How Should Bike Helmets Be Fitted?

Patient Presentation
An 8-year-old male came to clinic for a health supervision visit.
During the visit, the nurse practitioner asked about his bicycle helmet use.
He and his mother said that he sometimes used the helmet but not consistently.
He said that it didn’t fit well and hurt his mouth so he didn’t use it.
His mother said the she had just tightened the straps once when he first started using it but didn’t actually fit the helmet to him
She also wasn’t sure how to fit the helmet.
The pertinent physical exam showed a healthy male with normal vital signs and growth parameters.
The diagnosis of healthy male was made.
The nurse practitioner was aware of the Bicycle Coalition of Maine’s “Eye-Ear-Mouth” fitting guidelines.
She was able to find the fitting instructions for the family and printed them out to take home.
She recommended keeping the helmet near the bicycle so that he would remember to wear the helmet.
She also recommended that he use it for other wheeled activities such as riding a scooter, skate boarding, and in-line skating.
She reminded him to make sure that he took the helmet off for other non-wheeled activities especially playing on playground equipment and climbing trees where the helmet potentially could become caught.

Discussion
Bicycling and other wheeled sports are great exercise and fun family activities. But to maintain the fun, safety must be a consideration.
There are ~540,000 emergency room visits for bicycle injuries every year. Of those visits, ~67,000 involve head injuries and ~27,000 require hospitalization.
About 770 people died from bicycle injuries in 2006, mainly from head injuries. It is estimated that a bicycle helmet could prevent 45-88% of brain injuries.

Unfortunately many people do not wear a helmet or it is improperly fitted.
In a cross-section study of 8 communities in Texas in 2002 that evaluated helmet use for wheeled activities, only 13.6% of people observed wore a helmet.
Of those that wore a helmet, only 72.5% wore them correctly. Wearing of the helmets was dramatically increased if companions wore helmets, particularly adults.

Learning Point
It takes ~ 10-15 minutes to properly fit a helmet. Taking the initial time makes it easier to later just put on the helmet, do a quick check and then be off for a great time with the bicycle or other wheeled activity.

  • Size
    • Measure the head when buying the helmet to get the approximate size. Sizing charts are available.
    • Put the helmet on and make sure it fits snugly and doesn’t rock from side to side.
    • Use different sizing pads to adjust the helmet so it doesn’t rock and fits snugly.
    • A sizing ring is sometime used and can be adjusted by clicking it in place (like using cable ties) or by turning the adjustable knob
    • The helmet should be comfortable and not squeeze the head.
  • Position
    • The helmet should be level on the head and low on the forehead – basically straight across the eyebrow about 1-2 finger-widths above the eyebrow.
  • Straps and Buckles
    • Pull the straps (usually from the back of the helmet) and center the left buckle under the chin.
    • When adjusting the straps and buckles it may be easier to do this with the helmet off the head and then replacing it on the head to check the adjustment.
    • The side straps should be adjusted so both form a “V” shape under and just in front of the ears. The slider should be locked if possible.
    • Buckle the chin strap and tighten it until it fits snugly with no more than 1-2 fingers under the strap. The buckle should be centered under the chin.
  • Checking the adjustments – “Eyes-Ears-Mouth”
    • Does the helmet rock forward into the EYES? If yes, unbuckle the helmet and tighten the back strap by moving the slider back toward the EAR.
      Buckle the helmet again, retighten the chinstrap, and test the helmet again.

    • Does the helmet rock back more than two fingers above the EYEbrows? If yes, unbuckle the helmet and shorten the front strap by moving the slider forward from the EAR.
      Buckle the helmet again, retighten the chinstrap, and test the helmet again.

    • Open the MOUTH wide. The helmet should pull down on the head. If not, readjust and tighten the chinstrap.
    • A rubber band is found on the chinstrap. Roll the rubber band down to the buckle and place all four straps through the rubber band. The rubber band must have all four straps and be close to the buckle to prevent slipping.

Helmets should be checked each time they are used and refitted as necessary. Helmets should not be used for non-wheeled activities such as playing on playground equipment, climbing trees, and for other activities where the helmet potentially could become caught.

They usually are cleaned by water and a cloth but manufacturers recommendations should be followed. Helmets should be stored in a place with convenient access so they will be used and a place where they will not be damaged accidentally.
Helmets should be replaced if they are involved in a crash whether or not any damage is visible. They should also be replaced if they have been damaged in any way.

