Keeping Kids Rear-Facing - The New AAP Policy

For those of you who read my blog, you may recall a post about a year ago entitled Rear-Facing Car Seats Until At Least 2. A little over a year later it is official. The American Academy of Pediatrics now advises that children stay rear-facing until at least two years old and even once they reach two years of age, they should only begin riding forward-facing when they outgrow the weight and height limitations of the rear-facing position. This means you may very well have smaller 3 year olds still facing backwards.

In an article discussing the new AAP car seat policy statement, Dr. Hoffman, a member of the AAP's committee on injury, violence, and poison prevention stated, "Parents are really viewing these transitions as graduations. There is a perception that this graduation is a positive thing. It's not. In these transitions, you lose protection every step of the way. Therefore you need to delay these transitions for as long as possible." This is a wonderful point and something pediatricians need to explain to their patients. The fact is children are safest facing backwards. Facing forward is not something that should be rushed but rather something that should be put off for as long as possible.

Similac Recall

Similac announced a recall of certain lot numbers of its powdered infant formula due to "the remote possibility of the presence of a small common beetle in the product." According to the FDA, "the formula containing these beetles poses no immediate health risk, however, there is a possibility that infants who consume formula containing the beetles or their larvae, could experience symptoms of gastrointestinal discomfort and refusal to eat as a result of small insect parts irritating the GI tract." The FDA advises parents to seek medical attention for any child who has GI symptoms which persist for more than a few days.

This recall applies only to powdered formula and does not include any of Similac specialty formula lines: Similac Expert Care™ Alimentum®, Elecare ®, Similac Expert Care™ Neosure ®, Similac® Human Milk Fortifier.

To find out if your canister of formula has been recalled, visit the Similac website and enter the lot number, which can be found on the bottom of the product.

Clogged Tear Ducts - Proper Preventative Care

Clogged tear ducts, a.k.a. nasolacrimal duct stenosis, is a fairly common problem among newborns. The tear duct's opening is located on the inner portion of the lower eyelid. The duct runs from the eyelid to the inside of the nose where it drains into the nasal cavity. For a small percentage of children, the inferior portion of the duct remains closed after birth and does not allow tears to properly drain from the eye into the nasal cavity. For these children, tears flow over the lower lid and down the cheeks.

Children with nasolacrimal duct stenosis often have small amounts of discharge from the duct coming out of the opening on the lower eyelid. This drainage is not cause for concern and can be wiped away gently with a warm cloth.
However, a blocked nasolacrimal duct does increase an infant's risk of infection of the nasolacrimal sac (dacrocystitis) and of the skin under the eye. Parents should seek medical attention for their infant if there is copious discharge from the duct's opening into the eye, if the eye is crusted shut in the morning, if there is any redness in the white of the child's eye, or if there is any redness or swelling of the skin under the eye or around the duct's opening. These infections have the potential to become very serious and require prompt medical evaluation and treatment with antibiotics.

Most children with congenital nasolacrimal duct stenosis will outgrow the problem. As the child grows, the duct also grows and the inferior opening located within the nasal cavity dilates relieving the stenosis and allowing the duct to function properly. By 2- years-of-age, over 95% of children with nasolacrimal duct stenosis have improved on their own.

For the small percentage of children who continue to have a problem after their two-year-old birthday, they should be referred to a pediatric ophthalmologist. Some pediatricians will refer a child after one-year-of-age. However, most pediatric ophthalmologists will give the parents of younger children a choice between watchful waiting and surgery. For children who have not had any severe infections of the duct, a simple surgical procedure in which the surgeon uses a probe to dilate the nasolacrimal duct is all that is needed to rectify the problem. For children who have had an infection of the duct, they may need both a probing of the duct as well as the placement of a temporary stent inside the duct to keep it open while the duct heals.

While watchful waiting is an appropriate decision for the child without a history of infection, children with a history of infection warrant an early referral to a pediatric ophthalmologist as their chances of resolution without surgery is very low.

Proper care of the nasolacrimal duct can mean the difference between an uncomplicated course of stenosis that is self-resolving and one that is complicated by infection and surgery. While many parents are told to simply massage the duct and sac by rubbing their finger in tiny circles in the inside corner of the eyelid this is actually not the proper technique. The massage is not being done to open the duct, as the closed portion of the duct is located within the nasal cavity, and not up by the eye. The massage instead is done in order to relieve the pressure within the duct and facilitate drainage of any discharge within the sac and duct into the eye. If the discharge material is allowed to remain inside the sac and duct, pressure within this area will increase and cause stretching of the inner lining of the nasolacrimal duct and sac. This stretching would allow normal nasal cavity bacteria to escape the confines of the duct and seep into the surrounding skin causing an infection.

Thus, proper massaging technique is essential to drain the nasolacrimal sac and duct and prevent infection. The correct way to massage the duct is to press your finger into the crevice between the inner eyelid and nose, right below the nasolacrimal duct opening and then move your finger up, milking out any discharge through the opening on the lower lid and out into the eye. This should be done a couple of times a day depending on how much drainage the child is experiencing. With this proper technique, the risk of infection is greatly reduced and the chance of the child requiring a surgical correction is less than five percent.

Nasolacrimal duct stenosis is a fairly common problem among newborns. Learning and using the proper massage technique is essential in order to avoid infection and subsequent surgery. By diligently massaging the discharge out of the sac and duct, parents can reduce the pressure and bacterial build up within the system and buy their children time to outgrow this problem naturally.

Earth Day 2010 - Fun Activities To Do With Your Kids:

Thursday, April 22nd will be the 40th annual Earth Day. For those looking for activities to do with their children this week, as it is also National TV Turn-off Week (see last week's blog), Earth Day offers a whole host of fun activities.

Many schools will have Earth Day programs scheduled to help celebrate and raise children's awareness about the Earth. Depending on your child's age, there are multiple fun ways to supplement this education at home. Checkout the web for some great ideas about how to make Earth Day fun in your house. Kaboose has a section on Earth Day arts and crafts all using recycled materials. With Mother's Day around the corner, this is a great opportunity to make gifts such as seeded bookmarks or flower pressed paper. Gardens are an easy go-to activity for Earth Day and can be as low key as an indoor herb garden or a terrarium in a soda bottle. There are also many websites devoted to Earth Day related science projects for older children. These can range from making smog in a bottle to watching a bean grow into a plant through a zip-lock bag.

Many cities have Earth Day celebrations. So check your local paper to see what is planned for your area. There may be a park clean up, a local tree planting, an outdoor concert or movie. Earth Day offers the perfect opportunity to spend some quality time doing something fun and educational as a family.

National TV Turnoff Week: Turn Off The TV, Turn On The Fun -

April 19th - 25th has been designated as National TV Turnoff Week. Families are encouraged to participate by eliminating TV watching and video game playing for one week. Although this may seem like an easy task since many children spend more time per year watching TV and playing video games than they do in school implementing a TV-free week in your home may require some strategic planning.

How to Implement a Successful TV-Free Week in Your Home:

1. Make sure your family knows it is coming. Sometime this week, make a family announcement that next week is a TV and video game free week.

2. Expect resistance. Most children will challenge this decree. Stay firm and explain that this is non-negotiable.

3. Plan each day's activities so that there are fun things to do. Limit down time when children will invariably ask to watch TV. By discussing TV Turnoff Week early with your family, you will give them time to plan and organize activities for the upcoming week. Make a calendar for next weeks activities and post it in a common area so that everyone can see what is on the agenda for the afternoon and evening.

4. Involve the whole family in deciding what activities would be fun to do, but be ready with suggestions.

Enjoy the Outdoors:
Go for an after dinner walk or star gazing. You can get a book out of the library this week about constellations and try to find them in the sky next week.

Cook or Bake together:
Involve your children in planning and cooking fun dinners such as taco night or pizza night. You can let each child make his own individual mini pizza with his own toppings.

Play together:
You can organize family board games. Each night allow one child to be in charge of picking a game. You can make teams and play boys against girls or kids against adults. You can even team up with a neighbor's family and play family verse family charades or Pictionary.

Arts and Crafts:
Discuss if there are any projects your children would like to do together. You can try getting a family oriented magazine that has fun seasonal projects and let your children look through it for ideas.

Read together:
For younger children, you can go to the library this week and let them choose books to read or have read to them next week. It may also be fun to read a book together as a family. You can choose a chapter book, such as Charlotte's Web or Stuart Little, for example, and you can read a chapter or two aloud to them each night.


Although it will definitely require more planning than turning on the TV or allowing them to play video games, if well planned a week without TV can remind a family of the fun they can have together.

