* SMART MOMS *

Keeping Kids Rear-Facing - The New AAP Policy

2011-05-10T16:30:00.000-07:00

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

2010-09-23T19:16:00.000-07:00

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

2010-04-26T19:22:00.000-07:00

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:

2010-04-18T21:12:00.000-07:00

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 -

2010-04-11T19:25:00.000-07:00

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?

2010-04-05T20:47:00.000-07:00

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:

2010-03-30T00:21:00.000-07:00

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:

2010-03-22T19:52:00.000-07:00

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:

2010-03-15T11:34:00.000-07:00

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:

2010-03-02T00:04:00.000-08:00

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?

2010-02-22T12:43:00.000-08:00

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:

2010-02-17T09:57:00.000-08:00

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:

2010-02-01T22:51:00.000-08:00

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

2010-01-26T22:18:00.000-08:00

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:

2010-01-18T11:28:00.000-08:00

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:

2010-01-10T21:02:00.000-08:00

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:

2010-01-04T21:48:00.000-08:00

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

2009-12-07T11:48:00.000-08:00

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:

2009-11-23T21:20:00.000-08:00

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?

2009-11-15T20:25:00.000-08:00

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:

2009-11-03T19:59:00.000-08:00

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:

2009-10-26T15:22:00.000-07:00

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:

2009-10-18T22:14:00.000-07:00

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:

2009-10-12T14:54:00.000-07:00

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:

2009-10-04T22:24:00.000-07:00

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:

2009-09-22T01:01:00.000-07:00

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?

2009-09-14T00:16:00.000-07:00

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?

2009-08-30T23:57:00.000-07:00

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:

2009-08-12T22:36:00.000-07:00

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:

2009-08-03T19:36:00.000-07:00

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

2009-06-28T20:53:00.000-07:00

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

2009-06-15T22:02:00.000-07:00

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

2009-06-08T12:49:00.000-07:00

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

2009-06-01T16:40:00.001-07:00

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.

Poisonous Plants - Is Your Garden Safe For Your Children and Pets?

2009-05-25T14:47:00.000-07:00

Last spring, inspired by a Martha Stewart magazine cover, I decided to plant a garden. I went to the local nursery and bought all sorts of plants without at all considering whether or not they could be poisonous. In my naiveté, I assumed that if a plant was poisonous to children or pets it would says so on the plant's tag, right there next to how much sun and water the plant needed -- "Full sun. Water well. Poisonous if eaten." As you may have guessed, that is not the case.

It was only after I had planted my new garden that I found out from a friend that a number of plants I had chosen were in fact lethal should my daughter decide to eat a leaf or flower. Looking around at the petals and leaves scattered on the lawn I realized my garden was a minefield.

Many common plants are actually very dangerous. Wisteria, Foxglove, Irises, Rhododendrons, Azaleas, Oleander, Jasmine and Buttercups are all poisonous, just to name a few. Thanks to the internet, however, it is easier than ever to learn which plants are safe and which to avoid.

Below are two of the more thorough and informative resources out there. Texas A&M University has a list of some of the more common toxic plants, what parts of the plant are poisonous and what effects the toxins have. Colorado State University has a searchable database that includes photos of the offending plants as well as suggested treatments if ingested.

If your child does ingest a questionable plant, before trying any at home treatments, such as inducing vomiting or syrup of Ipecac, you should call your local poison control at 1-800-222-1222. The Poison Control Center will be able to tell you if the plant was poisonous, what to watch for and if you need to bring your child to the emergency room.

Low Cost Prescription Drugs & New Autism Study

2009-05-11T08:04:00.000-07:00

To celebrate Mother's Day, I decided to give myself a week off from writing anything too technical. Instead, here are some little tidbits of, perhaps, interesting information.

Wal-Mart is expanding its discount prescription drug program. As some people may know, not all pharmacies charge the same amount for the same prescription medication. Wal-Mart has some of the lowest drug prices. Hundreds of prescription medications are available for only $4 for a 30-day supply. There are 300 medications for which a 3-month supply is only $10 and many other medications that are available for a slightly higher price. No Wal-Mart near you? Not to worry, you may soon be able to order prescription medications from Wal-Mart through the mail. Until then, most pharmacies will tell you over the phone how much it will cost to fill a specific prescription. So, if you are filling an expensive prescription it may pay to shop around.

CNN had a very interesting article on its website this Monday regarding autism and a new study which reported that children with autism have an enlarged amygdala. The amygdala, which is a part of the brain, is a normal size at birth but then for some unknown reason in children with autism it begins to grow. This increase in size may explain why children with autism have difficulty with what is known as "joint attention." Difficulty with joint attention is a hallmark feature of autism. This study is very promising and will most likely lead to further research to determine when and why the amygdala begins to rapidly increase in size. Pinpointing when this change in the brain begins may allow us to figure out what the trigger is and hopefully how to prevent or treat it.

On a closing note, I hope that all the mothers reading my blog had a lovely Mother's Day!

Swine Flu: The 11th Plague or A Treatable Virus?

2009-05-03T23:26:00.000-07:00

As each day brings a deluge of apocalyptical news reports chronicling the spread of swine flu across the globe, it is difficult to get a realistic idea of how dangerous this virus truly is.

There recently have been revisions in the death toll reported from Mexico. There are now only 19 confirmed deaths attributed to the swine flu. It seems that the original numbers reported included anyone who died with "flu-like" symptoms. It is important to keep in mind that every year 36,000 people die in the US from the "regular" flu. Without testing for the swine flu virus, it is impossible to tell based on symptoms if a person has the regular flu or the swine flu and by lumping the two together you get an inflated mortality rate.

Even now with Mexican health officials testing to confirm the presence of the virus, it is difficult to calculate a Mexican mortality rate. This is because it is very difficult to know how many people in fact have been infected with the virus. Many people with mild illness may not be seeking medical treatment. So, we know 19 people have died in Mexico but we don't know out of how many infected individuals.

So far in the US, there have been 226 confirmed cases and one death in Texas. However even this is misleading since the toddler who died in Texas was a Mexican child who was brought here for medical treatment. Many news reports state that the child also had underlying medical problems, which may have contributed to his death.

Yet, even with the corrected crude numbers that we currently have from Mexico, it would seem that the mortality rate is higher there than in the US. Why would this be? Again that is unclear. We don't have a lot of information as to what exactly was the cause of death in these 19 cases. Was it respiratory failure, pneumonia, dehydration? We also don't know how long each person was sick prior to seeking medical treatment. Tamiflu and other antiviral medications work best if started within 48 hours of the onset of symptoms. It is very possible that those who died in Mexico were not able to start antiviral medications quickly enough.

Here in the US with all the media hysteria it seems that anyone who even thinks they could be getting sick has rushed to the doctor. This has allowed the Center for Disease Control, CDC, to have a much better idea of the overall number of cases of swine flu and in theory should allow for a doctor to be able to start antiviral medication, if needed, in a timely fashion. The majority of US cases have been mild illnesses. With the number of US cases growing, without any increase in severity, we should be breathing a sigh of relief.

However, we are not out of the proverbial woods yet. Influenza virus is known for its rapid ability to mutate. It is feared that the virus could become more virulent over time. Of course, only time will tell.

