Δρ Νικόλας Καλογήρου - Παιδίατρος / Dr Nicolas Kalogirou Paediatrician

18/05/2025

WHATEVER HAPPENED TO EVIDENCE BASED MEDICINE ? THE VULNURABLE CHILD SYNDROME

These posts are about debunking advice coming from Healthcare professionals which contradicts evidence based practice . I am not trying to discredit the body of medical professionals or finger point , merely raising awareness with regards to Evidence based medicine and critical thinking which are the cornerstone of modern medicine. If it's not backed by evidence it's not a scientific fact . That's called a belief, a hoax or a superstition . We are men and women of science , not tribal Shamans or new age gurus . Bad science , despite the good intentions , can do a great deal of harm .

I hear through the grapevine all sorts of irrational prompts from health care professionals that would normally make me chuckle had they not been potentially harmful. Utterances like :

1. Don’t give your infant eggs over the summer. He may get salmonella or
2. Don’t feed your baby strawberries until age 1 because they are allergenic

Well, actually no ! Properly stored and hard boiled eggs are safe for babies. Plus you end up depriving an infant from a good source of protein and nutrients for many months . In terms of the latter there is no evidence whatsoever that early introduction of strawberries is risky. Actually exactly the opposite is true. The later you introduce a food the more likely your child may develop an allergy to it.

The advise I find most upsetting is what I call the vulnerable child syndrome where people make up unvalidated threats about a looming disaster. Let me give you a common example. A previously healthy 2 year old is admitted to the hospital with a chest infection. Upon discharge their doctor says the child should stay away from kindergarten for 1 month and avoid all social contacts because he is super vulnerable and may get very sick again. That’s despite the child being completely recovered and up and running. Basically keep your child in a glass cage more or less.

Feel free to look at the literature all you want. You will not find ‘’recent infection’’ in the list of causes of weak immune system. If anything our immune systems can handle multiple pathogens simultaneously ( let alone in succession ) hence why human species survived the millennia of evolution . Once a child is up and running he or she can go back to school . Period.

How does this causes harm ?

For start it deprives the child from the wonderful world of peer interaction with all the developmental and socio-emotional benefits this has for their development. In addition , not all families have the social support network to get someone to child mind for a month. This causes a huge practical inconvenience to working parents who may take this advise at face value and do exactly as told.

It doesn’t really matter whether this piece of advise stems from ignorance , lazy medicine or playing it safe ( aka defensive medicine ) . It is harmful.

03/05/2025

16/04/2025

WHICH IS THE BEST FORMULA MILK ?

Apologies for the click bait title , if you are looking for an answer to that then please scroll further . That aside , this is a question that pops up in antenatal visits , sometimes with unexpected twists . For example I remember a lady that would simply not take ‘’there is no best formula ‘’ for an answer. She was fiercely adamant to know and hammered me relentlessly , as if it is a well guarded secret known only to paediatricians who are the gatekeepers of this clandestine truth .

Ironically a simple google search can tell you the following which ought to be common knowledge :

In the EU, the ingredients in infant formula are strictly regulated and each manufacturer must follow strict EU guidelines on composition. Formula producers have to add ingredients in accordance with this regulatory framework .

While manufacturers make various claims about their products, all brands have to meet the same nutritional standards and therefore have a similar composition. So buying a more expensive brand does not mean that your baby will grow or develop better than if you were buying a cheaper one. The basic nutritional profile of infant milks is actually very similar. Fancy formulas ( ‘Gold’ formulas ) contain added fatty acids and other bits and pieces that try to mimic breast milk , but they haven’t yet been proven to be healthier for babies. If you want to spend the extra money, you are welcome to, but you may not get what you think you are paying for.

The widespread practice of frequent formula changes to ‘treat’ normal baby things ( (like spitting up, colics and bowel habits) , is not actually scientifically validated . Plus it tends to cause misery for everyone, with the poor infant’s little system struggling to adjust to the dietary twists and turns. Usually the best approach is just stick to whatever formula the infant likes and give some time to settle. (Normalising normal things is a big part of being a good doctor )

One caveat : sometimes families may have preferences based on personal , cultural or religious beliefs ie organic vs non-organic , goat vs cow milk , soy based , no palm oil added etc – that’s fair in my opinion but in no way better than others.