Slings - Are They Safe?

Before having a child, I never thought I would be comfortable using a sling. They looked precarious and scary. I was nervous I wouldn't tie it right or that I would lean over and my baby would just fall out. After having an infant, I received a sling as a present from a neighbor. Not wanting to seem ungrateful, I tried and loved it.

Slings, if used correctly, can be wonderful. In the infant stage, they can simulate a womb like feeling, keeping the infant nestled in and close to mom. This is has the benefit of being calming for babies and keeps curious strangers from getting too close to vulnerable newborns.

As the child grows, many slings grow with the child with different positions for different stages of infancy and toddlerhood. However slings can pose a risk of suffocation as illustrated by the recent Infantino sling recall.

The Infantino sling is an infant sling, although the recent deaths that occurred with this sling could occur with the use of any sling. The Consumer Product Safety Commission released a statement on March 12, 2010 advising caution when placing a child under 4 months of age in any sling. According to the statement, there have been 13 deaths related to sling use in the last 20 years. Twelve of those deaths were in children under 4 months of age. Most of the deaths occurred in low birth weight infants or infants with breathing problems including a recent cold.

As most parents know, infants should always be placed to sleep on their backs. This includes when they sleep in a sling. Parents also need to ensure that there is nothing blocking their nose and mouth preventing them from breathing. You should never put extra material, toys, blankets etc. inside the sling with the child. While wearing the sling, you should check frequently to ensure that your child is on his or her back and has not rolled over onto his or her stomach or side, or slid too far down into the sling. Also be sure that your body is not pushing up against the sling in such a way so that you are hindering airflow around the infant's nose and mouth.

In addition, young infants have poor head control and are not able to extend their necks to help them breath if they are placed in a crunched position. Parents need to ensure that when placing an infant in a sling that he has a fully extended neck and is not in a position with his chin touching his chest.

If used correctly and with the appropriate vigilance, slings can be wonderful. However, parents need to be aware of the possible risks associated with using a sling in order to prevent against them. Parents should use extreme caution if placing a child less than 4 months of age in a sling. Parents should not place a child who is sick, congested, having problems breathing, or who had a low birth weight or has low muscle tone in a sling. In addition to these new warnings, parents should of course always follow the manufacture's instructions and warnings for the use of their particular sling.

If you do have an Infantino SlingRider or Wendy Bellissimo Baby Carrier, you can get more information regarding the recall and free replacement products at the Infantino website.

Good Touch, Bad Touch:

No one looks forward to having talks with their children about uncomfortable situations but no matter what your child's age there are talks that you should be having with them on a regular basis.

For younger children, it is important to introduce them early to the concept of good touch, bad touch. This allows them to have the words and the confidence to talk to you if they experience a bad touch. It is a horrible thing to think about but if someone does approach your child you want them to be prepared, to know that they can say no, and that they should come and talk to you about it. If you do not talk to them about it first, then you leave them open for manipulation by a perpetrator.

So how do you approach the subject? You can start by defining the terms "good touch" and "bad touch" for your child. "Good touches are touches that you like, touches that you feel comfortable with and that make you happy, like a hug from mommy. Bad touches are touches that make you uncomfortable or sad. They are touches you don't want. Sometimes people try to touch you in your private parts or ask you to touch their private body parts. These are bad touches."

You can then go on to discuss what parts of the body are private by saying, "Do you know what parts of your body are private? No one is allowed to touch you in a private area."

You can then ask them for examples of good touches and bad touches. You should also ask them if anyone has ever given them a bad touch. To end the discussion, review with your child what they can do if someone tries to touch them and who they can tell or turn to for help.

There is a wonderful resource that can be accessed by googling "Good Touch, Bad Touch, Secret Touch: Your Body Belongs To You"; the first link is a quick read and a great primer for parents about to have the conversation with their little one. The University of Iowa Children's Hospital also has a very useful webpage on Good Touch, Bad Touch with talking points and examples to go through with your child.

Children as young as 4 years old can begin to understand the concept of good touch, bad touch, but even younger children can understand that parts of their bodies are private. There are some non-threatening books to help introduce and illustrate the concept of private parts. One such book "Some Parts Are Not for Sharing" illustrates this point with a children's story about fish.

Like all tough talks it is not sufficient to have the talk once and then hope that your children will seek you out should they need to talk. The conversation needs to be repeated on a fairly regular basis to reinforce the topic and to make sure your children understand that it is not taboo to talk about their bodies or if they are ever uncomfortable.

Poison Prevention Week - Children Act Fast, So Do Poisons:

National Poison Prevention week is a yearly reminder to check over your home and make sure that all dangerous and toxic substances are properly stored away from the reach of small children. Although it is common to baby proof when your little one starts crawling, parents often fall behind as their child quickly grows and develops new skills to get into things.

When rechecking your home, be sure that medicines and vitamins, especially any vitamins containing iron, are out of reach. Common overlooked "hiding places" for medicines are nightstands, purses, and in car consoles or glove compartments. It is also important to remind any guests, who may not be used to thinking about where they leave their pills, to be sure to store their medicines out of children's reach while visiting.

Double check bathrooms to be sure that all chemicals, such as hair-dye containing bleach and acetone nail polish remover, are stored in childproof cabinets or drawers. It is best to use childproof latches that are self-locking as opposed to those that need to be manually locked every time they are opened.

All cleaning supplies should be stored up high or in self-locking childproof cabinets. It is best to keep cleaning supplies in their original containers. Never store toxic chemicals in old beverage bottles.

Childproofing does not end in the home.
Some of the most toxic chemicals are found in the garage. Anti-freeze, paints, varnishes and pesticides, are all extremely dangerous and should be stored up high or in locked cabinets out of reach of children.

As discussed in my May 2009 blog post, "Poisonous Plants: Is Your Garden Safe for Your Children and Pets?" spring is an excellent time to look over your garden and ensure that you have no toxic plants. Some very common garden plants are toxic when ingested. These include Wisteria, Foxglove, Irises, Rhododendrons, Azaleas, Oleander, Jasmine and Buttercups. For a list of many common household poisonous plants, visit Texas A&M University's "Poisonous Plants" website.

Make sure you have poison controls phone number, 1-800-222-1222, near your home phone and stored in your cell phone. If your child does ingest a potentially toxic chemical or plant, call poison control immediately. Do NOT make your child vomit and do NOT give syrup of ipecac unless instructed to do so by a healthcare professional. This is because some chemicals will burn the lining of the esophagus. By making the child vomit you will burn the esophagus a second time doing twice the damage as the original ingestion.

For more tips on how to protect your home from poisons, visit the American Academy of Pediatrics' website.

Prevnar 13 (PCV 13): The New Pneumococcal Vaccine At Your Pediatrician's Office:

On February 24th, a new version of the pneumococcal vaccine was approved for use in children under 6 years old. The older version Prevnar 7 will soon be phased out and replaced by Prevnar 13. Both are made by Pfizer and protect against Streptococcus pneumoniae, which causes invasive pneumococcal disease, including meningitis, as well as some ear infections. The difference between the two vaccines are the number of serotypes, or strains of the virus, each vaccine protects against. As indicated by the name, Prevnar 7 protects against 7 serotypes of Strep. pneumoniae where as Prevnar 13 protects against 13.

The dosing schedule will remain the same. It will be a 4 dose series given at 2, 4, 6 and 12-15 months of age. For children still under 15 months of age, who have not received all 4 doses, they will receive Prevnar 13 in place of Prevnar 7 for any remaining scheduled doses. There is no need to restart the vaccination process with the new vaccine.

Only one dose of Prevnar 13 is necessary to confer immunity against the additional 6 serotypes of Strep. pneumoniae. Thus, for children who have completed their Prevnar series, but who are less than 5 years old, it is recommended that they get one dose of Prevnar 13 at their next regularly scheduled visit. Prevnar 13 can be given 2 months after the last Prevnar 7 dose. (For children with underlying medical conditions such as sickle cell anemia or children who do not have a spleen, the cut off age for giving an additional dose of Prevnar 13 is increased to 18 years old.)

The most common adverse reactions to Prevnar 13 were similar to most childhood vaccines: "redness, swelling and tenderness at the injection site, fever, decreased appetite, irritability, increased sleep and decreased sleep."

Prevnar 13 is not yet available but should be shortly. You should feel free to discuss any questions you have regarding the new version of Prevnar with your pediatrician. Since all offices will not be receiving Prevnar 13 at the same time, your pediatrician should inform you which version of Prevnar your child receives at any upcoming visits and if it is Prevnar 13 it should be noted as such on his yellow vaccination card to avoid unnecessary additional doses in the future.