The recommendations for what you and your family can do to minimize your risk of being infected with the swine flu are the same recommendations that you hear every winter in order to decrease the spread of regular influenza. Practice good hand hygiene. Wash your hands with soap for 20 seconds or use an alcohol based hand sanitizer. Avoid taking young children, the elderly and anyone who is immunocomprimised to crowded places. If you do get sick stay home from work or school and seek medical attention within the first 48 hours.

For more information about the symptoms of swine flu or its spread in the US visit the CDC's website.

Autism, Speech and Motor Delays: How to tell if your child is meeting his milestone and what to do if he isn't

2009-04-27T15:44:00.000-07:00

April is Autism Awareness Month. As you may know from the myriad of public service announcements on the television and radio this month, 1 in every 150 children is diagnosed with an autism spectrum disorder.
Autism spectrum disorders affect children's development and social skills. The spectrum is broken down into three categories:
1. Autism
2. Asperger syndrome (Some lay people refer to this as high-functioning autism.)
3. Pervasive developmental disorder not otherwise specified (A catch-all group for any child that does not meet the strict requirements for the above two diagnoses.)
It is indisputable that the number of children diagnosed with autism has increased over the years. The reason behind this may in part be attributed to the fact that more pediatricians and parents are aware of autism and on the lookout for it. It may also be due to autism being classified as a is a spectrum of disorders which allows children who do not meet the classic autism criteria to still be diagnosed and qualify to receive the services they need.
Autism spectrum disorders are lifelong conditions; however, with early intervention children may be able to learn skills that allow them to function better both developmentally and socially. For this reason, early intervention is key. If you are concerned about your child's development, social skills or communication skills you should bring this to the attention of your pediatrician. Don't wait for your child's next check-up. If you believe your child isn't meeting his milestones or seems uninterested bonding with you, make an appointment as soon as possible to discuss your concerns and the possible need for an evaluation by a developmental specialist.
However keep in mind that isolated developmental delays are more common than autism. If your child has an isolated developmental or speech delay, your pediatrician will discuss with you what further work-up is necessary. Some developmental and speech delays may be caused by an underlying problem that if fixed will help resolve the delay. For example, if your child has a speech or communicative delay your pediatrician will probably refer him for a comprehensive hearing evaluation.
Regardless of the cause, isolated speech and motor delays also respond best to early intervention. Speech, physical, and occupational therapy are all available through the local regional center or public school depending on your child's age. The CDC has a wonderful website that explains how to get your child evaluated and what resources are available for children with developmental delays.
Remember every child is different and the vast majority of variation in developmental patterns is completely normal but if you have any concern at all you should discuss it with your child's pediatrician.

TV Turnoff Week: Turn off the TV. Turn on Life.

2009-04-20T16:23:00.000-07:00

Today, April 20th, marks the kick-off of National TV Turnoff Week. Parents are encouraged to use this upcoming week as a seven-day hiatus from television and video games for their family. Instead, families are encouraged to spend time doing activities together.
TV Turnoff Week is supported by the AAP and The Center for Screen-time Awareness. The most recent statistics show that the average American child spends over 1000 hours a year watching TV and playing video games. To put that in perspective, they only spend 900 hours a year in school. Television, video games, computers and now cell phones are becoming an increasing part of everyday life for the American child. Although there may be many advantages of living in such a technological era, there are well-documented detriments as well.
America is quickly becoming a nation of overweight individuals, and obesity is highly correlated with increased screen-time. Studies have shown that children who spend 4-6 hours of screen-time a day have a higher risk of being obese. All this time spent in front of screens is at the expense of less time spent playing sports, doing outdoor activities, reading and having family time.
Implementing a TV turnoff week in your home can be challenging. Habits are hard to break. Having a plan will help to keep children occupied and can lead to this week being a time of family bonding instead of boredom. Encourage to children to play outside or go for bike rides in the afternoon. Arrange play-dates after school. Foster some family competition by scheduling a family game night. Involve children in dinner by having a family cookout. Children can participates in creating a menu or help with cooking.
You can also use this week to start a project, such as planting a vegetable or herb garden. Children can help in choosing what vegetables to grow and planting them. They can also engage in some artistic activities by making little signs to label the garden. A trip to the library can also be fun. Most libraries will issue children their own library cards. Allow your children to take out a few books, some to read on their own and then some to read together at night before bed. Even for children who can read, reading more difficult stories together can be fun. Ask the librarian for suggestions or try choosing a children's adventure novel and then read a chapter aloud a night.
These are just a few ideas of ways to pass seven days without a television. As the TV Turnoff posters say, "Turn off TV. Turn on life." For more ideas or listings of activities in your area check out The Center For Screen-time Awareness's website.

Rear-Facing Car Seat Until At Least 2: The New Recommendation

2009-04-13T17:00:00.000-07:00

Parents should not be surprised if the next time they visit their pediatrician they are told to keep their child in a rear-facing car seat until they reach the highest weight or height allowed by the seat manufacturer. This change in advice has been spurred by recent analysis of the protection car seats provided during actual crashes. This analysis showed that "children under the age of 2 are 75% less likely to die or sustain serious injuries when they are in a rear-facing seat." The data revealed that children ages 12-23 months were 5 times less likely to be injured, regardless of the type of crash, if they were in a rear-facing car seat.

Children in forward-facing car seats are at a much higher risk of injury to their head and spines because their heads are disproportionately large for their bodies. Rear-facing seats better distribute the force of a crash and children are therefore less likely to be severely injured as a result. A recent commentary in the journal Pediatrics encouraged pediatricians to convey this information to their patients and to dispel the myth that if a child's feet touch the back seat then they should be put in a forward-facing seat. According to the commentary, "lower-extremity injuries are rare for children facing the rear, on the order of 1 per 1000 children. In addition, riding facing front does not eliminate a child's risk of lower-extremity injuries, because these injuries, as well as injuries to the head and spine, have been described among forward-facing children in [car seats]." As the author pointed out in an article published in the AAP News, having to treat a leg fracture after a car crash is far better than having to treat paralysis.

You may find your pediatrician weary of giving you an end age or weight as to when you can safely turn your child forward-facing, this may be because studies done in Sweden recommend children to remain rear-facing until 4 years of age. For this reason, European car seats are manufactured differently to allow larger children to remain rear-facing. In the US, most convertible car seats can accommodate children in the rear-facing position until around 35 pounds, which should allow over 95% of children to remain rear-facing until their second birthday.

Parents should check their car seat manual for the weight and height limits of their child's car seat should discuss any concerns they have with their pediatrician or a certified child passenger safety technician in their area.

Parenting In The Virtual World - How To Keep Kids Safe On The Internet

2009-04-06T09:42:00.001-07:00

Through the Internet and social networking sites, children can now hangout with their friends without leaving their homes. But unlike sitting in a friend's basement, you're not always sure who else is there. There are unseen risks involved with virtual communities. Depending on the settings of one's web profile, their personal information, photos, etc. may be open to anyone who wants to see them. Children may be more lax about what they share on-line. They may say and do things on-line that they would shy away from in person. Teens may also feel pressured by their virtual community to post comments or pictures that may be inappropriate or elicit unwanted attention.