Suggestions for specific needs of young children, small or large heads, etc. can be found at the Bicycle Helmet Safety Institute.

Questions for Further Discussion
1. What are my state’s laws regarding bicycle helmet use or helmet use for other wheeled activities?
2. Should children riding as passengers on a bicycle or being towed by a bicycle wear a helmet?
3. What is the cost for a bicycle helmet and where can families obtain low-cost ones in the community?
4. When is a child old enough to ride a bicycle and how should a bicycle be fitted?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sports Safety and Exercise and Physical Fitness.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

Centers for Disease Control. Revised Final FY 1999 Performance Plan And FY 2000 Performance Plan
X. Injury Prevention and Control.
Available from the Internet at http://www.cdc.gov/od/perfplan/2000/2000x.htm (rev. 1/12/2000, cited 8/18/08).

Forjuoh SN, Fiesinger T, Schuchmann JA, Mason S.
Helmet use: a survey of 4 common childhood leisure activities.
Arch Pediatr Adolesc Med. 2002 Jul;156(7):656-61

National Highway and Transportation Safety Administation. Easy Steps to Properly Fit a Bicycle Helmet.
Available from the Internet at http://www.nhtsa.dot.gov/people/injury/pedbimot/bike/EasyStepsWeb/index.htm (rev. 9/2006, cited 8/21/08).

American Academy of Pediatrics Policy Statement. Bicycle Helmets. Pediatrics. 2001;pp. 1030-1032. Available from the Internet at: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;108/4/1030 (rev. 8/1/08, cited 8/21/08).

Bicycle Helmet Safety Institute. Helmet Related Statistics
from Many Sources.
Available from the Internet at http://www.helmets.org/stats.htm (rev. 8/20/08, cited 8/22/08).

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Interpersonal and Communication Skills

    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    September 29, 2008

  • What Else Causes Acute Pharyngitis That Isn't Group A Streptococcus?

    Patient Presentation
    A 6-year-old female came to clinic with a 1 day history of sore throat and fever to 102° Fahrenheit.
    She also had a runny nose but no cough, ear pain, abdominal pain, nausea, emesis or rash. Her brother had similar symptoms as did several students in her class.
    There were known streptococcal infections in her school.
    The past medical history showed 1 previous strep throat and 2 ear infections.
    The review of systems was otherwise normal.
    The pertinent physical exam showed a mildly ill-appearing female with a temperature to 38.4° Celsius. Her vital signs and growth parameters were otherwise normal.
    HEENT examination revealed clear rhinorrhea and bilateral tympanic membranes with small effusions, normal landmarks and mobility.
    She had an erythematous pharynx and tonsils without palatal petechiae or exudates.
    She also had anterior cervical nodes bilaterally that were < 0.5 cm.
    Lungs were clear and her skin examination reveled no rashes.
    The laboratory evaluation included a rapid strep test that was negative.
    The diagnosis of acute pharyngitis most likely caused by a respiratory virus was made.
    The parents were given instructions for symptomatic care and when to telephone concerning new or progressing symptoms.
    Her throat culture eventually was negative.

    Discussion
    Acute pharyngitis is a common problem accounting for 1-2% of all outpatient visits.
    Patients usually complain of pain to various degrees, fever and erythema of the pharynx.
    Acute pharyngitis is more common in the colder months of the year.

    The most important bacterial cause is Streptococcus pyogenes, or beta-hemolytic, group A streptococcus (GAS). It causes 15-30% of tonsillopharyngitis in school age children.
    GAS is often spread between family members with children being the reservoir.
    Common signs of GAS include erythema and exudates of the tonsils and pharynx, petechiae on the soft palate, anteriorcervical adenitis and scarlatiniform rash.
    Common symptoms of GAS include pharyngeal pain, fever, headache, abdominal pain, nausea and vomiting.
    Treatment for GAS usually includes penicillins, cephalosporins and macrolide antibiotics.

    Learning Point
    Acute pharyngitis is most commonly caused by viruses, particularly rhinovirus, coronavirus and influenza.
    Commons signs of non-GAS infection include conjunctivitis, stomatitis, and ulcerations of the pharynx.
    Common symptoms of non-GAS infection include cough, coryza, hoarseness and diarrhea.