Where I stand ? When a mother opts to formula-feed her newborn and the midwives ask what kind of formula I prefer ( oh yes , in Cyprus it is accustomed that the paediatrician chooses the formula brand of your baby – but I've also seen obstetricians having an opinion on the matter which makes me wonder why ... ) , I reply ‘’ I don’t mind which one you choose ‘’ . I realize not being ‘’ affiliated ‘’ with formula companies is bad for business and while I 'll be happy to be proven otherwise , so far I just don’t see the evidence.

30/03/2025

SHOULD YOU BE CIRCUMCISING YOUR CHILD’S TIGHT FO****IN ?

Although the title implies this is a personal expert opinion , it is not. I am not an expert on fo****ins and neither do I think expert opinions have much to add in medicine. In the hierarchy of quality of evidence , you will find the expert opinion category at the very bottom. By expert opinion I mean someone saying ‘’this is what you need to do, but not because it is backed by evidence , but because I say so based on my personal experience and the big fat diplomas on my wall’’. In science the maxim says ''In god we trust , everyone else must provide evidence''.

Lets start with an example which may be entirely fictional and never took place . A 2 year old boy attends its local emergency department with a fo****in infection causing him trouble to wee. This is the first one he had in his life . He ends up getting admitted on intravenous antibiotics ( !) and the attending surgeon tells the family that he has a ''severely neglected fo****in'' which needs to be cut . The boy ends up having a circumcision shortly after discharge. Now , I think there are a few inaccuracies in the story and people are entitled, after all, to expect a very high standard of factual accuracy from doctors . So lets take a look at the data .

At birth the fo****in is attached to the g***s and has a tight opening which is not retractable in almost 100% of males . Retractability increases with age, with full retraction possible in
10% of boys at 1 year
50% of boys at 10 years
99% of boys at 17 years

Thus a non-retractable fo****in is a normal variant in young children. This may sometimes cause ballooning during urination and local discomfort. It needs no intervention apart from gentle manual retractions by parents at home. Medieval practices like forcefully retracting the fo****in in the paediatrician’s office have long been abandoned ( although I occasionally hear horror stories about this still happening in Cyprus ) . Apart from being excruciatingly painful and cruel it would often -upon healing- cause local scar tissue and rebound of tight fo****ins at a worse level.

An abnormal tight fo****in ( often called phimosis) is the kind that may need circumcision and is defined as : ring of scar tissue at fo****in or fo****in not retractable at the conclusion of puberty or persistent obstruction in urination in older children with narrow urinary stream or causing recurrent infections. This is the exception, not the rule.

Bottom line :
The ominous opinion about a ‘’severely neglected ‘’ fo****in in a 2 year old who never had issues before is misleading. A vast number of 2 year olds have non-retractable fo****ins and these will get better with time . It’s basically like saying there is a problem that a 2 year old is not yet toilet trained. Circumcision has no place in this age group except in unusual cases.

16/02/2025

Worth reading this mum's moving story about her breastfeeding journey. Kudos to the lactation consultant and of course to Maria.
If I may , just a couple of remarks from the medical perspective

1. Breastfed babies are ''allowed'' to loose more than 10% of their birth weight ( up to 12.5 %) and some may take more than 7-10 days to regain their birth weight ( up to 3 weeks ) . Whoever tells you that's dangerous without taking into account the clinical status of the baby and pushes for formula supplements , I am sorry but that's just lazy medicine. Simple as that.

2. A good lactation consultant is the key person you need . Truth is they have a much better insight than medical doctors about the practicalities of breastfeeding and most importantly can spend much more time with you than the 10 min visits you get with doctors which is hardly enough to go through breastfeeding trouble shooting . Hence sometimes the advise ''oh just give him some formula and it will be alright ''.

3. Even if you had to use top up feeds with formula in the early days, that doesn't mean you are committed to continue these for ever. That's a myth. You can wean off these supplements quickly in the first week of life as soon as milk flow increases and can meet the baby's demands.

28/12/2024

LIFESTYLE PRESCRIPTION ? ARE YOU BEING SERIOUS ?