Parents and pediatricians need to address the dangers that children may encounter while using the Internet. Just as parents prepare children for the outside world by teaching them to look both ways before they cross the street and not to get into the cars of strangers, parents need to teach their children what behavior is safe and unsafe on the internet.

Computers should be in a common room in the house and your child's use of them should be monitored. Parents should discuss with their teens and children what type of information they share on-line and how to maintain their privacy. Most social networking sites have options available that allow you to keep your page private so that only friends you approve of have access to your information. Parents should check and make sure that their children's personal information is being safeguarded from strangers.

Younger children need it explicitly explained to them that when they are on the computer it is similar to being out in public. There are many strangers on the Internet and you don't talk to strangers on-line, even if they seem nice. In order for young children to maintain a sense of autonomy while using the computer, you can bookmark a number of appropriate sites for them and store them all under a bookmark heading with their name on it. These bookmarked sites are sites they are allowed to visit on their own whenever they have computer time. Any other sites they would like to visit need to be first approved by a parent.

Teenagers are much harder to monitor on the Internet. However that does not mean that parents should not be involved in their teen's virtual life. Parents should let their children know that they are going to regularly check their teen's Facebook or MySpace pages the same way they would pop into the family room if their child and his friends were hanging out at home. This is not invading your child's privacy. It's parenting. The only way to know what is happening in your child's life is by being involved and knowing where they are. Most parents would not let their child roam around for hours without knowing where they were going or with whom. These same rules should apply to the Internet. It is important to know what sites your child is visiting and with whom they are chatting.

Given how much time children and teens spend on the internet and in virtual communities, it is incumbent upon us to find the time and make the effort to make sure they are safe on-line. Setting up some basic ground rules for Internet use is a good first step in protecting your children on-line.

For additional information:
Dr. Cross has written a AAP Grand Rounds commentary and blog post on the AAP's Council On Communications and Media blog on this topic.

Anything But Clean - Common Toxins in Children's Bath Products:

2009-03-29T21:07:00.000-07:00

The Campaign for Safe Cosmetics (CSC) released a report on March 12th detailing the widespread use of toxins in baby and children's bath products. The report entitled "No More Toxic Tub" found that 82% of the products tested contained formaldehyde and 61% contained both formaldehyde and 1,4-dioxane.

Again it seems that we are far behind the developed world in regulating and limiting our exposure to toxins. Both Canada and the EU have banned 1,4-dioxane from cosmetics. Formaldehyde has been banned from cosmetics in Sweden and Japan and is allowable only in a concentration under 0.2% in Canada and the EU. Another toxin mentioned in the report, Methylparaben, is also on the EU's Banned and Restricted List but is found in an alarming number of US products.

These substances seem to ubiquitous in baby shampoos, wipes and children's bath products. For the family trying to use hypoallergenic products marketed for children with sensitive skin, they may still be unknowingly applying formaldehyde, a potent skin irritant, to their little one's skin. Even Aquaphor contains sodium laureth sulfate and imidazolidinyl urea both of which, according to the CSC, are commonly contaminated by 1,4-dioxane and formaldehyde respectively. In looking at my own daughter's Lansinoh wipes I found that they contain Methylparaben and thus would be banned from sale in Canada and the EU.

What is alarming is that these toxins can be and are removed when the products are manufactured for sale in other countries. However, since the US does not require them to do so, many manufacturers do not sell products in the US that meet the EU standards.

So how do you know what products are safe? The CSC report lists common ingredients likely to be contaminated with 1,4-dioxane and formaldehyde. According to the CSC, you should also steer clear of Methylparaben and Triethanolamine. The CSC has also released the results of its testing and name brands such as Mustela, Johnson and Johnson, and Aveeno all have products that tested positive.

Short of the FDA overhauling its regulation of the cosmetic industry it is unlikely that these toxins will be removed from most products. But as with BPA in baby bottles, if the consumer makes a stand that they want toxin-free products someone will eventually develop a product to fulfill that niche.

Another Hib Outbreak - Are Your Children Protected?

2009-03-23T09:33:00.000-07:00

Philadelphia has reported 5 new cases of children with invasive Haemophilus influenza type b (Hib) disease. Of these 5 children, 2 have died as a result of Hib. Hib is part of the normal vaccine series. Children receive the primary series at 2, 4 and 6 months of age and a booster at 12 to 15 months of age. These five children were all either unvaccinated or under-vaccinated.

This comes on the heels of the 5 cases, including one death, of invasive Hib disease in five Minnesota children. According to the Center for Disease Control (CDC), only one of these five children had completed the 3 shot primary vaccination series, and that child was later diagnosed with an immunodeficiency. Three children were unvaccinated due to parental refusal and the fifth child was only 5 months of age and therefore too young to complete the primary series. The five Minnesota children lived in different counties and had no contact with each other. None of the children attended daycare.

According to the American Academy of Pediatrics, "before vaccination against Hib was available. Hib meningitis killed 600 children a year and infected 20,000. It was the most common cause of bacterial meningitis. Children who survive the disease were often left with mental retardation, seizures or deafness."

These new cases of Hib are perhaps in part due to a decrease in herd immunity. Since 2007 there has been a Hib vaccine shortage because Merck, one of the two manufactures of the Hib vaccine, had to cease production as a result of bacterial contamination. There should still be sufficient vaccine available for all children to receive the 3 shot primary series but the CDC has asked physicians to delay giving the booster shot -- normally given to children between the ages of 12 and 15 months. When majority of the members of a community are vaccinated, the unvaccinated members are safer because the chance of an unvaccinated person coming into contact with the disease decreases. This concept is referred to as herd immunity. However with so many children unvaccinated in conjunction with a national Hib vaccine shortage, unvaccinated children are at an increased risk of infection. This applies not only to children whose parents refuse the vaccine but also to young infants who are simply too young to receive all three shots.

I have often heard parents rationalize delaying vaccination because they are not sending their children to pre-school or daycare. Unfortunately, these parents may be fooling themselves into a false sense of security. As illustrated by all five cases in Minnesota, children can acquire Hib, or any other infectious disease, even if they do not attend a child-care program.

We do not know what causes autism. There have been multiple studies looking for a link between vaccines and autism, but none has been found. Although we do not know what causes autism, we do know what is the number one cause of bacterial meningitis -- Hib. The only way to protect your child from this disease is to vaccinate him against it.

For a very interesting list of vaccine preventable diseases, what these diseases do and how many children died or contracted these diseases prior to vaccines becoming available see the AAP's page "Why Immunize?".

Your Child's Artwork Can Win $500:

2009-03-15T19:36:00.000-07:00

The American Academy of Pediatrics is sponsoring its 5th Annual National Art Contest For Children. The contest is open to children in grades 3-12. Children can submit multiple pieces of artwork on the theme "Protecting Children from Tobacco Smoke." There will be a first and second place winner for each of the three age groups: grades 3-5, 6-8 and 9-12. First place winners will receive a cash prize of $500 and a trip to Washington D.C for a presentation ceremony. Second place winners will receive a cash prize of $250. Matching cash prizes will be awarded to each 1st and 2nd place student's school.