New Medical iPhone Application for Parents and Medical Websites You Can Trust:

For parents on the go or those just trying to find credible on-line medical information, Cook Children's Hospital has released a wonderful resource -- a free iPhone Application called KidsCheckup.

The application has a myriad of information including algorithms to help determine whether something is a medical emergency requiring immediate medical attention. There are also sections that provide reliable information on general children's health topics as well as common medical conditions and how to treat them.

For those tech savvy parents with an iPhone this is an application worth checking out.

For those of us who have to resort to the Internet, it can be difficult to determine what sites are legitimate and what sites should not be trusted. In general, any site where the public can write in and give advice is no better than polling random people on the street.

If you are looking for credible information, hospital affiliated websites, such as the Mayo Clinic's site, are a good place to start. The American Academy of Pediatrics has also just launched a new website for parents.

Other wonderful websites are Dr.Greene.com and eMedicine. Dr.Greene.com is a user-friendly site intended for parents. Whereas, eMedicine has more detailed information and sometimes uses medical jargon since it's target audience is medical professionals. Used together these sites provide a comprehensive overview of most childhood medical conditions.

Although websites and iPhone applications do not replace face-to-face medical evaluations, they can provide parents with information to allow them to better understand their child's illness as well as provide appropriate anticipatory guidance for when to seek medical care.

Body Mass Index - Is Your Child A Healthy Weight?

Body Mass Index, BMI, may not be a concept that you have ever discussed with your child's pediatrician. Although most parents are very familiar with the pediatric height and weight curves and can tell you their child's percentiles for both; the BMI curve is often not discussed at most check-ups.

However, as part of the fight against childhood obesity, all pediatricians are being asked to plot and discuss children's BMI with their parents at every check-up.

BMI can be calculated for children over the age of two. BMI's in the 95 percentile and above indicate that the child is obese. Children whose BMI's fall in the 85-95 percentile are classified as overweight. Children in the 5-85 percentile are considered a healthy weight and those under the 5th percentile are classified as underweight.

As you can see, there is a broad range of what is considered a healthy weight. In some cases, a healthy BMI may be very misleading. For children whose BMI is steadily climbing, even if it is still below the 85 percentile, there is reason for concern. This time of pre-overweight may prove to be a more effective time for intervention than once a child is overweight or obese. To calculate and track your child's BMI you can use the Center for Disease Control's BMI calculator.

If you do decide to calculate your child's BMI, remember that although the percentile is important, trends are important too. For children who are obese, it may be quite a while until their BMI is within a healthy range but slow and steady progress down, over possibly years, is the goal.

To help with this goal there are many resources available. The White House's anti-obesity campaign "Let's Move" was unveiled this month and with it a website was created with a tremendous amount of information from estimated caloric requirements for children at every age to tips for dealing with picky preschoolers.

Although BMI is not calculated until 2 years of age, it is important to start establishing healthy habits at a young age. It is best to try to teach your children to eat right and exercise daily long before their weight is ever a concern. This means that you may find your pediatrician asking more questions about your little ones diet and activity level. You may even be handed a "Prescription for Healthy Active Living." These handouts reiterate the basic recommendations for healthy living for children:
5 – Eat 5 fruits and vegetables a day.
2 – Limit screen time (TV, computer, video games) to 2 hours a day.
Children younger than 2 should have no screen time at all.
1 – Strive for 1 hour of physical activity a day.
0 – Limit sugar-sweetened drinks.

Finger Amputations - A Preventable Injury:

Finger and thumb amputations continue to be a substantial source of injury to young children. A study recently published in the January issue of the Journal of Trauma has reiterated the need for improved safety measures and child proofing to decrease these injuries. Luckily, many of these measures are fairly easy and low cost child proofing devices.

Although given all the media hype, one might think that strollers pose the biggest finger amputation risk to young children, however, the culprit is in fact something much more common and often overlooked -- doors.

In young children ages 0-2 years, the leading cause of finger amputations is having a finger caught in a door. As any parent of a toddler can attest to, young children are fascinated with opening and closing doors. Doors pose a hazard not just to the child operating the door but also to other children who may place their fingers unknowingly in the rear door jam when someone is about to close the door. Doors can also fly shut suddenly and forcefully because of wind severing a small finger that was in the door jam at the time.

There are a number of products on the market to prevent doors from closing. One of the easiest devises is made by KidCo and aptly called the Finger Guard. It is a clear or gray rubber device that is non-marking and no adhesive strips are needed to install it. It simply slips onto to the back of the door and prevents it from closing. It is easily taken on and off and thus can be used only when needed. Another similar product is placed on the front part of the door. This again prevents the door from closing, however it is less effective at preventing injuries to fingers in the rear door jam. Either of these devices can be easily packed to bring with you on vacation in order to quickly child proof hotel rooms or a grandparent's house.

Other products are available that act as a door catch holding the door open. These are great for windy areas and don't need to be taken on or off to close the door, ensuring that they are used more often. One such product is the Magnetic Door Stopper from Home Depot. The downside to these devices is that as your children get older they will be strong enough to close the door despite the catch.

When deciding which products work best for your home remember that child proofing is an ongoing process and that as your children grow, what was once sufficient may need no longer do an adequate job of keeping them safe. A watchful eye is always important but in the case of finger amputations these injuries happen in a second and without proper child proofing even the most vigilant parent will probably not get there in time to prevent the injury.

When Your Child Has Warning Signs of an Immunodeficiency:

Most children are sick multiple times a year and as discussed in Nov. 15th's blog post "Constantly Sick: Is It A String Of Colds Or An Immunodeficiency?" this is not cause for concern. Although immunodeficiencies are rare, 1 in 500 children will have one so all parents should be familiar with the warning signs. Of course, one would hope that your child's pediatrician would recognize these warning signs early on, however, it is often not that simple. Although a child may see the same doctor throughout the year for his check-ups, it is not uncommon for him to see a different doctor when he is sick. Therefore, it is possible that these early warning signs could be missed if your pediatrician is not made aware of these additional visits and illnesses.

You don't need to tell your pediatrician about every cold, or mild viral illness your child has had since your last visit. But you should make him aware of any of the following warning signs.

10 Warning Signs of Primary Immunodeficiency
1. 4 or more new ear infections within 1 year.
2. 2 or more serious sinus infections within 1 year.
3. 2 or more months on antibiotics with little effect.
4. 2 or more pneumonias within 1 year.
5. Failure of an infant to gain weight or grow normally.
6. Recurrent, deep skin or organ infections.
7. Persistent thrush in mouth or fungal infection on skin.
8. Need for intravenous antibiotics to clear infections.
9. 2 or more deep-seated infections including septicemia.
(Septicemia is a bacterial infection of the blood).
10. A family history of Primary Immunodeficiency.

If your child has two or more of the above warning signs, you should bring this to the attention of your pediatrician. The presence of these warning signs does not conclusively determine that a child has an immunodeficiency but they suggest that further studies may be warranted.

Is Your Child Eating Enough? - The Proper Serving Sizes for Toddlers and Children

Until I had my own child, I didn't really understand why during a child's check-up so many parents would be concerned that their child was not eating enough. For the most part, these were children who were following their growth curves perfectly and looked very healthy. I would reassure the parents by showing them the growth curves and telling them that they are obviously eating enough to grow and that they shouldn't worry.

Now, after having my own child, I get it. Many meals I sit there and think, "That just couldn't be enough food for her." Then I remember what a proper serving size is for her age. Like most children she is usually eating exactly as much as she should.

Servings, especially for toddlers, may seem impossibly small: 2-3 tablespoons of vegetables, or a quarter to a half a slice of bread. In reality, that means a quarter of a peanut butter and jelly sandwich may be all they will want. The trick with toddlers is variety. If they are done with the PB&J, then offer a few slices of banana, half of a piece of fruit, or a few berries. Then switch to some dairy, a small glass of milk or a piece of cheese.

As you can see from the American Academy of Pediatrics "Feeding Guide for Children," although the portion sizes are small, the number of portions a child has in a day are often between 3-5. This means that at most meals, he may not eat a lot of one thing but will eat a small amount of many things.

Trying to serve balanced meals may seem overwhelming to the new parent. But, it is often easier than it seems. Try to offer protein, dairy and fruit/veggies at every meal. This will usually ensure that he is getting enough protein, carbohydrates and fat for the day. Having a few no-cook back-ups in the fridge will help to round-out meals and allow you to serve him a tablespoon or two and save the rest for another meal.

