have to follow their bodily and behavioral cues. If you have a younger child, take note of fussiness as a true signal that your child needs more sleep. My kids always tease me for blaming everything on sleep, and— in the course of occasional emotional outbursts, my kids have been known to preemptively say, “And, no, the reason I’m reacting this way has nothing to do with being sleepy— you always blame sleep.” Note: I see my tendency to blame bad attitudes on sleep deficits not just as smart (and based on known truths about sleep and its link to behavior) but also as compassionate— wouldn’t my kids prefer I blame their orneriness on a sleep deficit rather than on their having a character flaw or generally being troll-like?

2. Translate those goal hours into a target bedtime and wake-up time. Knowing the number of hours we want our children to snooze, we next need to plot out a reasonable bedtime and wake-up time to achieve these goals. This can be trickier than it sounds, as many factors are at play such as school start times (maybe for more than one sibling and at more than one school), how long it takes your child to get ready and eat breakfast in the morning (a plug for breakfast, which is proven to help learning), and how long it takes to get to school. And this is without even mentioning how your will fit your own hygiene and responsibilities into the picture! In the case of my kids, sleeping from 9:30pm until 6:30am (or from 10pm until 7am), will get them the 9 hrs of the sleep they seem to need. Thankfully for our family, these hours work pretty well with our distance from the school and with the school’s start time—phew. I know that for some families, taxing work obligations and bus schedules may make such a schedule impossible. As with everything in life, we must simply do the best we can. Where this schedule puts the squeeze on my family is in the evenings, as we sometimes get home late from work or sports games and then get a late start on dinner, which makes a bedtime of 9:30 a challenge. Still, sleep needs to be a priority. It just has to be. So maybe we need to eat some tuna fish for dinner, or maybe we need to plan ahead for those nights and have some frozen or pre-made options on hand. If we want our kids to be happy, well-behaved (or at least behaving at their best), and alert for good learning and school performance, they need to get as close to their optimal night’s sleep as possible.

3. Take 15 minute baby-steps from the current bedtime to the target bedtime. This step is the heart of our plan and the reason for our need to start our sleep plan ASAP. You see, while procrastination may work in other circumstances, sleep patterns change only as fast as a 15 minute nightly increment, or so the sleep specialists say. So, let’s consider my kids, one of whom currently has a self-imposed bedtime of—again, gulp—something like 12:30am (don’t judge). We need to move that 12:30 am bedtime back 3 hours to 9:30 pm, and to do that the most effectively and with the least consequence of his turning into a zombie, we need to move his bedtime 15 minutes earlier each night. Being 3 hours off-target means being twelve 15-minute steps away from the goal bedtime or twelve days of sleep preparation away from reasonable. We have cut things close! My son’s first night home, he should go to bed at 12:15am, the next night 12 midnight, the next night 11:45pm, etc. Ideally, he would also move the wake-up time 15 minutes earlier each day, so that he would he still get his 9 hours nightly— that is, wake-up at 9:15am on day1, 9am on day 2, etc. That said, I will be totally honest and admit that he actually has pre-season sports obligations at school for some days before school starts that will start at the school start time of 8am. SO, he will be getting less sleep than we wanted, and we really should have started this plan two weeks ago. Oh well. He may slowly turn into a bit of a zombie, but hopefully the worst of his sleepy haze will be over before school starts. We will all just have to do the best we can. He may have to throw in a cat-nap here and there (nothing longer than an hour, which might completely wreck our efforts), or he may have to follow his body’s cues to get to bed a bit earlier than the schedule. And that is fine.

4. Prioritize good sleep hygiene. In addition to trying to get onto a good schedule, we will all need to apply principles of “sleep hygiene,” or healthy habits to promote sleep.These principles are not rocket-science, but they require some forethought.

• No screen time in the hour before stated bedtime. This means having no TV even anywhere nearby, since the lights of the TV will awaken the mind even if out of view. And definitely no video games.

• Digital devices should spend their nights in some other room altogether—not the bedroom. Use an alarm clock to wake-up rather than a smartphone, and don’t buy that bit about night-screen lighting and “Do Not Disturb” settings—the devices are still better at a distance. People still glance at their phones for texts and checks, and that means a part of their brain is still “on” (and interested in how many “likes” or hearts a post has gotten) rather than shutting down

• Plan on a minimum of 30-45 minutes to get ready for bed and to calmly wind down.

• Consider reading an enjoyable, non-school-related, non-stressful, not-too-exciting book or magazine. Or choose downright dry reading material, for that matter (would you like to borrow a medical journal?).

• Consider listening to calming music or sounds of nature (not peppy music!).

• Consider scribbling a short list of gratitudes for the day— peaceful thoughts!

• Consider meditating or breathing deeply— an app like Headspace or CALM can be very helpful in achieving this goal. If new to meditation, you might also check out Goldie Hawn’s book Ten Mindful Minutes, which is aimed at introducing kids to these concepts and skills.

• Consider enjoying a bedtime story with your your parents (even if they are big kids now).

• Consider a warm, relaxing bath, which can really help relaxation (but may add time to the projected bedtime preparations, so you must account for that).

• Make your room dark and preferably a bit cool, and then consider total quiet vs white noise based on your personal preference.

• Exercise earlier in the day will help your quality of sleep, but do NOT do any high-energy, cardio exercise right before bed—endorphins will start flowing and wake you up.

• Eat a healthy diet with dinner preferably not immediately before bedtime (if necessity requires such timing, then a lighter meal will allow for better sleep).

• Do not discuss big life questions or worries right before bed! Parents, keep in mind that kids often ask big questions (such as “What happens after someone dies?”) just as you are kissing them goodnight. But don’t fall for it! Tell them you value their question and will discuss it in the morning.

• Try visualization of one of your favorite places—even imagining walking around there and entering different rooms can be a pleasant descent into dreamland.

• If your child tends to run through a list of worries at night, consider making a “worry box.” Have your child write a few concerns on strips of paper and put them in the box. Then explain that these concerns should be thought about only in very small and deliberate doses at ANOTHER time (for example you can offer to take one strip of paper out tomorrow in the day, to allow the child to worry for 5 minutes max). Let us limit worry time if we can, as thinking about worries makes worries grow, doesn’t solve anything, and shortens sleep.

We all want to be sure our kids are awake and alert for the start of classes, so let’s get right to work on this. Or, shall I say, let’s get right to sleep! I certainly don’t want any zombies anywhere near me! But all this talk about sleep makes me feel like yawning. I mean, doesn’t your pillow call you, too? What time did I go to bed last night? It was only. . .only. . . ZZZZZZ.