Artwork should be submitted by July 31, 2009 to: National Art Contest, American Academy of Pediatrics, 141, Northwest Point Boulevard, Elk Grove Village, IL 60007. Artwork must be accompanied by a consent form and entry form. For more information visit the AAP website.

Not only is this a fun contest for youngsters to participate in, it is also a wonderful opportunity to talk to your child about smoking. Even preschoolers are old enough for a simple discussion about the harms of smoking. When discussing smoking with young children focus on the fact that it is not good for your body. A simple statement such as, "Smoking lets dirty air into your lungs and can make your lungs sick" is enough to get the point across. For tips on talking to your preschooler about smoking check-out this site. For more advice on how to talk to your school-age or pre-teen about smoking, visit the following site.

Iron: An Important Mineral For Your Infant's And Toddler's Development

2009-03-08T22:30:00.000-07:00

Iron is a very important mineral in infants' and children's diet. Without sufficient iron in their diet, children's motor, mental and behavioral development can be hampered. Unfortunately, these developmental delays are not always correctable even when the proper dosage of iron is later added to the diet. A study following infants diagnosed with iron deficiency found that at 11-14 years of age many of these children still demonstrated functional deficiencies in school.

Despite numerous studies documenting the importance of iron, many infants and toddlers do not get the iron they need. A recent study in Pediatrics magazine found that 58% of breastfed and mixed-fed infants (infants fed a combination of formula and breast milk) did not get the recommended amount of iron a day.

Early in infancy breast milk is a sufficient source of iron. Although breast milk is not high in iron, the iron is very well absorbed. From birth to 6 months of age, a full-term infant's daily iron requirement is only 0.27mg/day. This jumps to around 11mg/day by 6 months of age. Preterm infants have a higher iron requirement and should usually be started on 2mg/kg/day of iron supplementation around 1-2 months of age, although parents of a preterm infant should talk with their pediatrician before starting any vitamins as the iron requirement can vary with birth weight.

Most formulas are now iron fortified. Infants taking solely formula receive a sufficient amount of iron through the formula. However for breastfed and mixed fed infants, an additional source of iron supplementation should be introduced between 4-6 months of age. This can be in the form of vitamins such as Tri-Vi-Sol with iron, which has the added benefit of fulfilling both the infant's vitamin D and iron requirement, or through iron-rich foods.

By 6 months of age, most infants are transitioning to solid foods. By choosing iron-rich foods as a baby's first transitioning food you can ensure that your infant receives the proper amount of iron through his diet. In the US it is common for an infant's first food to be iron-fortified cereal. Most fortified cereals have about 45% of the recommended iron per serving, which is usually 4 tablespoons. Therefore, an infant would have to eat 8 tablespoons of iron-fortified cereal a day in order to fulfill his iron requirement from cereal alone.

Red meat is another iron-rich food. In other countries, it is very common for pureed meat to be one of the first foods an infant eats. As odd as this might sound here in the US, where meat is typically one of the latter foods to be introduced, even The American Academy of Pediatrics endorses its early introduction at around 6 months of age.

By 6 months of age, a breastfed or mixed-fed infant must consume at least two servings of iron-rich foods a day in order to ensure that he is getting 11mg of iron from his diet. If less than two servings of iron-rich foods are being consumed on a regular basis then iron-containing vitamins should be started.

Iron continues to be important in the toddler's diet. At one year of age, infants transition from formula to whole milk. Whole milk is low in iron and its calcium inhibits iron absorption. For this reason, it is recommended that toddlers do not consume more than 16-24 ounces of milk a day. Toddlers who are notoriously picky eaters still require one to two servings of iron-rich foods a day. If their picky eating habits make this difficult, then they should continue taking a vitamin containing iron.

Constipaiton: How To Keep Your Little One Regular

2009-03-01T21:50:00.000-08:00

Not all children have a bowel movement every day. For some children, it is normal to go every couple of days. This is not necessarily an indication that your child is constipated. So, how do you know if your child is constipated? It can, at times, be difficult to tell.

Symptoms of constipation can range from hard pellet-like stools to large voluminous bowel movements. Constipated children often have pain with bowel movements and have to strain to go. This causes some children to withhold bowel movements out of fear that it will hurt. Withholding in turn leads to more constipation and the viscous cycle begins. While some children withhold out of fear of pain, others withhold out of fear of using a public restroom, and still others withhold as an exertion of independence. Regardless of the initial reason for withholding, once it results in constipation bowel movements will hurt and this will reinforce for the behavior.

Treating constipation almost always includes dietary changes. Drinking more water and eating more fruits and vegetables is key. Prunes, prune juice and raisins are all foods that can help. Individually wrapped prunes are easy to throw in your child's lunchbox. Raisins can be added to morning cereal or an afternoon snack. Switching to breads and cereals that are high in fiber will also help. Increasing your child's fiber intake can at times be difficult if he is a picky eater. Although fiber supplements are rarely necessary in children, they can be helpful for children who are going through a particularly picky eating stage. You should talk with your child's doctor before adding any supplements to your child's diet. Avoiding foods that bind is also important. Limit such foods as bananas and rice, which can add to constipation.

It's always a good idea to have a morning routine for your child that includes uninterrupted time on the toilet so that they do not feel rushed. Since for some children warm foods or liquids help facilitate the urge to go, start the morning with a warm bowl of cereal with raisins and maybe even a small cup of chamomile tea. Then allow your child to sit on the potty for 5 minutes while they relax with a book or toy.

For children who have been constipated for quite some time stool softeners may be necessary. Although most medication for constipation can be purchased over-the-counter, it is best to speak with your pediatrician before starting any stool softeners, laxatives or enemas. If medication is needed, there are many options. There are stool softeners that can be given orally, such as Colase or Miralax. Miralax has the added benefit of being a tasteless, odorless powder that can easily be added to drinks, applesauce or pudding. For children who cannot take medicine by mouth there are glycerin suppositories that can be given rectally. In addition to a stool softener, some children may also need a stimulant such as Senokot. For the child who needs both types of medications, there is the combination product Senna-S, which combines a stool softener with a stimulant. If a child is extremely backed up and having abdominal pain he may require a pediatric fleets enema before beginning daily treatment with a stool softener. If medication is needed, your pediatrician may recommend continuing it for quite a while after the initial bout of constipation has been resolved in order to avoid having the problem recur. During this time period dietary and behavioral changes should be implemented so that when the medications are weaned the child continues to go regularly.

Dental Injuries: Do You Know What To Do?

2009-02-22T15:58:00.000-08:00

Dental injuries are common. In young children, they can be due to poor coordination and falling. In older children, car and sporting accidents are more common. Dental injuries can range from a small chip to knocking a tooth out of its socket. Every parent should know beforehand the steps to take should their child's tooth become injured or knocked-out. Knowing ahead of time how to properly care for a knocked-out tooth and knowing which injuries require immediate attention can affect how salvageable a tooth is and what treatment options are possible.

A chipped tooth is when only the enamel, the white, outer-most layer of the tooth, has been broken off. The tooth should have no increased sensitivity because the tooth's living tissue, the pulp, has not been injured. If the tooth's edges are sharp and uncomfortable, dental wax can be applied until a dentist can be seen. Depending on how much of the tooth is chipped, a crown or cap may be necessary for aesthetics and function. Your child's dentist should be called but most likely an urgent visit is not necessary and an appointment in the next day or two should be fine.

