Δρ Νικόλας Καλογήρου - Παιδίατρος / Dr Nicolas Kalogirou Paediatrician

01/10/2025

THE FOLATE HYPE

I see a trend in the community of families with autistic children and other developmental challenges to test for folate deficiency or use folate as a means of therapy . This is an extremely complicated and nuanced topic and I thought I ‘d do a quick review of the evidence. Please note that this not in any way a medical advise and you should discuss this matter further with your healthcare provider before you take any actions.

1. There are 4 different forms of vitamin B9. Folate is the form as it occurs in foods and folic acid is the synthetic form found in vitamin supplements . Folinic acid ( aka leucovorin ) and methyl-folate are activated forms of folate which by pass the body’s pathway of activating folate into a chemically active substance ( in case these pathways are defective which is sometimes the case).

2. Vitamin B9 is extremely important in brain growing during fetal life and early childhood as well as brain function thereafter . The mechanisms behind these are complex but if we were to think of our brains as a car engine then folate would be as important as engine oil.

3. MTHFR gene is involved in one of these folate activation pathways. It has been proposed that in some people with autism defective forms of this gene may be responsible for causing deficiency of active folate forms and thereby the autism . Hence autism would be reversed if one gave this child folate supplements . To date this theory has not been validated by evidence. In simple terms there is no definitive link between MTHFR gene mutations and autism and testing for this is not recommended.

4. Folate receptor autoantibodies (FRAT ). In our brains there is a folate receptor which helps move folate from blood into the brain. There is evidence that in SOME autistic people FRAT block this process hence causing deficiency of folate in our brains thereby causing autism. It is clear that folinic acid ( which does not need to use folate receptor to enter brain) can correct this problem in this specific population . It is NOT a cure for autism in general .

5. It is not very clear what subset of children with Autism have folate defects or have FRAT -related autism and would benefit from supplements nor there is any consensus in the medical community as to whom we should be giving folate or should be testing for FRAT antibodies. FRAT antibody testing is not currently available in Cyprus ( at least that I am aware of )

Parents sometimes fall pray to dubious advise by practitioners of alternative and integrative medicine and I can totally see the appeal . Especially if on the other end what classic medicine has to offer is sometimes an authoritative ‘’respect my authority – I know what is best for your child’’ attitude and giving you a list of 10 generic one-size-fits-all recommendations and wishing you good luck. This can lead to a breakdown in rapport and trust.

If I was a parent of a child with autism I would probably be willing to try pretty much everything provided is safe. So knowing that there is a vitamin that stands a chance of inducing positive changes in some autistic children wouldn’t I too be knocking on my paediatrician’s door asking for it just in case my child would benefit ? Absolutely .

This begs the question : given the complexity of testing would it be reasonable to do a trial of folinic acid in all children with autism ? I do not have the answer to this and there are much more clever and important figures in the science community out there who I trust will help with this very valid question .

14/09/2025

DON’T BOTHER CHILDREN WHEN THEY ARE SKATEBOARDING

The title is borrowed from Jordan Peterson and suggests that overprotective parenting can hinder a child's ability to face the challenges of the real world, and that children naturally seek competence in risky activities so they can learn to navigate risk and build necessary skills for life.

But it is also pertinent and captures the essence of another problem we see in developmental clinics . A significant number of young children who are physically deconditioned from lack of free play and are being labelled as having ‘’motor disorders’’ and referred to neurologists or developmental specialists . This is a cohort of children to whom if you apply the performance criteria of motor coordination and physical condition tests they fall under the norms . I am talking about their endurance, balance and agility like the ability to skip , hop, balance on one leg for a period of time , climb on playground climbers and even run well or throw a ball.

WHO recommends that children under 5 should get a minimum of 3 hours per day of physical activity ( such as outdoors play ) with 1h of that being moderate to vigorous activity. International and European studies show that only around 1 in 5 children meets this target ( no data from Cyprus that I could find but I suspect our ratio is probably the same ) . Only yesterday I was examining a 6 year old who when asked to lift her legs off the examination couch towards the ceiling she couldn’t hold them up for more than a couple of seconds . She did not have a neurological problem or needed MRIs or fancy tests. She was simply deconditioned .

Play - based childhood is being slowly converted into screen-based childhood . The rate at which technology is transforming our daily lives into becoming automated and mechanised , points to a rise in the number of sedentary children and as a result a trend towards the loss of their motor abilities . This is probably going to reach epidemic proportions soon enough , to the point that we may actually have to lower the testing standards as to what we consider normal motor skills in children.