Children often require repeated exposure to a food before they will actually taste it. So don't be discouraged if your child won't eat strawberries. Try again in a few days. At the same time, there may be some foods your toddler really does not like. If he has one or two foods that he seems to dislike, you don't need to push the issue. However, if all your child will eat is cheese, you may need to start rounding out his diet and broaden his palate or you will find yourself facing a four-year-old that expects a special dinner of food he likes prepared for him every night.

Some Helpful Go-To Foods To Have On Hand:
No-Cook Proteins for Toddlers:
1. Humus - It lasts a while in the fridge and can be served on toast or crackers. It also comes in many varieties. You can try red pepper humus or baba ganoush as a way to sneak in some vegetables.
2. Deli meats - Aim for the healthier meats such as turkey or chicken breast.
3. Smooth Peanut butter
4. Canned tuna or salmon. These can be mixed with a little mayonnaise as well as canned vegetables like corn or peas.

Dairy - Most dairy products have a decent amount of protein so if you have a lower protein day increasing these may help:
1. Yogurt
2. Milk
3. Cheese

Fruit/veggies:
1. Canned fruit
2. Canned veggies
3. Berries

BPA - An Update:

In a follow up to my Nov. 2008 blog post, "BPA - Is it safe?", I am happy to report that the US government and the FDA have finally decided to take a closer look at the effects Bisphenol A (BPA) has on small children.

The FDA has recently come out in support of a 2008 claim made by US government toxicologists that "the chemical is cause for some concern." Although it seems that they are lagging significantly behind parents and the bottle industry in addressing this concern, it is better late than never.

BPA is found in plastics, usually marked with the recycle code 7 or 3. These plastics are used in bottles, cups and as liners for metal and plastic food containers, including those in which powdered and ready-to-feed formula come. BPA leaches out of these products and into the liquid inside the container, which is then consumed by the child.

Scratches in the surface of bottles increase the amount of BPA that can leach out as does heating the plastic or liquid. There are now a significant number of BPA-free bottles and cups available in most price ranges, although infant formula manufacturers have yet to come out with BPA-free containers for their products.

When choosing formula parents may want to choose canned powdered formula or ready-to-feed formula packaged in glass bottles as opposed to formula in plastic containers. This is because The US Department of Health and Human Services has reported that liquid formulas packaged in plastic have been shown to absorb more BPA from their containers than their powdered equivalent. For more information about BPA, its potential health effects, the research and advice on limiting your child's exposure please see my blog post "BPA - Is it safe?".

Great New Parenting Website:

The American Academy of Pediatrics has a great new user friendly website for parents. The new website is similar to Baby Center's website with information broken down into topics relevant to different aged children. However, unlike other parenting websites, parents can rest assured that the information on this site is accurate and approved by the American Academy of Pediatrics. So check it out at www.healthychildren.org. I am sure it will prove a good resource now and for the future.

Constipation - Enemas or Oral Laxatives:

Constipation is a common childhood problem, which usually responds to dietary changes as well as stool softeners or laxatives. However, for some children, constipation can result in fecal impaction, which is when a hard collection of stool becomes lodged so that it cannot pass through the anus. As can be imagined, this can be extremely uncomfortable. Children often present to the pediatrician with cramping abdominal pain. If the physical exam suggests constipation and there is a positive history of constipation, an enema is often used to try to dislodge the stool and relieve the pain.

An interesting study published in the December 2009 Journal of Pediatrics tested the common practice of using enemas to relieve fecal impaction versus using an oral medication, Polyethylene Glycol-Electrolyte solution, aka PEG, which is available over the counter by the trade name Miralax. The study found that the two methods had similar success rates.

Both pediatric enemas and Miralax are available over the counter, however before diagnosing and treating your little one with severe constipation or fecal impaction it is best to consult your pediatrician to ensure that there is nothing more serious that could account for his symptoms. When discussing with your pediatrician which of the two methods, enemas or oral medication, should be tried to relieve the impaction there are many things to consider.

How quickly the treatment will work:
Enemas may work more quickly. In the study, both treatments were used for 6 consecutive days. However, the results showed that when enemas were used children usually had a bowel movement within 25 minutes. Miralax can take at least a day to start working and multiple days of treatment may be needed to fully relieve the impaction.

Ease of getting your child to take the medication:
Enemas need to be given rectally. For some children, this may prove to be difficult to administer. However, other children may refuse to take oral medications making an enema a good alternative.

Side Effects: Enemas have a higher likelihood of causing abdominal cramping until the child has a bowel movement. The cramping usually resolves within an hour. Miralax has a higher likelihood of causing fecal incontinence (uncontrollable leakage of watery stool). This may continue until the fecal impaction resolves.

Regardless of which method is used to relieve the impaction, either method should be followed by maintenance medication to prevent impaction from happening again. This medication needs to be continued for at minimum a couple of weeks to allow sufficient time for the child's bowels to return to normal. What medication and what dose should be used for maintenance should be discussed with your child's pediatrician.

The Stomach Flu - Acute Gastroenteritis

Acute gastroenteritis (AGE), more commonly known as stomach flu or a stomach virus, is a viral illness effecting the stomach and intestines. It is a very common illness in children and can be caused by a number of different viruses. The diagnosis of AGE is based on the symptoms a child presents with, most notably vomiting and diarrhea. Other symptoms include: fever, diffuse stomach pain, loss of appetite and increased tiredness or irritability.

Although concerning to parents, a loss of appetite is normal. The main concern is dehydration. Thus, if your child refuses to eat, he may just not feel up to it, but you need to encourage him to drink plenty of liquids. Children need to replace all the liquid lost from vomiting and diarrhea. Drinking large quantities at one time may induce vomiting, so it is better to give them a few sips at a time. For younger children, fill a sippy cup or straw cup with water, Pedialyte, juice or a sports drink and let them sip on it throughout the day. Pedialyte is a good alternative to water in this situation because it not only replaces the fluid lost but also the electrolytes. Unfortunately, some children do not like the taste. In order to avoid dehydration, this is one instance where it is better to just let them drink what they like. Even frozen juice or ice pops are okay. If your child has no urine output for 8 hours or more, has no tears when he cries, has a dry mouth (no saliva) or his eyes look sunken, you should call your doctor, as these are signs of dehydration.

AGE is usually fairly shot lived, resolving in 3-5 days. Although in young children, the diarrhea may persist for longer. This is in part due to inflammation and damage to the intestinal lining by the virus leading to decrease lactase enzymatic activity. Lactase is the enzyme in the body that breaks down milk products. After a bout of AGE, for a short period of time, it is more difficult to digest milk products. Thus, excess milk or dairy products should be avoided. This does not mean that children need to switch to lactose-free formulas or that infants should stop breastfeeding. Mothers who are breastfeeding should continue to do so and most children can remain on their regular formula. Instead, it should simply reassure parents as to why, although their child may seem better, they are still having some lingering diarrhea.

Parents should also start a bland diet revolving around the BRAT foods. The BRAT diet is an acronym for bananas, rice, apples and toast. Other bland carbohydrates can be substituted for rice and toast such as pasta. These foods can be prepared with a little butter but salsas, beans, and sauces should be avoided.

What you can do at home:
1. Keep your child well hydrated.
2. Start the BRAT diet.
3. Limit excess dairy products (but continue with normal formula or breast milk).
4. Limit spicy foods.
5. Practice good hand hygiene to avoid spreading the virus.

When to call your doctor:
1. Signs of dehydration
2. Bloody stool, black tar-like stool or stool that resembles red jelly
3. Bloody vomit or vomit that resembles coffee grounds
4. Abdominal pain that is localized to one consistent area of the stomach, especially the right lower quadrant of the abdomen
5. Difficulty arousing your child, or if they seem particularly sick to you

Safe Cooking Tips For Your Thanksgiving Feast:

Happy Thanksgiving!!!!
Here are some cooking tips that I gave out last year to help everyone have a happy and healthy Thanksgiving.

1. Fully defrost your turkey before cooking it. This may take 2-3 days.
According to the Food and Drug Administration (FDA), "When thawed correctly in the refrigerator or at a temperature of no more than 40 F, a 20-pound turkey needs two to three days to thaw completely. Thawing the turkey completely before cooking is important. Otherwise, the outside of the turkey will be done before the inside, and the inside will not be hot enough to destroy disease-causing bacteria."

2. Cook your turkey until it reaches an internal temperature of 180 degrees.
Make sure when inserting the thermometer that it is not touching a bone as this will artificially raise the temperature.

3. It is safest to cook stuffing outside the bird but if cooking it in the bird be sure the stuffing reaches a temperature of 165 degrees.