A tooth fracture is when a larger part of the tooth has been lost. Under the enamel is a yellow layer called dentin. The enamel and dentin surround the living tooth tissue, called pulp. A serious tooth fracture exposes dentin and possibly pulp. Fractures to both permanent and baby teeth require a dentist's evaluation as soon as possible. When a baby tooth is fractured, the goal of treatment is to minimize damage to and preserve the developing permanent tooth.

When a tooth is loose following an injury or is knocked in, or to the side, a dentist should be called immediately. These injuries can cause damage to the tooth's ligament, its socket or, in the case of a baby tooth, to the immature tooth below. Treatments may include repositioning, splinting or extraction. If repositioning the tooth is possible, it should be done as quickly as possible.

The most serious injury is when a permanent tooth has been knocked out, or avulsed. For the best chance of salvaging the tooth, it should be re-implanted in less than five minutes. Do not handle the tooth by the bottom, or root. If necessary, rinse the tooth but do not scrub it clean. Place the tooth back in its socket as quickly as possible. Hold the tooth in place while going immediately to the dentist or ER. If you are unable to re-implant the tooth, due to extensive injury either to the jaw or tooth, place it in a glass of milk as soon as possible. If milk is unavailable submerge the tooth in saliva. The guidelines advise that the tooth be submerged in liquid, in less than fifteen minutes. Survival of the tooth depends on the extent of injury and how quickly the algorithm is followed. Baby teeth should not be re-implanted as it can damage the developing tooth below.

Reacting quickly to dental injuries will ensure the greatest chance of salvaging the tooth. Parents should discuss with their child's dentist what they should do in the case that a dental emergency occurs when the office is closed. Your dentist may have an on-call service or may refer you to a local ER that has an on-call dentist. Knowing before hand who to call and what to do will allow you to remain calm and to provide the best care until a dentist is seen.

For more information regarding dental injuries and treatment decisions, The American Academy of Pediatric Dentistry provides a wonderful comprehensive article on their website.

Thumbsucking and Pacifier Use - When to Call It Quits:

2009-02-15T20:12:00.000-08:00

With close to 90% of children either sucking their thumb or using a pacifier, it is almost a child's rite of passage to engage in one of these behaviors. Most children outgrow these habits on their own without any parental intervention at all. By 4 years of age, only 12% of children are still sucking their thumbs and even fewer, a mere 4%, are using a pacifier.

Despite the fact that all children will eventually give up sucking their thumb or using a binkie, there is a fear that a child will do permanent damage to his mouth and teeth by continuing this habit past infancy. But at what age do you truly have to worry about the consequences of thumbsucking and binkie use?
According to the American Dental Association (ADA), children should stop non-nutritive sucking prior to the eruption of their permanent teeth. They state that most children discontinue thumbsucking and pacifier use between 2 and 4 years of age. The ADA also points out that how aggressively a child sucks will have more of an impact on whether dental damage occurs, than how long a child continues these behaviors. For this reason, if a child is passively putting his fingers in his mouth at a time of stress but not aggressively sucking, he will probably do very little damage to his mouth.

Most children will begin to discontinue these behaviors on their own due to social peer pressure when they start to have regular interaction with other children. The American Academy of Pediatrics (AAP) does not suggest intervening with these behaviors until at least 4 years of age. But that does not mean that you cannot encourage alternative self-soothing behaviors at an earlier age.

Understanding why children continue with these habits will allow you to better work with your child to develop other coping methods to replace their thumb or binkie. Sucking is a natural infant reflex. Babies are often seen sucking their thumb or fingers inutero. For some children, the sucking reflex becomes a habit when they repeatedly use sucking to soothe themselves in times of stress or boredom.

For older children, simply being aware of when they engage in this habit can go a long way in helping to break it. When a situation arises in which your child would normally turn to his thumb or binkie, even just acknowledging to him that you know he is scared or feeling shy can help to relieve some of his stress. You can assist your child by helping him find alternative methods to self-soothe or relieve boredom. By prompting him to use these methods, you will help him to learn adult ways to cope with these situations.

It is often easier to discontinue pacifier use than thumbsucking. Making a small whole in the tip will deflate the binkie. Since a deflated binkie no longer gives the same sensation when sucked, it quickly looses allure.

For thumb sucking, placing a glove over the hand can help especially if your child tends to suck his thumb through the night. There are also over-the-counter, bitter tasting substances that can be applied to the nail to deter sucking. Before using either of these methods, it should be explained to the child that he is not being punished but rather that you are working together to break the habit. Lastly there are appliances that can be placed in the child's mouth that can make thumbsucking uncomfortable and may be necessary if structural changes are occurring.

Discuss with your pediatrician or dentist if you notice any changes to your child's teeth or to the roof of his mouth. But keep in mind these changes are rare and most children will break the habit on their own when they are ready. It is important to remember to be patient. As with any habit -- breaking it takes time.

Brushing: Advice for Keeping Your Baby's and Child's Teeth Healthy

2009-02-09T09:25:00.000-08:00

February is National Children's Dental Health Month. There are multiple campaigns across the country to encourage children to brush, brush, brush. But sometimes it's not that easy. The following are tips for when to start brushing your infant's teeth, how to teach your little one to brush and some ideas to try with those not-so-happy brushers.

Brushing Your Infant's Teeth:
You should start caring for you infant's teeth as soon as they push through the gums. A baby's teeth and gums should be wiped clean with a damp cloth or gauze twice a day. As they start to have more teeth, you can switch to a soft infant toothbrush.

Brushing Your Toddler's Teeth:
When your child is old enough to spit instead of swallow toothpaste, usually around 2-3 years of age, you can start using a pea-sized amount of tartar-control fluoride toothpaste on a child size toothbrush with soft bristles. Using a tartar-control toothpaste will help to decrease any plaque buildup.

As soon as a child shows interest in brushing his own teeth, he should be encouraged to "help" you brush. Young children do not have the motor skills needed to effectively brush on their own; but, you can allow your child to be involved. After you have thoroughly brushed his teeth, give him the toothbrush and allow him to finish up. Be sure to look over his work and praise him when he is done. This encouragement will help build his self-esteem and confidence.

Brushing Your Child's Teeth:
As your child gets older, explain what you are doing when you brush his teeth. "We need to make sure we get every tooth. We clean our teeth with little circular motions. First, we clean all the fronts, then all the backs, then all the tops and bottoms. Last, we lightly brush our gums and our tongue." By verbalizing what you are doing and brushing your child's teeth in the same way each time, your child will start to recognize a pattern and be able to follow it when he begins brushing alone.

Eventually the routine will transition from you brushing his teeth and him finishing up, to him brushing on his own and you finishing up. You will need to do a once over on your child's teeth after he is done brushing until he is at least 7 years old. You should also continue to help him put the toothpaste on his toothbrush to ensure that only a pea-sized amount is used.