For example , am I allowed to label a 5 year old who can’t climb the slide in a playground as having '' motor delay '' , if that child had not had the opportunity to practice that skill time and again in his life ? Going back to my initial thought, these children do not need to be seeing doctors or physiotherapists or occupational therapists . They simply need more free play .

03/09/2025

Introducing our new administrative assistant Mrs Konstantia Christofi. Delighted to have you onboard and wishing you a great start !

24/08/2025

THE COMFORT CRISIS

One question I am frequently asked is ‘’what shoes should I buy for my baby ‘’ or ‘’does my baby need to wear shoes when taking her first steps ‘’ ? Most people think that fancy expensive orthopedic shoes matter greatly and are willing to spend loads of money on these.

Taking a look at this from an evolutionary perspective , I suppose it’s clear that shoes were not part of nature’s original plan. Billions of babies since the dawn of time managed to roam around the earth on their bare feet perfectly fine. Anatomically our feet contain as much muscles as our hands . So if one thinks the amount of dexterity a strength we have with our hands you would be surprised how weak our foot are because shoes basically shield us from what are feet should be doing .

Shoes restrict the natural movement of babies feet, may interfere with the development of balance, coordination, and muscle strength, and can even hinder the ability to learn to walk . In fact, shoes that are too structured can limit natural foot development and interfere with muscle growth and balance. Hence the high percentage of preschoolers with flat feet ( amongst other orthopedic issues like for example hunchbacks from sedentary lifestyles )

Naturally people living in WEIRD societies ( Western , Educated , Industrialized , Rich , Democratic ) like to engineer discomfort out of their lives . We strive to prescribe comfort for all aspects of our daily living , even more so when it comes to our offsprings , but there are certain comfort items that can sometimes do more harm than good.

It goes without saying I am not advocating for letting your toddler walk bare foot in the streets or in supermarkets . But trust me when I say this , there is absolutely no harm walking bare foot at home or in your back yard and absolutely do not use shoes during the sensitive period of your baby learning to take her first steps.

07/08/2025

Part time secretary( 9 am -1pm ) wanted for my office. Must have adept language skills in Greek and English. Please email your cv to : n.kalogirou@doctors.org.uk

07/08/2025

📣📣📣ΑΝΑΚΟΙΝΩΣΗ ΘΕΣΗΣ ΕΡΓΑΣΙΑΣ: Προσφέρεται θέση εργασίας για γραμματειακή υποστήριξη σε ιατρείο για μερική απασχόληση (πρωινό) .

Απαραίτητα προσόντα είναι άριστη γνώση ελληνικής γλώσσας, καλή γνώση Αγγλικών, χρήση ηλεκτρονικού υπολογιστή και ευγενικός, επικοινωνιακός και ευχάριστος χαρακτήρας. Θα θεωρηθεί ως πλεονέκτημα σχετική εργασιακή εμπειρία, γραμματειακές σπουδές ή επιπλέον γλώσσα.

Οι ενδιαφερόμενοι παρακαλώ να αποστείλουν το βιογραφικό στην διεύθυνση n.kalogirou@doctors.org.uk

06/08/2025

And not only that but this maxim has now been incorporated into clinical decision making tools like the UK sepsis tool for example.

01/08/2025

In light of the recent disastrous events with the wildfires that blazed through Limassol rural area with people loosing their homes and the thousands of square meters of burned vegetation, the post today will not be about paediatrics.

I happen to live in Souni . The once lush and green landscapes around us has now turned into a bleak and baren landscape . Although I was fortunate that my house wasn’t damaged many families sadly lost their homes . Our small community is devasted by the magnitude of the disaster . Amidst the chaos I tried to brace my self and started contemplating how people can handle the tragedies and the hard knots of life . Sometimes you have to look for those little sparkling bits in the darkness and watch the space for tiny opportunities that can make you feel better

I reminded my self of a book by Prof. Jordan Peterson called 12 rules for life. In Rule 12 he says - "Pet a cat when you encounter one on the street". This is a metaphor of course and it's not about the cat itself . It sounds silly but It encourages mindful engagement with the present moment and noticing opportunities for positive experiences, like stopping to pet a cat ( or a dog for that matter ) , even when life around you lies in ruins.

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.