    Other causes of acute pharyngitis that are not GAS include:

    • Bacterial
      • Anaerobes, mixed
      • Arcanobacterium haemolyticum
      • Chlamydia
      • Corynebacterium diphtheriae
      • Francisella tularensis
      • Neisseria gonorrhoeae
      • Streptococcus – Groups C and G
      • Treponema pallidum
      • Yersinia enterocolitica
      • Yersinia pestis
    • Viral
      • Adenovirus
      • Coronavirus
      • Coxsackievirus – A
      • Cytomegalovirus
      • Epstein-Barr virus
      • Herpes simplex virus – Types 1 and 2
      • Human Immunodeficiency Virus
      • Influenza – Types A and B
      • Parainfluenza virus
      • Rhinovirus
    • Other
      • Chlamydophilia psittaci
      • Chlamydophilia pneumoniae
      • Mycoplasma pneumoniae

    Questions for Further Discussion
    1. Within how many days of symptom onset should GAS be treated?
    2. What is the sensitivity and specificity of rapid strep tests?
    3. What are the potential complications of acute pharyngitis?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Sore Throat and Throat Disorders and at Pediatric Common Questions, Quick Answers for this topic: Strep Throat

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Gerber MA.
    Diagnosis and treatment of pharyngitis in children.
    Pediatr Clin North Am. 2005 Jun;52(3):729-47..

    Alcaide ML, Bisno AL.
    Pharyngitis and epiglottitis.
    Infect Dis Clin North Am. 2007;21(2):449-69.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Professionalism
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    September 22, 2008

  • What Other Abnormalities are Associated with Prune Belly Syndrome?

    Patient Presentation
    A general pediatrician on-call for a regional children’s hospital received a telephone call from a physician in a distant emergency room.
    The physician said, “Do you know this 5 month old boy with Eagle-Barrett syndrome?
    Well today he has a fever to 103° Celsius, and has been having some emesis.
    I’ve already done his laboratory work and his urine has too numerous to count white blood cells, some red blood cells and bacteria on the gram stain.
    He also has a total white blood cell count of 18,500 with a 72% left shift and his CRP is 4.5. Looks like he has pyelonephritis again.
    I’ve already done his blood and urine cultures and given him some ceftriaxone.
    I’d like to transfer him to your institution because you usually care for him there.”While the emergency room physician was talking, the pediatrician was trying to remember what Eagle-Barrett syndrome was.
    When the pediatrician asked, the emergency room physician replied, “Oh, it’s Prune Belly syndrome that’s why you guys take care of him.”The general pediatrician suddenly realized the significance of all the other information that the emergency room physician had given him, and also that he was not the appropriate pediatrician to be contacted at the children’s hospital.
    After asking a couple more questions about the patient’s status and treatment and arranging the transportation to the children’s hospital,
    the pediatrician told the emergency room physician, “I’m not a nephrologist and these children are usually taken care of by them. I am going to contact the nephrologist and if he has any other questions or suggestions for treatment he will call you back directly.
    The child most likely will be going to the nephrology service but we will work that problem out here.
    If you have any other questions, you can call me back or can call the nephrologist.”After finishing, the general pediatrician contacted the nephrologist who agreed that the diagnosis of pyelonephritis was logical and that the patient was being appropriately treated.
    He also agreed to admit the child onto the nephrology service.
    The patient’s clinical course showed that he had Pseudomonas pyelonephritis that was treated successfully with ciprofloxacin.

    Discussion
    Prune Belly syndrome is characterized by various anatomical urinary tract anomalies, cryptorchism and deficiency of abdominal wall musculature. It has a characteristic distended abdomen with wrinkled skin which gives rise to the name.
    This syndrome was first described in 1839 by Frohlich. In 1950 Eagle and Barrett described 9 cases and later other physicians suggested Eagle-Barrett syndrome as an alternative eponym.

    The incidence is approximately 1:40,000 live births. Females can have an incomplete form of the syndrome but obviously cannot have cryptorchism. They may have other genital abnormalities such as vaginal agenesis, hydrocolpos, and bicornuate uterus.
    The severity varies from lethality in utero, to children with abnormal musculature and undescended testes but with normal renal function.
    Patients may be identified in utero because of screening ultrasounds or because of uterine measurements being small for dates secondary to decreased urine production.
    In the neonatal period, the infants usually present with the characteristic shriveled abdominal skin.
    Urological abnormalities include:

    • Cryptorchidism – testes usually at the level of the iliac vessels.
    • Urethra – anterior is usually normal, posterior is often dilated. Some have posterior urethral valves.
    • Prostate is absent or hypoplastic
    • Epididymis, vas deferens and seminal vesicles are often abnormal and contribute to infertility
    • Bladder is smooth walled, may be dilated, have diverticula or patent urachus,
    • Urachus is patent
    • Ureters are often are dilated, elongated and tortuous with little or no peristalsis. Vesicoureteral reflux is found in 70% of patients.
    • Kidneys may be dyplastic or have multicystic dysplastic kidney disease. Amount of renal parenchymal disease determines ultimate renal function

    The treatment is a combination of medical and surgical interventions.
    Surgery may include a variety of urinary diversion and reconstructive surgeries to improve urinary stasis and prevent infections. Early orchiopexy is indicated.
    Abdominoplasty may also be indicated.
    Medical treatment includes monitoring and treatment of renal insufficiency as well as prophylactic antibiotics to decrease infections.

    Learning Point
    Other associated abnormalities for patients with Prune Belly syndrome include:

    • Anorectal abnormalities – atrial septal defect, Tetrology of Fallot, ventriculoseptal defect
    • Cardiac abnormalities
    • Gastrointestinal abnormalities
      • Constipation – because of poor abdominal musculature
      • Hirschsprung disease
      • Imperforate anus
      • Malrotation and volvulus
      • Omphalocoele and gastroschisis
      • Stenosis and atresia
    • Motor developmental delay – because of poor abdominal musculature poorly assisting movement and balance
    • Orthopaedic abnormalities
      • Developmental hip dislocation
      • Congenital verticle talus
      • Pectus excavatum
      • Sacral Agenesis
      • Scoliosis
    • Respiratory problems
      • Pulmonary hypoplasia and neonatal problems such as respiratory distress syndrome
      • Respiratory infections – because of poor abdominal musculature

    Questions for Further Discussion
    1. What are the indications and preferred type of dialysis in patients with Prune Belly syndrome?
    2. In general, what are the indications for kidney transplant?
    3. How are misdirected telephone communications handled at your own institution and how could they be improved?
    4. What are good resources for looking up medical eponyms?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for these topics: Birth Defects and Kidney Diseases.

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Jennings RW.
    Prune belly syndrome.
    Semin Pediatr Surg. 2000 Aug;9(3):115-20.

    Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1737-38.

    Mahajan JK, Ojha S, Rao KL.
    Prune-belly syndrome with anorectal malformation.
    Eur J Pediatr Surg. 2004 Oct;14(5):351-4.

    Abdominal Muscles, Absence of, with Urinary Tract Abnormality and Cryptorchidism. Online Mendelian Inheritance in Man.
    Available from the Internet at: http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=100100 Page(rev. 9/7/2007, cited 8/11/08)

    Franco I. Prune Belly Syndrome. eMedicine.
    Available from the Internet at http://www.emedicine.com/med/TOPIC3055.HTM (rev. 1/18/2008, cited 8/13/08).

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills

    18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism
    20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

  • Systems Based Practice
    25. Quality patient care and assisting patients in dealing with system complexities is advocated.
    26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    September 8, 2008

  • What Types of Foods Should Vegetarians Eat to Maintain Proper Nutrition?

    Patient Presentation
    A 16-year-old female came to clinic for health supervision.
    During the interview she said that over the past few months she had decided to become vegetarian.
    When further questioned, she said she initially stopped eating meat, fish and poultry and was eating eggs and dairy products, but recently she has stopped eating those also.
    She said that she is drinking soymilk, using some tofu, and “throwing some nuts on my salad.”She was not eating any other soy products and used few nut products or oils. She had been eating a fairly restricted diet of lots of “stir fried vegetables,” salads and bread.
    She said she didn’t do any reading about vegetarian diets or really plans any of her meals; she just eats what is available.
    She denied trying to lose weight, purging, increasing her exercise or being unhappy with her body image.
    Her motivation for beginning her vegetarian diet was that she thought that it would be healthier.
    The past medical history and social history revealed a healthy female living in an omnivore family.
    The pertinent physical exam showed a healthy appearing female. Her growth percentiles were in the 25-90%. She had maintained her weight over the past year and was Tanner stage IV for pubertal development.
    The diagnosis of a teenager who had begun a vegetarian diet without adequate nutritional information was made.
    As she also needed screening blood tests, laboratory evaluation included a complete blood count, B12 level, and fasting cholesterol and triglycerides.
    These were eventually normal with the exception of a hemoglobin of 12.2 mg/dl and hematocrit of 35%.
    She was counseled about the risks of poor nutrition and was interested in learning about different options to increase the variety of foods she ate and how to prepare them. A dietician appointment was arranged.
    She also willingly agreed to take a daily multivitamin with extra iron and was to follow up in 2-3 months.