Tips For Those Not So Happy Brushers:
1. Use incentives, such as a sticker chart, which can be placed in the bathroom, or a 15-minute later bedtime on the weekends if your child brushes well all week.
2. Continue with positive reinforcement and remember Rome wasn’t built in a day. Always tell him what a great job he did, even if you have to re-brush his teeth yourself. After he has started to brush, even a little, without a fight, you can start to encourage him to do it better. Try to still give praise for what he did do well while encouraging him to do a better job such as, "You did a great job but I think you need to spend a little more time on the bottom teeth. You have a lot of teeth and we want to make sure we get them all clean."
3. Make brushing into a game. Put an egg-timer in the bathroom. Children enjoy setting the timer and hearing it ring when it goes off. A digital clock can work too. You can make a game of watching for the number to change. After the first change (the first minute), you yell "switch" and you switch from top teeth to bottom teeth or from the left to the right side. After the second minute, everyone yells "all done".

When to go to the dentist?
Teeth should always be uniform in color without spots or streaks. If you notice discolorations on your child's teeth, you should bring him to the dentist or speak to your pediatrician. The American Academy of Pediatrics recommends that children have their first dental visit at 1 year of age and should have regular dental follow-up. If you do not have access to a dentist, your child's pediatrician may be able to do these initial visits. Children with a high risk for cavities may need to see a dentist as early as 6 months of age. You can discuss with your pediatrician when you should schedule your child's first visit. For a list of pediatric dentists, visit the American Association of Pediatric Dentistry.

Combatting a Cold - Home Remedies To Help Ease Your Little One's Pain

2009-02-02T08:21:00.000-08:00

With cold season upon us, and all the warnings against giving over-the-counter cough and cold medicines to young children, here are a few home remedies that can safely help ease your little one's cold symptoms.

Congestion:
Bulb Suction/Nasal Aspirator: For children who cannot blow their noses well, a nasal aspirator or bulb suction can help. These are available at most pharmacies. The American Red Cross makes a nasal aspirator, which has both a plug that can be opened to clean it out after use and a graduated tip to prevent the user from inserting it too far into the child's nose.
To use a bulb suction, push the back end in with your thumb, then insert it into the child's nostril and quickly release your thumb. Be careful not to put the tip up against the sidewalls of the nose because this can traumatize the skin and cause it to swell, making it even more difficult for the child to breath.
Saline sprays and drops: If the mucus is very thick, you may need to use a saline spray or drops to loosen it prior to suctioning. Baby Simply Saline has a graduated tip that makes it easier not to go too far into the nose when dealing with a wiggly baby. If you are using saline drops, make sure they are non-medicated drops. The only ingredient should be saline or sodium chloride.
Steam: Sitting with your infant or child in a steamy bathroom for 10 minutes is a great way to help loosen up the mucus. This can be done prior to suctioning the nose. It is safe to do this multiple times during the day and can be very helpful if done before bed.
Elevating the child's head when sleeping: You can elevate the head of the bed by placing a few rolled up towels under the crib mattress. Do not place anything directly under the child's head since it is not safe to have pillows or loose bedding in an infant's crib. If this is not enough elevation or if your child keeps rolling down the bed, he can sleep sitting up in his car seat. Make sure to strap him in and place the car seat in a safe place.
Humidifier: A cool mist humidifier can help with congestion when placed in the child's room. Do not add any menthol or medicated products to the water. For young children and infants, a regular humidifier simply filled with water is best.

Cough and sore throat:
Honey: In children over 1 year of age, a teaspoon of honey has been found to be as effective as dextromethorphan, the main ingredient in most children's cough medicines. Honey not only helps in suppressing a cough, it also has been found to have anti-microbial properties, which means it can actually help kill bacteria and viruses. Honey cannot be given to children less than one year of age as it can contain spores that can cause botulism in infants.
Cool night air: For a croupy, barking-like, cough, bringing a child into the cool night air often helps. Be sure to bundle the child up well and then take him outside. The cool air helps to decrease the inflammation and swelling in his airways allowing him to breath easier.
Chamomile Tea: A cup of tea can help soothe a sore throat. For children over 1 year old, the tea can be sweetened with honey. For children less than one year, unsweetened, luke-warm chamomile tea can be given in their bottle. For children under a year of age, you can give one ounce of tea per day for every month old that they are. For example a 3 month old can have 3 ounces of tea a day and a 6 month old can have 6 ounces of tea a day.
Soup: For children over 4-6 months of age who are taking solids, warm soup can also help soothe a sore throat.

Mouth sores: Some common childhood illnesses can cause sores in the mouth and throat that hurt and often cause children to refuse to eat. Anything cold can numb the area. Frozen juice pops, which can be made at home from their favorite juice, can be both hydrating and soothing.

Fever: Raising the body's core temperature is one of the ways the body fights an infection. For this reason, a low-grade fever does not need to be treated unless it is causing the child discomfort. Both infant's and children's Tylenol (acetaminophen) and Motrin (ibuprofen) are safe and effective. Both can be used in children 2 months and older. You should contact your pediatrician prior to giving medication to an infant less than 2 months of age or to a child who has not been vaccinated. For more information on fever in a newborn click here.

Time is the ultimate cure for most childhood colds but these home remedies may help to ease their symptoms while they wait it out.

Massive Peanut Butter Recall Due to Salmonella Outbreak

2009-01-25T21:39:00.000-08:00

A myriad of peanut butter products have been recalled this week in conjunction with a Salmonella Typhimurium outbreak. The source of the contaminated peanut butter and peanut paste has been traced to a Peanut Corporation of America (PCA) plant in Georgia. PCA does not sell peanut butter products directly to consumers but rather is a large manufacturer and distributor of peanut butter and peanut paste to numerous cafeterias and food manufactures across the country. The peanut paste is then used to make peanut butter cookies, crackers, ice cream etc. which explains the broad recall that is currently underway.

The Center for Disease Control (CDC) has traced the start of the outbreak back to September 2008. According to the CDC, as of January 20th, 486 people have become ill and 6 have died as a result of this outbreak of Salmonella Typhimurium. Cases have spanned the country with 43 states involved. The CDC's website is being updated almost daily with new information. Both Smuckers and Skippy have posted press releases on their websites stating that they do not purchase peanut products from PCA and are not involved in the Salmonella outbreak or recall. For a complete list of products known to be involved in the recall, visit the publicly available database on the Food and Drug Association's (FDA) website.

Salmonella usually causes symptoms within 12-72 hours of ingesting contaminated food. Symptoms are fever, diarrhea and stomachache. Diagnosis is confirmed with a stool sample. Most people can clear the infection without treatment within a week. Antibiotics are generally not prescribed for the diarrheal illness since they do not shorten the course of the illness. However, if the infection spreads from the intestinal tract to the bloodstream antibiotics are needed. Young infants, elderly and anyone with a weaken immune system are at greater risk of the infection spreading and are usually started on antibiotics preventatively.

It is mandated that all cases of Salmonella be reported to the local Department of Health. Since it can be spread via fecal to oral transmission, effective hand washing is extremely important and any child with the disease must remain home from school or daycare. Different states have different rules regarding returning to daycare or school after a salmonella infection. In California, a child is required to have 2 negative stool cultures on 2 different days before returning to group activities.

It is important not only to discard any recent products that have been recalled but also to check the pantry. Since the start of the outbreak dates back to September, it is possible that food sitting in people's pantries is contaminated. To be safe, both the CDC and the FDA recommend checking the database before consuming any peanut containing foods. If there is any uncertainty as to the safety of a particular food, it is best to discard it.