Asking patients to change their lifestyles in order to get better is common ground in advanced healthcare systems. That’s not because they are naïve , but rather because it is now increasingly understood that they play a huge role in the development of certain conditions. We call these functional disorders and they encompass some very common ailments like IBS , chronic tummy aches , dyspepsia, chronic headaches, chronic fatigue , back pains and so on.

Looking back , I still recall the first consultation I attempted doing lifestyle adjustment in Cyprus. It was a teenage girl with chronic headaches . There was absolutely nothing in her physical exam ( and I was very thorough ) to suggest that there was a medical disease process . Therefore, instead of fancy tests and medications , we had a discussion about the adverse effects of excessive screen time , social media, poor diet habits, drinking plenty of fluids , poor sleep hygiene and lack of physical activity . The sheer horror in her parents eyes suggested it wasn’t at all what they expected to hear from a doctor . I presume down the line some other doctor must have offered them a whole assortment of ‘typical headache management’ with brain MRIs, neurology consults , blood tests and perhaps fancy medications. I have not seen them since.

The sad truth is , if you have a functional condition , there is not a lot that classic medicine can do for you . Trust me when I say that you will end up going around in circles unless you address the elephant in the room – your bad habits. Let me be clear , this has nothing to do with alternative medicine, Reiki, Tai chi or sacrificing goats and dangling their entrails around your neck . Lifestyle prescriptions is irrefutable evidence-based science documented by clinical trials.

The pathogenesis behind it is complex and hard to explain but I ‘ll try and briefly give you the outline. Our homo sapiens bodies and DNA have not yet been able to adjust to how our civilizations have evolved . They were build for roaming in savannas, gazing at long distance plains , eating fruits from trees ,hunting -gathering and when dusk falls going to sleep early . They ‘ve not been made to handle excess screen time from near distance , modern life anxieties and pressures , FOBO and FOMO and social media, inactivity and sedentary lifestyles and living in small apartments in big cities . They can’t cope with high fat , high sugar and processed diets, air pollution , alcohol , smoking , excess caffeine and drugs and most importantly can’t cope with lack of sleep . All these factors in isolation or most often in concert , can make our bodies ( and minds ) experience real physical symptoms .

That’s food for thought for whoever wants to look a bit further into lifestyle medicine or wants to learn how to appreciate doctors who touch on this topic instead of quickly pulling out their prescription pads.

Wishing all a happy new year !

07/12/2024

MARGINALIZING NEURODIVERSE CHILDREN

I thought I ‘d share an experience of how children who do not conform to expected standards are singled out and portrayed as problematic and needing to be fixed . This perpetuates perverse stereotypes and can lead to simplistic explanations such as ‘’why does Timmy have ADHD ? – because he misbehaves. And why does Timmy misbehave ?- because he has ADHD. Period ‘’.

The family of a 3 year old boy was told by the kindergarten teacher that he needed to see a specialist ASAP as -and I quote- he must have AHDH or some learning disability . The boy was reportedly exhibiting problematic behaviours which were challenging and disruptive .

This struck me as odd, as I have seen this boy a number of times in my general paediatric clinic and never picked up any developmental difficulties. However , as no one is infallible and I may have missed something I decided to have another look. To minimize cognitive bias I choose to do this jointly with a senior physiotherapist in a centre I collaborate with, so as to have an independent observer. For those of you who don’t know , cognitive bias is the condition where doctors ( and other professionals such as health policy makers ) have a pre-formed opinion about something and are so convinced about is verity that they turn a blind eye to all the evidence pointing otherwise.

During the assessment it transpired that the boy had mild language delay and his attention and activity levels where below expected norms. Nevertheless these traits were not enough to meet criteria for any specific developmental diagnosis . Even so , I felt that this did not explain the challenging behaviour. There are lots of children with developmental difficulties who do not misbehave and vice versa many neurotypicals who do. He came across as a sweet and happy little boy who was very cooperative and sociable .