4. Refrigerate hot food being made in advance immediately.
Do not let it cool to room temperature before putting it in the fridge. Although this is a common practice, it allows bacteria to grow.

5. Avoid cross contamination by designating one knife, cutting board and sponge to be used only for raw meat.

Have a wonderful Thanksgiving!!!!!!

Constantly Sick: Is it A String Of Colds Or An Immune Deficiency?

It is not uncommon for parents to come in to the pediatrician's office concerned about the number of colds their child has had. That they seem to have had a cough for months and that surely this must be something more than a string of colds. Is it possible that there is something wrong with their immune system?

The answer is almost always that the number of colds they have had is absolutely normal. A child who has a perfectly healthy immune system gets on average 6-10 colds a year. Children in day care or who are exposed to second hand smoke tend to get even more. A common cold can last a week to 10 days sometimes with a lingering cough for an additional week. That can add up to over 100 days of viral illness in one year, which if clustered in the fall and winter months can seem like your child is continuously ill.

So when do you need to worry? A cold is a viral illness that generally causes cough, runny nose, fever, loss of appetite and sometimes vomiting. A child who has these symptoms, even if it is as often as 10 times a year, is most likely perfectly healthy. On the other hand, children whose colds almost regularly progress to more complicated illnesses such as bacterial pneumonia, children who get infections with rare organisms, or who have recurrent fungal infections may warrant a referral to the immunologist. For more information about immunodeficiencies, the Riley Hospital for Children's Allergy and Immunology has a very informative website.

When to visit your pediatrician? A run of the mill cold usually does not require a visit to the pediatrician's office, but if your child is experiencing any of the following symptoms you should notify your child's doctor immediately.
1. If your child is having difficulty breathing or is working harder to breath
2. If your child has asthma that is getting worse with the cold
3. If your child is having trouble keeping liquids down and is having decreased urine output
4. If your child is difficult to arose or is hard to keep awake
5. If your child has a low grade fever for a few days and then suddenly spikes a high fever
6. If your child develops a rash that looks like little red dots that do not turn skin colored when you press on them
7. If your child is 2 months or younger with a fever above 100.5 and/or symptoms of increased fatigue or decreased appetite

If you do need to call your pediatrician, going through a simple checklist before you call can help ensure that you give your child's doctor all the information they need to help you.

Colds are a common and normal part of childhood. Children under 6 years of age should not be given cold medicines unless instructed to do so by a doctor. While this may be frustrating, there are many home remedies that parents can use to ease the symptoms of a cold and help their little ones feel better.

Are The Antibiotics Women Take During Pregnancy As Safe As We Think They Are? A New Study Suggests Maybe Not:

A concerning study was publish this month in the November issue of Archives of Pediatric and Adolescent Medicine. The Center for Disease Control sponsored a retrospective study that looked back on the antibiotics women received immediately prior to and during pregnancy and any subsequent birth defects their infants had. They compared these birth defects to birth defects seen in infants born to women who had not taken antibiotics prior to or during pregnancy.

The results were surprising. Women who had taken either of two very commonly used antibiotics for urinary tract infections, Sulfonamides (Bactrim), or Nitrofurantoin (Macrobid) had a significantly increased risk of having a baby with a birth defect.

"Sulfonamides were associated with six birth defects, more than any other class: anencephaly (adjusted OR 3.4, 95% CI 1.3 to 8.8), two left-sided heart defects, hypoplastic left heart syndrome (adjusted OR 3.2, 95% CI 1.3 to 7.6) and coarction of the aorta (adjusted OR 2.7, 95% CI, 1.3 to 5.6), choanal atresia (adjusted OR 8.0, 95% CI 2.7 to 23.4) transverse limb deficiency (adjusted OR 2.5, 95% CI 1.0 to 5.9) and diaphragmatic hernia (adjusted OR 2.4, 95% CI 1.1 to 5.4).

Four defects were associated with nitrofurantoin use: anophthalmia or microphthalmos (adjusted OR 3.7, 95% CI 1.1 to 12.2) hypoplastic left heart syndrome (adjusted OR 4.2, 95% CI 1.9 to 9.1), atrial septal defects (adjusted OR 1.9, 95% CI 1.1 to 3.4), and cleft lip with cleft palate (adjusted OR 2.1, 95% CI 1.2 to 3.9)." (OR = Odds Ratio, CI= Confidence Interval)

Other commonly used medications such as Penicillin, Cephalosporins, and Erythromycin were found to be associated with fewer defects. However, even women taking these medications did have an increase risk of having babies with certain birth defects.

"Women who took Penicillin during pregnancy were three times more likely to have a child with an intercalary limb deficiency than women who had not taken penicillin. Women who had taken Erythromycin during pregnancy were more than two times as likely to have a child with anencephaly or transverse limb deficiency. Lastly, having taken a cephalosporin during pregnancy statistically increased a women's chance of having a baby with an atrial septal defect."

However, before concluding that all the birth defects found associated with these medications were actually caused by them, it is important to remember that it is difficult to ascertain whether it is the infection or the treatment causing the defects. For example, asymptomatic urinary tract infections in non-pregnant women would not warrant treatment. However, failure to treat asymptomatic urinary tract infections in pregnant women can lead to intrauterine growth retardation and low birth weight infants. This is just one of many examples of where it is the infection during pregnancy that does the harm.

It is also necessary to try to tease out what part timing plays in determining if a woman has an infant with a birth defect. Unfortunately, the above study was based on patient recall, which often is not entirely accurate. Women were asked what antibiotics they were given and when during the pregnancy they took them, often long after the actual event. This type of study does not lend itself to gathering very specific information as to what week of pregnancy the women acquired the infection or received treatment. However, the study does provide enough information to make further testing necessary.

These medications need to be evaluated for the risks they may pose and to help doctors decide what medications should be the first line of treatment used if a women does get an infection during pregnancy. Until further studies are done, it would be wise, when possible, to err toward the safer side of the antibiotic spectrum, such as penicillin, erythromycin and cephalosporins and to avoid, the once considered safe, Macrobid.

Baby Einstein Offers Refund for DVD's - Videos Do Not Increase A Child's Vocabulary:

Disney, which owns Baby Einstein, is offering a refund or exchange for any DVD bought in the last 5 years. DVD's can be returned to Disney for $15 or exchanged for another Baby Einstein product. No proof of purchase is necessary. This move came after Campaign for a Commercial-Free Childhood threatened a class-action lawsuit for false advertising claims made by the videos' packaging. These videos were originally marketed as educational, although Disney has since dropped that labeling.

This is a victory for groups trying to limit children's TV exposure, especially children less than 2 years of age. There have been no studies showing benefits to children under 2 watching "educational" programming. In fact, contrary to Disney's original claims that the videos could teach vocabulary to young children, multiple studies have shown the opposite to be true. There appears to be an inverse relationship between verbal development and hours of television watched. In Australia this month, the government has gone so far at to recommend a ban on television watching for children under 2, stating that TV watching "can stunt their language development and shorten their attention span."

In today's society, it seems almost impossible to not have children under two watch any TV, but it is important to remember that TV watching is a learned habit. Children who watch TV on a regular basis quickly start to "ask" to watch TV, either verbally or for younger children by pointing to the television. This should not be mistaken for a signal that TV is good for them. Children get far more out of interacting with their parents or even playing by themselves then watching television. While watching an occasional television show will not have life long detrimental effects on your toddler, it is important to remember that any time spent mindlessly in front of a TV is time not spent doing something else more educational and useful to their development, such as reading.

Reading to infants and having books around the house has been shown to increase a child's vocabulary. Additionally, children who have been read to from a young age often enjoy leafing through books by themselves even before they can read. Allowing your children to learn to spend time by themselves with books can have the added benefit of providing some of the down time parents are often seeking when they turn on the television for their little ones.

For additional information on media and children visit Ask the Mediatrician.

Giving Acetaminophen with Vaccinations May Reduce Their Effectiveness:

A new study published in the medical journal Lancet this week reported that routine administration of acetaminophen (Tylenol) to children after vaccinations decreased their antibody response.

The children in the study were given acetaminophen suppositories every 6-8 hours continuously for a 24-hour period. How this applies to most parents is not entirely clear. In reality, many parents give only one dose of acetaminophen either immediately prior to or after vaccinations, few give it around the clock for a day. According to the study, if a child develops a fever after vaccination, giving one does of acetaminophen does not decrease antibody levels. However, the authors state that acetaminophen should not be given prophylactically to prevent a fever.

Why would acetaminophen decrease antibody levels? One proposed hypothesis is that acetaminophen interferes with the body's inflammatory response and thus decreases the antibody levels.