Melamine Found in US-Manufactured Infant Formula: FDA reassures that small amounts of melamine are safe

2009-01-18T17:23:00.000-08:00

Melamine made it back into the news this week as scientists at Consumers Union, a nonprofit watchdog group, called the Food and Drug Administration (FDA) out on their decision to allow US-manufactured food products, including infant formula, contaminated with melamine and cyanuric acid to be sold in the US. Consumers Union is not alone in its outrage at the FDA's response to melamine-contaminated foods reaching US shelves. Congresswomen Rosa L. DeLauro, chairwoman of the Agriculture – FDA Appropriations Subcommittee, released a statement back in October chastising the FDA for their lax approach on this issue. That was before trace amounts of either melamine or cyanuric acid were found in all 3 major brands of US formula. The FDA discovered melamine or cyanuric acid in 4 of the 89 infant formula containers they tested in the fall of 2008. More alarming is that the FDA did not release this information until the Associated Press filed a Freedom of Information Act request.

Melamine is a nitrogen rich compound found in plastics, adhesives and pesticides. In China, melamine was intentionally added to raw milk to disguise the fact that the milk had been watered down. In the US, melamine most likely finds its way into food products by unintentional contamination secondary to its legal use in food packaging. Although melamine can be dangerous in large quantities when ingested alone, as was the case in China, it can cause health problems at lower levels when combined with cyanuric acid. According to the World Health Organization (WHO), cyanuric acid can be an impurity of melamine.

In China, the tainted infant formula contained 2500-6000 parts per million (ppm) of melamine, whereas US formulas contaminated with melamine have all had less than 0. 5ppm. Yet what, if any, is a safe level of melamine? Prior to October, the FDA had no official policy regarding melamine except that it is not approved to be directly added to food in the United States. Since October, the FDA has declared that food containing less than 1 ppm of melamine is safe. The WHO has stated that an individual's total daily limit of melamine should not to exceed 0.2mg/kg of body weight/day. The Canadian government has voiced the concern that even if the small amounts of melamine and cyanuric acid found in individual cans of infant formula are safe, some infants use multiple ready-to-feed bottles a day and could therefore ingest a larger amount of the toxin. To ensure that infants stay within the safe range, even when consuming multiple bottles a day, the Canadian government has lowered its allowable level of melamine in infant formula from 1ppm to 0.5ppm.

Infants are an especially vulnerable group. This is because infants are not born with fully developed kidneys. Their kidneys continue to mature over the first year of life. It is for this reason that infants should not consume large amounts of water or salt and why it is so important that powdered infant formula be mixed correctly. Thus, it stands to reason that the amount of melamine an adult kidney can clear safely, may still be too much for an infant's kidney to handle.

The FDA may be taking a lax approach to melamine in order to avoid panic. Hopefully their desire to calm fears is not putting US infants at an unnecessary risk. We should not accept a tolerable level of toxins in our food. As is usually the case, if a food can be made safer than that should be the goal.

UPDATE: 1/22/09 - China Sentences 3 People To Death For Involvement in Melamine Scandal

The Human Papilloma Virus (HPV), Gardasil, and Cancer: What are the connections and should young boys be vaccinated too?

2009-01-12T10:29:00.000-08:00

Gardasil, Merck's vaccine against the Human Papilloma Virus (HPV), has been in the news again recently with the announcement that they are seeking FDA approval to expand its use to include males ages 9-26 years old. This has reopened the discussion about HPV and how aggressively we should fight to eradicate this virus.
HPV (Human Papilloma Virus) is the most common sexually transmitted disease in the US. Yet most people are never even aware that they have been infected. The CDC (Center for Disease Control) estimates that about 6.2 million people are infected with genital HPV every year. Eighty percent of women will have acquired genital HPV by the time they reach 50 years old. Even more alarming are the statistics for young Americans. In 2000, there were 4.6 million new cases of HPV infection in 15-24 year olds. To put that in prospective, in the same age group, there were only 7,500 new cases of Hepatitis B and 8,200 of Syphilis.
To understand the significance of HPV, one must first understand the natural course of the virus. Of the 6.2 million people infected with HPV annually, 90% will clear the infection on their own within 2 years. However, if a woman’s body does not clear the infection, there is the potential for cervical cancer to develop. The progression to cervical cancer is slow, usually 10-15 years or more after the initial infection. Prior to cervical cancer developing, there are changes in the cells and tissue of the cervix. These changes are screened for with a Pap smear. In the U.S., there is an intense screening protocol that recommends women receive Pap smears every 1-3 years. Abnormal Pap smears are followed up with additional tests and if changes in the cervical cells are confirmed, the tissue is removed or destroyed in an attempt to prevent a progression to cancer. Although cervical cancer is the second most common cancer in women worldwide, the rigorous screening protocol in the U.S. has limited the amount of deaths to 3000-4000 annually.
Gardasil, which was approved by the FDA in June of 2006 for use in females 9-26 years old, is a vaccine against four strains of HPV -- HPV types, 6, 11, 16 and 18. There are over a hundred types of HPV but the vaccine is designed to vaccinate only against types 6, 11, 16, and 18, which are the major disease causing types. Types 6 and 11 cause 90% of genital warts and types 16 and 18 cause 70% of cervical cancer. HPV types 16 and 18 have also been implicated in anal, penile, oropharyngeal (mouth and throat), vulvar and vaginal cancers. Thus, the vaccine may protect against these cancers as well.
There is still much hesitation surrounding Gardasil. As a parent, it is often difficult to wade through all the news reports and information out there in order to ultimately decide if this vaccine is right for your child. With any vaccine, there are certain questions that need to be answered. For Gardasil the questions are, "Is it safe, is it effective and will the protection against HPV last throughout her adult lifetime?"
All new vaccines are just that, new. As time goes on and more girls are vaccinated without serious adverse effects, we will become more comfortable that the vaccine is safe. Gardasil was tested by Merck before its release and has been approved by the FDA (Food and Drug Association) but still the number of girls that have been, and will be, immunized since the release of the vaccine far outnumbers those observed in the clinical trials. Once a vaccine is released to the public, a government database collects information on any adverse effects people are experiencing and if needed additional warnings are added to the vaccine's packaging. Since Gardasil's release, its warning has been modified to include joint and muscle pain, fatigue, physical weakness and general malaise.
Is the vaccine effective? It has been shown to be 100% effective against cervical cancer caused by HPV 16 and 18, and 99% effective against genital warts caused by HPV types 6, 11 . Of course, it can’t be effective if a person has already acquired an HPV infection of type 6, 11, 16 or 18. It is a vaccine, not a treatment. So, it is critical to vaccinate prior to acquiring an infection. Since HPV is a sexually transmitted disease, it is best if girls are vaccinated prior to their first sexual experience. But at what age does the typical American girl become sexually active? The US National Health and Nutrition Examination Survey found that the occurrence of HPV in girls 14-19 years old was 24.5%. That number jumped to 44.8% for girls 20-24 years of age. That means that about 1 in every 4 girls leaving high school and almost 1 in every 2 girls leaving college would be infected with HPV. Therefore, the current recommendation is to vaccinate girls at 11-12 years of age in order to hopefully vaccinate them before they acquire the disease.
There is of course the concern that the effectiveness of the vaccine will wear off over time. This is the reason that some vaccines require booster shots. The studies released thus far show that the vaccine is effective up to 5 years post vaccination. Of course, the hope is that the vaccine will protect a women though her adult lifetime. There are on going studies to evaluate Gardasil's continued effectiveness and if a booster is deemed necessary, one will be added to the vaccination schedule.
Less than three years after Gardasil's emergence and the commencement of these questions, new questions are now surrounding the vaccine and its potential use. Should it be given to males?
It stands to reason that if you are trying to eradicate a disease you want to vaccinate the carriers of the virus as well, in this case, young men. The vaccine would have some benefit men as it would protect them against genital warts as well as some very rare cancers: oropharyngeal, anal and penile cancers. However, the main reason to vaccinate men is to decrease the risk of them giving the virus to women. The US would not be the first country to approve Gardasil's use in males. Australia, Mexico and countries in the European Union have already done so. We will have to wait and see what the FDA does. For now, Gardasil is only available for girls.