Digging into it a bit further we found out that he had just joined this school which had twice as much children that the previous one and he was no longer getting his 1 o clock nap due the school’s timetable . Could it be that tiredness coupled with a more demanding and overwhelming environment plus the inability to fully express himself verbally may have all contributed to acting out? Certainly he did not have ADHD , let alone learning disability but he was neurodiverse in the sense that certain traits were off the typical range . This boy did not need to see a specialist or a diagnostic label attached to his forehead . He did not need 'fixing ' . He simply needed the adults in the room to be more patient , more supportive and more understanding.

I think this is an example of how the ‘deficit model’ is increasingly affecting younger and younger children . The ‘deficit model ‘ is where the modern society places such high demands for performance and sets the bar so high that people with lower than average skills struggle to cope and start ‘failing’ . This leads to an increasing trend in referrals and consequently more and more people receiving diagnoses.

03/11/2024

WHATEVER HAPPENED TO EVIDENCE BASED MEDICINE ? WHY YOUR BABY DOESN’T NEED A HEAD SHAPING PILLOW

These posts are about debunking advice coming from Healthcare professionals which contradicts evidence based practice . I am not trying to discredit the body of medical professionals or finger point , merely raising awareness with regards to Evidence based medicine and critical thinking which are the cornerstone of modern medicine. If it's not backed by evidence it's not a scientific fact . That's called a belief, a hoax or a superstition . We are men and women of science , not tribal Shamans or new age gurus who sell magic potions online . Bad science , even when it comes with good intentions , can do a great deal of harm .

Lots of parents become anxious when their baby’s head develops flat spots and becomes misshapen. Flat head syndrome, or positional plagiocephaly is where a baby’s head changes shape from pressure applied to the skull from sleeping position.

The incidence of flat head syndrome has increased since the “Back to Sleep” campaign of the 1990s where parents were first encouraged to put their babies to sleep on their backs with no pillows in the crib in order to prevent Sudden Infant Death Syndrome (aka cot death syndrome ) .

Health professionals are no longer supposed to recommend the use of special pillows as a way to prevent or treat plagiocephaly . Why ? Simply cause this would be against all official advice ( emphasis on ALL ) that has served to keep thousands of babies alive since the 1990s. All pillows , head shaping ones included , create an unsafe sleep environment for babies and raise their risk of suffocation. Plus neither has there been any solid evidence that suggests that these pillows actually prevent flat head syndrome. In most cases, flat head syndrome goes away on its own as the infant grows and does not cause any developmental issues. Let me repeat this once more, often spontaneously resolves and does not cause any brain dysfunction.

It’s very disappointing to see that health professionals in Cyprus are still advocating for the use of these pillows. I understand the need to be seen to be doing something , perhaps under the immense pressure of parental anxiety about their child’s head , however it’s a matter of safety and safety comes first. It’s like someone advising you not to wear a seat belt because you have a sore arm and just take your chances with it .

So if you have been told to use such a pillow – my advise to you is chuck it in the bin and do not risk your baby’s safety.

26/10/2024

ON SLEEP TRAINING : A PARENT'S ACCOUNT

Dear all, Maria has asked me to share her recent experience of sleep training her 12 month old baby. We had a brief discussion a few weeks ago after asking me to help with getting her baby to sleep through the night . I briefly explained how habit loops form and signposted her to scientifically validated online resources. She choose to couple sleep training with quitting breastfeeding . A few comments first

1. Sleep training does not necessarily mean stopping breastfeeding. This is how Maria choose to do things.
2. Sleep training is not in any way harmful to a child's emotional or developmental wellbeing .
3. Sleep training may clash with some families' belief systems and values. It is not for everyone. If you are happy with your child's current sleeping arrangements then sleep training is not for you.

Here is what she had to say

Hello to all mommies out there! My name is Maria and I’m a mom to a one year old baby girl. I would like to share with you my journey of quitting breastfeeding and encourage all moms, that nothing is impossible! That all you need is patience!

I breastfed her from the moment she was born until she reached one year. Every day I would say I should stop breastfeeding but something was also stressing me out that was about her night sleep mostly. When I got the courage to stop breastfeeding I didn't start gradually because that way I knew it would make it harder for me so I made the decision to stop breastfeeding right away. What did I do? Absolutely nothing girls, At the noon when she got tired I would just put her in her bed (of course she showed that didn’t like it for the first two days but stil all you need is to be patient ) I would lay next to her and I knew that slowly she would get to used to sleep by herself without my intervention! However the actual difficulties began with the night sleep and her meal because she didn’t want a baby bottle to sleep at night, but only breastfeeding!