    Discussion
    Vegetarians have a diet pattern that emphasizes consuming plant foods (i.e. vegetables, grains and nuts) and avoiding flesh food (i.e. red meat, poultry, fish).
    Some vegetarians include milk and egg products in their diets and would be more accurately described as lacto-ova-vegetarians.
    Vegans are vegetarians who avoid all animal products including foods such as dairy products, eggs, butter, honey and gelatin.

    What constitutes being a vegetarian to one person, may have a different meaning for another person. In a national study, 2.5% of the participants (aged > 6 years of age) considered themselves to be vegetarian.
    When 24-hour diet records were examined, only 0.9% of the participants did not eat red meat, poultry or fish.

    Infants, children and adolescents with well-planned vegetarian and vegan diets grow and develop normally.
    For adults, there is data to support a decreased risk of some types of cancer, diabetes, coronary artery disease, hypertension and obesity.
    Besides these advantages, some people choose vegetarian and vegan diets for economic, environmental and religious reasons.

    In general, infants should be breast feed for up to one year if possible.
    Soy formulas are available and are recommended for vegetarian and vegan infants who are not breastfeeding.
    Commercial soymilk should not be started until after one year of age because of the low bioavailability of iron and zinc in soy. Some commercial soymilk may not be fortified with Vitamin D and calcium and therefore labels need to be checked.
    Parents and other caretakers need to be careful with choking hazards such as nuts and raw vegetables.
    If growth is a concern, supplementing avocado, nut or seed butters, tofu, and vegetables oils can increase calories.
    Sometimes a restrictive vegetarian diet can be masking an underlying eating disorder.

    Learning Point
    Primary nutrients to be concerned about for vegetarians and vegans are noted below along with examples of foods that are high in these nutrients.
    Soy products includes items such as tofu and tempeh, soybean oil, soymilk, soy cheese, soy yogurt, etc.

    • B12 (cobalamin) – breads, cereals, dairy products, eggs, fortified soy products, nutritional yeast, and supplements.
      It is important to have adequate sources of B12 particularly if a vegan.

    • Calcium – brocoli, collard greens, dairy foods, figs, kale, black strap molasses, sesame seeds, and fortified soy products.
    • Iron – bulgur wheat, dried beans, dried fruits, fortified cereals and grains, and fortified soy products.
      Adding a Vitamin C source when eating a plant food for iron increases its absorption (i.e. orange, strawberries, tomatoes).

    • Omega-3 Fatty Acids – canola oil, ground flaxseed, flaxseed oil, soy products, walnuts, walnut oil, and sea vegetables.
    • Protein – dairy products, eggs, grains, legumes, seitan (a wheat product), and soy products.
      Because of the low absorbability of amino acids found in plant sources a higher intake of protein may be necessary

    • Vitamin D – dairy products, fortified soy products, sunlight.
    • Zinc – cereals, whole grain, legumes, miso (made from soybean, wheat or barley), soy products, wheat germ, and yeast.

    Questions for Further Discussion
    1. What vegetarian meals options are available for children in the local school district?
    2. Where in the local community can patients and families get nutritional information, particularly for vegetarians?

    Related Cases

    To Learn More
    To view pediatric review articles on this topic from the past year check PubMed.

    Information prescriptions for patients can be found at MedlinePlus for this topic: Vegetarian Diet

    To view current news articles on this topic check Google News.

    To view images related to this topic check Google Images.

    Mangels AR, Messina V.
    Considerations in planning vegan diets: infants.
    J Am Diet Assoc. 2001;101(6):670-7.

    Messina V, Mangels AR.
    Considerations in planning vegan diets: children.
    J Am Diet Assoc. 2001;101(6):661-9.

    Haddad EH, Tanzman JS.
    What do vegetarians in the United States eat?
    Am J Clin Nutr. 2003 Sep;78:626S-632S.

    Dunham L, Kollar LM.
    Vegetarian eating for children and adolescents.
    J Pediatr Health Care. 2006;20(1):27-34.

    ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Interpersonal and Communication Skills
    19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

  • Professionalism

    22. Sensitivity and responsiveness to patients’ culture, age, gender, and disabilities are demonstrated.

    Author
    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital

    Date
    September 2, 2008