This study leaves a lot of unanswered questions.
1.What is the significance of the lower antibody rates? Were the lower antibody rates still within the range of being considered a significant response to the vaccine, meaning would that level of antibodies still confer immunity to the child?

2. If the child does not have a fever, does one dose of acetaminophen prior to or immediately after vaccination significantly affect antibody levels?

3. Does ibuprophen (Motrin) have the same effect on antibody levels?

Regardless of the unanswered questions given the results of this study, it would seem prudent to not prophylactically treat children with acetaminophen, or any other anti-inflammatory agent, prior to or after immunizations in order to prevent a fever. However if the child does develop a fever, there should be no qualms about treating it with acetaminophen. The exceptions to this advice would be any child with a history of febrile seizures. Parents of children with febrile seizures should discuss the use of prophylactic acetaminophen use with their child's doctor.

It would also be prudent to avoid using acetaminophen as a pain reliever for immunizations. For parents looking to reduce the pain of vaccinations, there are analgesic creams available. One such cream is called Emla and is a mixture of lidocaine and prilocaine. It is applied to the area 30 minutes to an hour prior to the injection. Parents can ask their child pediatrician for a prescription for an analgesic cream and apply it at home prior to leaving for the doctor's visit.

For a non-pharmacological way to ease pain, studies have shown that sucking on a pacifier dipped in a sucrose solution such as Sweet-Ease significantly reduces an infant's perception of pain. Although common in the hospital setting, most pediatrician's offices do not have Sweet-Ease. However, you can discuss with your doctor making an at home sugar solution and bringing it with you.

76 US Children Have Died from H1N1 (The Swine Flu) -- Should You Vaccinate Your Child? - An Opinion Editorial:

It is alarming to hear how blasé some people, including some pediatricians, have become about H1N1. On the news last week, there were reports that H1N1 was "no big deal" and that the government had overreacted. The reports went on to indicate that many people would be opting not to vaccinate themselves or their children.

I would like to put those reports in perspective. Below is an excerpt from a daily news digest sent to physicians from the American Medical Association. It is based on information recently released by the Center for Disease Control.

"CDC says 76 children have died of H1N1.
ABC World News (10/9, story 4, 1:50, Gibson) reported, "The CDC said...the [H1N1] virus is widespread in 37 states, and it is having" a "deadly effect on children." The CBS Evening News (10/9, story 6, 2:15, Couric) reported that data indicate the virus is "now widespread in ten more states." NBC Nightly News (10/9, story 4, 2:25, Williams) also reported, "New numbers out from CDC. They show widespread virus and increase in deaths."

The AP (10/9) reported, "Health officials said Friday that 76 children have died of swine flu, including 16 new reports in the past week-more evidence the new virus is unusually dangerous in kids. The regular flu kills between 46 and 88 children a year, according to Centers for Disease Control and Prevention data." The Washington Post (10/10, Stein) reported, "While most of the children who have died have had other health problems that made them particularly vulnerable, such as asthma, muscular dystrophy and cerebral palsy, 20 to 30 percent were otherwise healthy," CDC National Center for Immunization and Respiratory Diseases Director Anne Schuchat said."

This seems to be a very contagious virus. Meaning that if you come into contact with someone who has it, there is a high probability that you too will contract the disease. Luckily, the mortality rate is not as high as once predicted; but that does not mean that everyone who gets sick with H1N1 is okay. 20-30% of the children who have died thus far have had no previous medical problems. That means 15-22 perfectly healthy children got sick with H1N1 and died because of it.

Seasonal flu kills 46-88 children a year. Deaths from H1N1 will probably be slightly higher by the end of the year. That may not seem like a lot, and luckily it isn't given how many children have gotten sick with H1N1. However, these are preventable deaths. For the parents of children who a week before getting sick were perfectly healthy and then suddenly died, I am sure they would have done anything to have prevented their child from getting sick with H1N1. Unfortunately, until now, there was no vaccine available.

The H1N1 vaccine is produced in the same way that the seasonal flu vaccine has been produced for years. There is no adjuvant or squalene added to the H1N1 vaccine. There are preservative free (mercury/thimerosal free) versions of both the seasonal flu vaccine and H1N1 available for children and adults.

All the trials of H1N1 have shown it to be a safe vaccine with only mild side effects, such as headache, fever or muscle cramps. In addition, other countries have already been safely administering the vaccine. The H1N1 vaccine has been given to 39,000 people in China with no serious adverse effects reported.

Adults can decide if they want to play the odds and hope that if they get sick that they will be one of the many that get better and not one of the few that die. But children are reliant on their parents to keep them as safe as possible. It would be a shame if the mainstream media's love of dramatics makes it difficult for parents to find reliable information regarding the risks and benefits of vaccinating their children against H1N1.

For parents concerned about the 1976 Swine Flu Vaccination Program Being Halted for Fear of Guillain-Barré syndrome (GBS) click here for more information.

Concussions: What Are The Symptoms And When Should Athletes Return to Play:

Fall sports are in full swing and unfortunately so are on the field injuries. One of the more concerning injuries is a concussion. Every year it is estimated that 300,000 young athletes suffer from concussive episodes. Although concussions are more common in high impact sports, any blow or jolt to the head during practices or games can result in a concussion. Parents of athletes both young and old should be familiar with the signs and symptoms of a concussion as well as the guidelines for when it is safe to return to play.

Concussions, no matter how mild, are always something to take seriously. They are a traumatic brain injury. They can range in severity but even a mild concussion can have consequences especially if an athlete sustains a second injury before he or she has fully recovered from the first. Second Impact Syndrome, as it is aptly called, occurs when an athlete incurs a second concussion while still having concussive or post-concussive symptoms. As surprising as it may sound Second Impact Syndrome is associated with a mortality rate of 70-80%. It is therefore imperative that young athletes are appropriately screened for continued symptoms and do not return to play until they have fully recovered.

Symptoms of a concussion can occur immediately after the injury or weeks later. Symptoms can range from confusion after the play to feeling sluggish, moody or having trouble concentrating many days or weeks later. The Center for Disease Control has a wonderful toolkit to help parents, coaches and athletes identify the symptoms of a concussion.

Any child or adolescent who incurs a concussive injury should be evaluated by a doctor. The majority of concussions are mild and resolve in 7-10 days. Once symptoms have resolved, a return to activity should be attempted in a stepwise fashion. According to the American Academy of Pediatrics, children should be monitored while attempting each of the following steps. If concussive symptoms recur with an increase in activity, the activity should be discontinued and the athlete should return to complete rest for 24 to 48 hours before attempting the steps again.

STEPS FOR A SAFE RETURN TO PLAY:
1. Complete rest - okay to continue with school but no increased activity.
2. Light (low-intensity) aerobic exercise, such as walking, without a component of resistance. Weightlifting is prohibited.
3. Activity specific to the sport, such as running or skating. Resistance training okay.
4. Training drills without contact, followed by mental status testing. Resistance training okay.
5. Full-contact training after clearance by medical personnel.
6. Participation in a game.

If concussive symptoms persist or return, the athlete may be experiencing Post-concussive Syndrome. It is important for parents, teachers and coaches to be on the lookout for any change in mood, irritability or difficulty concentrating, as these may be subtle symptoms of Post-concussive Syndrome. An athlete experiencing Post-concussive Syndrome should not return to play and should be evaluated by a physician.

Lastly, having had a concussion in the past increases an athlete's risk by six fold that he or she will sustain a concussion in the future. Thus, it is extremely important that athletes inform their coaches not only of new injuries but also of any concussions they have experienced in the past.

H1N1 Update: Vaccine Update & How to Properly Disinfect Toys:

Vaccine Update:
New information on the H1N1 vaccine was released yesterday. Studies regarding the effectiveness of the vaccine are showing that only 1 dose is needed for adults and children over the age of 10. Recipients of the vaccine are showing immunity to H1N1 kicks in around 1-2 weeks after vaccination.

Unfortunately, for smaller children, (6 months to 9 years of age) two doses will be necessary to produce an adequate immune response. These two doses can be given 3 weeks (21 days) apart. This is in addition to the seasonal flu vaccine. Although most pediatricians' offices already have the seasonal flu vaccine, the H1N1 vaccine will not be available until October. The Center for Disease Control and the American Academy of Pediatrics recommends that all children 6 months of age and older receive both the H1N1 and the seasonal flu vaccine.