What did I do for the night ? I decided to put her in her own bed no matter how hard it was, and when she wanted to sleep I would give her a "baby bottle" (remember never let them to cry when it's time for their meal, because it will make it difficult for them to sleep as they will look forward to breastfeeding to relax) (Within 1 week I managed to stop breastfeeding) This whole journey of breastfeeding might seem difficult to accomplish but surely not impossible, it just requires simple things like tracking our babies sleeping pattern. Doing that will keep them calm and avoid breastfeeding after all!

Here is my advice 💡 for moms who have a baby over 2 years old:
- [ ] Don’t give your baby a bottle to replace breastfeeding, as this will make it harder for you to stop the bottle as well
- [ ] When the baby wants to be breastfed, try and replace it with a favourite snack, this way the baby will slowly forget about breastfeeding.
- [ ] Take your child to the park or find an activity at home that enjoys
- [ ] If the baby wants you to breastfeed him, talk to your child, babies are very smart and understand everything. Just explain that mom have no milk and set limits at this age

In conclusion, I understand that at the age of 2 years and above it is more difficult for a baby to stop the breastfeeding as the baby has learnt to be attached to you, but this doesn’t mean that you won’t find the strength to stop the breastfeeding, that is why I shared with you some of the above tips

Ps: For all the moms out there, always remember that if we are calm, our babies will also be calm and they will sleep better without the need to be breastfeeded or even use the bottle. My special thanks to dr Nicolas because in between our appointments he help me find the courage to stop breastfeeding when he told me that it is not as difficult as it seems! And he was right!

29/09/2024

IT’S NEVER TOO EARLY TO SLEEP TRAIN

When I think about sleep training I am reminded of a story . A couple of years ago I got an exasperated early morning phone call . On the other end of the line a lady was shouting at me , wanting me to explain why her 2 year old was not sleeping and demanding a solution . She was not my client. I was covering for another colleague at the time and merely answering the phone call. The fact that I was not her doctor made no difference to her , as long as she offloaded her fury. I politely offered a same day appointment to discuss in person and see what I could do to help . She never came . Obnoxious phone calls notwithstanding , this incident highlights some truths. That sleep problems are a source of great distress to parents and that sleep hygiene education is neglected during paediatric visits.

Unfortunately this is not a quick fix post nor a ‘’how to fix your child’s sleep in 3 simple steps’’ guide. Sleep training takes time , effort and commitment and most importantly parental investment in the right knowledge of how to go about this.

Here are some basic scientific concepts which will hopefully be a good starting point for those of you interested in learning more about sleep training.

1. Sleep consists of cycles each lasting about 60min. At the end of each cycle there is a brief awakening . This is an evolutionary remnant from back in the pre-historic days where we had to make sure the environment was safe and no lion around in the cave to eat us. We self -soothe back to sleep and don’t even remember these awakenings in the morning.

2. The skill to self -soothe back to sleep is inherent to all human beings. We just have to learn it. Just like you would potty train or teach your child algebra, the same way you have to teach your child to master sleeping skills . Hoping that children will learn this by themselves , it’s a possibility but will take years.

3. The capacity to self- regulate one's sleep (without parental intervention ) is a milestone that appears around age 6 months . Sleep training can start as early as infancy. And no , it’s not harmful to your child’s emotional development.

4. Toddlers who have not mastered this skill , wake up at night and need other types of interventions to soothe back to sleep. That’s probably a cuddle from a parent and milk . The brain habituates to this behaviour and learns to expect this intervention every time . With time the behaviour gets hard wired , akin to an addiction. This is called the bad habit loop. Hoping that your toddler will magically grow out of this behaviour and become a good sleeper will probably never happen. The brain has to be re-wired . You need to help them break the habit through sleep training.

For those interested in learning more about sleep training I recommend Dr Canapari’s book ‘’It’s never too late to sleep train’’. As a final remark from my personal experience . In cases where parents introduced sleep training early on , the process tends to be much smoother and uneventful , hence the title of the post.