How to Clean Toys to Kill H1N1:
H1N1 is fairly easy to kill and with proper care it should not be too difficult to disinfect your childrens' toys. It is important to keep in mind however that "flu viruses, including H1N1, can survive 8-12 hours on paper or cloth, 24-48 hours on non-porous surfaces like doorknobs s, and up to 72 hours on wet surfaces such as towels."

Diluted bleach is effective when cleaning toys or non-porous surfaces. A dilute bleach solution can be made by mixing10 parts water to 1 part bleach. Alternatively, plastic toys can often be washed in the dishwasher.

Stuffed animals or other porous toys can be disinfected by washing and drying the on the hottest cycle possible.

Lastly, children should be encouraged not to share utensils, cups or towels.

For more information on how to disinfect your home if your child does contract H1N1, visit the following website.

Are Your Children Properly Restrained In Their Car And Booster Seats?

This week is National Child Passenger Safety week and is a perfect time to check your children's car and booster seats.
Are your children in the proper seat for their age and weight?
Are the straps still fitting them properly or do they need to be adjusted?
The American Academy of Pediatrics' Guide for Families can help you do a quick car and booster seat check.

Things to remember:

1. Older children should be in a booster seat until the car's shoulder belt fits them correctly. This usually isn't until they are 4 feet 9 inches. Some cars have a way to lower the height of the shoulder belt. If it is not obvious if your car has adjustable seatbelts, consult the manual.

2. Once children outgrow their booster seats, they are still safest properly restrained in the backseat until they are at least 13 years old.

3. Rear-facing is the safest position for infants. Studies released earlier this year showed that infants are much safer in rear-facing seats and if possible children should remain rear-facing for as long as possible. Infants should remain rear facing until they are at least 1 year AND 20 pounds. After which they should remain rear facing, until they outgrow the rear facing weight and height limitations on their particular car seat.

If you are unsure if your children's car and booster seats are installed correctly you can find an inspection center near you at www.seatcheck.org.

H1N1 - The Swine Flu: As Schools Re-open How Can You Protect Your Children?

Swine flu will undoubtedly be back in the news this fall and winter as school starts up again and children are cooped up indoors breathing and coughing on one another. According to the Associated Press, Georgia Tech has reported 150 suspected cases and the University of Kansas 200 suspected cases in just the last two weeks since re-opening their campuses. If college campuses are any indication of what will be occurring in grammar and high schools across the nation, there will be a lot of concern both on the part of parents and school officials once doors open.

Luckily there will be a vaccine available. The bad news is that it will most likely not be ready for distribution until October. In addition, it seems that, at least initially, there will be significantly less doses available than anticipated. Hopefully though with a steady stream of vaccine production through the fall there will be enough available for all who would like to be vaccinated.

As the virus has been found to be more dangerous to pregnant women and children, these will be the first target populations for vaccination. Pregnant women should be vaccinated as soon as possible as they are at increased risk of complications due to their reduced lung capacity and altered immune system. Family members of children less than 6 months of age should also be vaccinated early in order to reduce the likelihood that they will bring the virus home to their unvaccinated infant. Children older than 6 months can be vaccinated and should start the two shot series as soon as it is available.

Both children and adults will need two doses of the vaccine spaced 3 weeks apart. This is in addition to the regular seasonal flu vaccine. It is thought that both the H1N1 and seasonal flu vaccine will be able to be given on the same day and that there will be thermisol-free versions of both. Parents of children over 2 years of age should discuss with their child's pediatrician if FluMist (the nasal spray version of the seasonal flu vaccine) is appropriate for their child as it could decrease the number of shots needed this flu season. A nasal spray version of the H1N1 vaccine should also be available and may make both seasonal and H1N1 vaccination relatively painless.

Vaccination is the best defense against this new flu strain; however, there will undoubtedly be numerous reports of the virus sweeping through schools within weeks of them opening their doors. This is because unlike the seasonal flu, H1N1 has remained fairly prevalent throughout the summer months.

It will be more important than usual to encourage your children to wash their hands. Since most children don't do this, try buying them an alcohol based cleanser that can be clipped to their backpack where they will see it and hopefully be more likely to use it. Start reminding them now in the week or two before school starts to wash their hands, or use a cleanser, in the hopes that they will continue the behavior when you are not around and able to prompt them. Also encourage them not to rub their eyes, nose and mouth. If they have asthma make sure it stays well controlled and if it is not well controlled call your child's doctor to talk about changing your child's treatment regimen.

Most importantly, allow your children to stay home when they are sick. This cannot be stressed enough. Children should not go to school if they are ill. Most schools will have a stricter policy this year of not allowing sick children to attend class and many schools will have a quarantine room for sick children awaiting pick-up by their parents.

Although there have been a few instances of resistant H1N1 most cases respond to anti-viral treatment. Treatment is most effective if started within the first 48 hours of symptoms. In the case of pregnant women, due to their high rate of complications and mortality, it is recommended that treatment be started as soon as H1N1 is suspected and even before confirmatory tests are completed. Symptoms of H1N1 are fever, cough, sore throat, runny nose, body aches, fatigue, chills and vomiting. The following is an excerpt from the Center for Disease Control's website:
"In children, emergency warning signs that need urgent medical attention include:
Fast breathing or trouble breathing
Bluish or gray skin color
Not drinking enough fluids
Severe or persistent vomiting
Not waking up or not interacting
Being so irritable that the child does not want to be held
Flu-like symptoms improve but then return with fever and worse cough"

Most children who contract H1N1 recover just fine but parents should not be complacent this year. There have been over a hundred pediatric deaths in the US since the start of the swine flu outbreak last September. If your child seems ill with a fever and cough, bring him to the doctor as soon as possible so that if H1N1 is suspected an antiviral can be started early.

Sports Physicals - Assessing for Cardiac Disease and Malformations:

With summer coming to an end, student athletes are preparing for fall sports and this often begins with the required pre-participation physical. Although this may seem like an unnecessary burden as you rush your child to the pediatrician before practice starts, it is in fact a very important visit.

One of the many things assessed during this visit is cardiac health in general, and more specifically, if a potentially undiagnosed heart problem could exist. Whether an EKG should be part of routine pre-participation physicals is debatable.

The current recommendation in this country is that it should not. The argument being that a thorough history and physical exam are as effective at uncovering potentially life threatening cardiac disease and malformations as an EKG. However, other countries disagree and routinely screen all athletes with an EKG prior to participation in organized sports.

What is not debatable is that a thorough history should be done and that further evaluation including an EKG or ECHO (echocardiogram) is necessary if any of the following questions are positive. Unfortunately, these exams are often rushed, or in an attempt to accommodate the patient, the forms are filled out using information from a previous yearly physical and these questions are never explicitly asked. The following is a list of questions that your child's pediatrician should ask prior to signing off on their pre-participation forms.

Have you ever passed out or nearly passed out during or after exercise?

Have you ever had discomfort, pain, or pressure in your chest during exercise?

Does your heart race or skip beats during exercise?

Has a doctor ever told you that you have high blood pressure, high cholesterol, a heart murmur, or a heart infection?

Has a doctor ever ordered a test for your heart (e.g., electrocardiography, echocardiography)?

Has anyone in your family died for no apparent reason?

Does anyone in your family have a heart problem?

Has anyone in your family died of heart problems or of sudden death before 50 years of age?

Does anyone in your family have Marfan syndrome?

Answering yes to one or more of the above questions does not necessarily mean that organized sports should be avoided but it does indicate a need for further evaluation and testing. If your child's answer is yes to any of the above questions, be sure to bring this to the attention of your child's pediatrician during the visit or when dropping off the forms.

Ticks - How To Remove Them and When To Worry:

If you Googled, "how to remove a tick?" you would get some very interesting methods: dousing it with rubbing alcohol, burning it with a hot match, or smothering it with petroleum jelly. You might even stumble across a study that was published in 1985 in the journal Pediatrics that compared these home remedies with the tweezers method and concluded that the most effective method of removing a tick is in fact by using tweezers.

The concern when removing a tick is that you remove not just the body but the mouthparts as well. When a tick begins feeding on a person, it embeds its mouthparts into the person's skin. In order to remove the tick in its entirety, it is best to follow these simple steps. Place the tweezers at the base of the tick's body nearest the person's skin. With firm and steady pressure pull the tick straight up and off the person. The Center for Disease Control (CDC) has a great diagram that illustrates the proper removal technique. It is best not to twist the tick as this increases the likelihood that it will break apart and some of it may be left in the person.

If the tick does break apart, leaving the mouthparts inside the individual, then these pieces should also be removed using tweezers. After the tick has been successfully removed, disinfect the area with either alcohol or iodine. Removing a tick is something that usually can be done at home quite easily; however, if you are unsure if the whole tick has been removed than you should contact your child's pediatrician.

After you have removed the tick place it in a plastic bag or container so that you or a doctor can identify what type of tick it is. The CDC's website has photos of multiple ticks that can be used for this purpose. The site also identifies each ticks typical geographical location as well as the diseases most commonly associate with each tick. Please note however that the site is incomplete in its information. Notably, (in this section) it omits information regarding Lyme disease. Lyme disease is most commonly transmitted by Ixodes scapularis, referred to as the Blacklegged Tick, or more commonly known as the Deer Tick. For further information regarding the symptoms of Lyme disease or any other tick borne illness please visit the Minnesota Department of Health website.

In general, most ticks need to be on the body for at least 24 hours before they can transmit a disease. Insect repellents containing DEET are effective against ticks, however they can be harmful to children when used in large quantities. Children should not use products containing more that 30% DEET and insect repellent should be washed off your child's skin as soon as possible after coming indoors. Doing tick checks during the summer and anytime your children have been playing outside in a wooded area will ensure that ticks are found in less than 24 hours. Be sure to check in the hair, groin, under the arms and behind the ears. If you are unsure how long a tick has been on your child, or if your child begins to show signs of illness including a rash or mild cold-like illness, contact your child's doctor.

Sparklers - The Surprising Dangers Of A July 4th Tradition

July 4th would not be the same without fireworks. But they are better left to the professionals. The numbers of injuries children sustain every year as a result of fireworks, firecrackers and even seemingly safe sparklers are astounding. What is even more alarming is that a quarter of the children injured are simply bystanders and half are injured while under an adult's supervision.

According to the American Academy of Pediatrics, there are about 8500 injuries related to fireworks a year and 45% are in children younger than 15. A surprising number of these injuries, 10%, are caused by sparklers.

Many parents view sparklers as a safe alternative to fireworks and a way to let even the littlest child join in the festivities. What most parents do not realize is that sparklers can reach an alarmingly high temperature of 1000° F at their tip. It is not uncommon for children to suffer from minor burns and corneal abrasions while playing with sparklers. Unfortunately, more serious injuries can result if the child's clothing catches on fire.

There are many safe alternatives to sparklers. Children can have fun in the dark with glow in the dark glow sticks. Noisemakers and party poppers popular for New Year's Eve can be fun on July 4th as well. Children often get a kick out of bubbles. Spice things up with a giant bubble wand or make tons of bubbles quickly with a bubble gun. If your children are old enough, involve them in the party planning and allow them to help decide on a fun activity for the evening.

Avoiding potentially dangerous situations can be easy when in your own home but can prove more difficult if you are going to a party at someone else's home. The simplest solution may be to offer to bring something for the kids to do so that you know the activity will be a safe one.

Have a wonderful July 4th and leave the fireworks to the professionals. You can check your local paper for a listing of shows in your area. If you live in the LA area visit www.safejuly4th.org for a list of local firework shows.

Note: New posts will be every other week for the remainder of the summer.

Summer Safety Tips

As school comes to an end and children are free to enjoy the carefree fun of summer, there are a few important talks that parents should have with their children before letting them loose.

The first is on the importance of helmets. Although helmets may take away from the Norman Rockwell like picture of children cruising through the neighborhood without a care in the world, helmets save lives -- but only if your wearing one. Reiterate to your children the importance of wearing a helmet EVERY time they are on a bike, skateboard, scooter, razor or anything else with wheels. Make sure that they take their helmet with them whenever they go over to a friend's homes to play. Also be sure that anyone babysitting for your youngster knows the rules and the importance of wearing a helmet.

The next important topic to make sure you review with your child is water safety. Children should always be monitored when swimming. Infants and toddlers should always be within an arms reach when in or near the water. Children should know that they need to have permission from an adult to enter the water. This is an important rule to enforce. If your child does not ask permission, he should know that he will have to get out of the water and will have a time-out.

Ideally, any pool your child goes to will be properly childproofed http://www.aap.org/family/tipppool.htm with a self-locking fence, but that unfortunately that is not always the case, which is why teaching children to ask permission every time they want to enter the water is a good habit to instill in them.

It is important that all children learn to swim but remember knowing how to swim does not mean your child does not need supervision in the water. Lastly, if your child does not yet know how to swim, you should make anyone watching your child, such as other parents or babysitters etc. aware of this fact.

The final topic to discuss with your child is one that many parents never even think to talk to their children about until they see them running across the street without a care in the world. Every year children are hit by cars while running to or from ice cream trucks. Children need to know that despite the fun music and lure of ice cream they need to follow the rules for safely crossing the street. For small children, they should always be holding an adults hand when crossing. Older children should be taught to look both ways and to always cross in front of the truck.

Talking to your children preemptively about summer safety will hopefully reduce visits to the doctor's or ER and allow them to have a fun filled vacation.

June is National Safety Month: Fire Safety

Part I of the "Safety Series"

 

As June is the official "National Safety Month," it is a great time to review basic safety precautions. 

 

Fire Safety - Children less than 5 are twice as likely to die in a fire. This has prompted the "Prepare. Practice. Prevent The Unthinkable." campaign which reviews fire safety for infants and toddlers. 

 

1.  Smoke Detectors: Check to make sure all smoke detectors are working. Ideally this should be done once a month by pushing the test button. Replace batteries once a year.  

Smoke detectors should be installed on every floor of your home. Install a smoke detector on the top of the stairs and also inside bedrooms. For more information on children and smoke detectors visit the following site.  The US Fire Administration has a great fire safety pamphlet  that explains the difference between different types of detectors and which should be used where.

2. Fire Extinguishers: Check to be sure the fire extinguishers are accessible and do not need to be replaced.

3. Escape Routes: Children as young as 3 can follow a fire escape plan if they have practiced it often enough. Review with your children what to do if they hear the fire alarm.  Teach them to crawl on the ground if the room is smoky and to feel the door before they open it.  They should know two exit routes from their bedroom. Teach them that if the door is warm to not open it.  If appropriate, have a safety ladder easily accessible in their room and teach them how to use it.  Routinely practice fire drills with your children.

4. STOP, DROP and ROLL:  Every year numerous children are burned when their clothing catch on fire when they get too close to an open flame. Teach your kids to STOP, DROP and ROLL.  Rolling smothers the flame and can save a child's life.

3. Carbon Monoxide detectors: Carbon monoxide is an odorless gas and is often referred to as the silent killer. All homes should have at least one carbon monoxide. For further information on carbon monoxide checkout the following fact sheet. 

4. CPR: Brush up or enroll in a CPR class. Many hospitals offer parent CPR classes. Also consider who else will be watching your child regularly. If you are hiring a babysitter consistently, you may want to offer to pay for him or her to take a CPR class.  Free CPR classes are available online. I personally cannot vouch for these but here is a link to a free on-line CPR class for parents. 

Summertime Viruses: Hand-foot-and-mouth Disease

With summertime, comes summer illnesses, one of the more common childhood illnesses is aptly called Hand-foot-and-mouth disease. This is a viral illness that can be caused by a variety of viruses, though most commonly it is due to an infection with coxsackievirus A16.

Children begin with a fever, usually quite high, which then is followed by sores in the mouth. These sores are painful and may look like little red bumps which then progress to blisters or ulcers. Children often refuse to eat and complain of pain in their mouths' and throats'.

Children generally become ill 3-6 days after being exposed either to someone else with the disease or a virus containing surface. Good hand hygiene and cleaning of toys that the sick child used are important in preventing the spread of the virus. Children are contagious for about a week after onset of illness.

Some children only develop the mouth sores in which case the illness is called Herpangina. Other children will have sores in their mouths' as well as a non-itchy rash on the palms of their hands and soles of their feet, thus the name Hand-foot-and-mouth disease.

The sores are generally gone within a week and children's eating habits will return to normal. During the time of illness, even if your child refuses to eat, it is important to keep him well hydrated. Most children find cool drinks and ice-pops soothing. Pasta or rice with butter is generally well tolerated. Spicy foods, foods hot in temperature or rough in texture, such as toast and crackers may cause pain.

Since a virus causes the illness, there are no antibiotics to help your child fight this infection but you can provided supportive care. You can treat the fever and mouth pain with Tylenol or Motrin. Older children may benefit from an oral analgesic spray such as Chloraseptic. Children over 1 year of age can try a tablespoon of honey to coat the throat.

Any high fever that persists for 5 days should prompt a call to your child's pediatrician. Children who are unvaccinated, who have a compromised immune system or are less than 2 months of age should also be evaluated by a pediatrician.