New Year's Resolutions - Helping Your Kids Kick-Off The New Year With New Behavior

2009-01-04T20:29:00.000-08:00

With the beginning of a new year comes a time to reflect on the past year and outline hopes for the year to come. New Year's resolutions do not need to be limited to grown-ups. They can be an activity to help children set goals and adopt healthier lifestyles as well. A wonderful dinner topic could be "Mommy and Daddy are making New Year's resolutions. Would you like to make one too? Is there anything that you think you could do better this year, anything you would like to change or learn how to do?" Give your children examples or prompt them to think of resolutions that you deem appropriate for them such as: going pee-pee in the potty, giving up a pacifier, not fighting with a sibling, not biting or hitting, cleaning their room, doing their homework without an argument, or eating healthier.

Let them know that you too are trying to make changes for the upcoming year. Share with them your New Year's resolution. Be sure to phrase your resolution in a positive light. For example, instead of saying "Mommy's resolution is to lose 5 pounds" say, "Mommy is going to try to eat healthier or exercise 4 days a week." Let them know that you will be working to accomplish these goals together.

Here are some simple guidelines to help you and your child with this year's resolutions:

1. Make the resolution specific and concrete. This will help the child understand exactly what is expected of him and to focus on accomplishing it. For example, eating healthier is too nebulous a concept for a child. Whittle that resolution down to eating healthier snacks of fruits and vegetables after school instead of chips and cookies.

2. Write the resolution down. Writing it down allows the child to solidify the goal. Depending on the child's age you might suggest that he decorate the paper to make it special. Then hang this is a place he will see daily, such as on the refrigerator.

3. Decide on a way to keep track of improvement or success. Positive reinforcement works best when trying to change a behavior. Place a small calendar next to the written resolution. Use stars or stickers to keep track of days when your child accomplishes his goal. These stickers can be used a daily reminder and a little reward at the end of each day for a job well done. On days that your child is successful, make a big deal of it. Tell him how proud you are of him and what a good job he did today. On days that he did not accomplish his goal, review with him what went wrong but always end on a positive note. For example, you might say, "You were doing well today but then this evening when you got frustrated with your brother, you didn’t use your words and you bit him. Tomorrow try using your words or coming to Mommy when you get frustrated instead of biting. I think tomorrow you will be able go the whole day without biting and tomorrow night we will be able to put a star on the calendar."

4. Schedule rewards. Of course, we all wish that changing behavior was a reward in and of itself but for children, just like adults, it is fun to be rewarded for a job well done. This reward can be weekly or monthly. What it will be and when it will be given should be laid out clearly. The reward can be something simple, such as an extra half hour of T.V. or computer time, a later bedtime for a night or a date with mom for an ice-cream sundae.

By encouraging your child to choose a New Year's resolution and working with him to attain his goal, you will be providing him with the opportunity to experience a sense of accomplishment and pride.

UPDATE: 1/7/09 - Looking for ideas for resolutions for kids? Check out the list of resolution recommendations on the American Academy of Pediatrics website.

Happy Holidays and Happy New Year

2008-12-22T11:45:00.001-08:00

Wishing everyone a happy holiday and new year. I will be taking a little holiday break. Will post next on Monday, Jan. 5th. See you in 2009!

Calling Your On-Call Pediatrician: How To Get The Most Out Of The Conversation

2008-12-15T14:33:00.000-08:00

Invariably it happens, your child gets sick when your doctor's office is closed. You call the on-call pediatrician but you are not sure you are describing your child very well. What’s worse is that you forgot to tell her that he also has this weird rash and now your not sure if you should call back or not.

These situations can be frustrating both for the parents and the doctor as it is sometimes difficult for the parents to convey, and the doctors to get a sense of, how sick a child is over the phone. By following a few simple steps before calling your child’s doctor, you will be able to better provide the information your pediatrician will need to give you the best advice. Your pediatrician will ask a series of questions to tease out whether what your child is suffering from is a simple viral illness and the child can stay home or something more serious. As you will be the pediatrician's eyes, prior to calling your child's doctor, assess your child for yourself.

1. Does he have a temperature? Take your child's temperature. For younger children, especially infants, the temperature should be taken rectally.
2. Does he have a rash? Remove all your child's clothing and look for rashes. If your child does have a rash, you will be asked for how many days he has had the rash. What part of his body it started on and has it spread? What does the rash look like? Is it red and raised like hives? Is it lacy? Is it blotchy?
An important feature of a rash is whether or not it blanches. (This means does it turn from red to skin color when you push on it.) An easy way to tell this is by using a clear glass cup. Push the bottom of the glass cup against the rash and see if the rash turns from red to skin color. If it does, it blanches.
3. Is your child dehydrated? Ways to assess for dehydration are: Is he peeing often? Are you changing the same number of wet diapers as usual? Does he have tears when he cries? Is the inside of his mouth moist? Do his eyes look sunken? How is he eating and drinking? Often sick children don't feel like eating, which is fine. What we are concerned about is liquids. Is he still drinking and about how much has he had? Next, is he keeping the liquids down? Does he have vomiting and diarrhea? If so, has it been one episode of vomiting or multiple? Is he vomiting food or greenish, yellow fluid, called bile?
4. How is your child breathing? Do you hear grunting, wheezing or whistling when he breathes? Is his breathing normal or labored? Is he working harder to breath? To assess this observe your child breathing without his shirt on. Do you see his ribs sucking in when he breathes? Does it look like he is using his chest and abdominal muscles to breath? Are his nostrils flaring?
5. Is he inconsolable? Most children are more cranky than usual when they are sick. It is important to determine if they are just a little more cranky or inconsolable.
6. Is he lethargic? Being more tired than usual is normal when you are sick but having difficulty arousing the child, or not being able to keep him up for even a short period of time may mean that your child is lethargic.

Add to this list any other information that is relevant to your child’s health, such as he has been pulling on his ears, or he has a dry hacking cough, or his sister is home with strep throat. Be sure to know the names and dosages of any medicine he is taking. Also have on hand the phone number to a local 24-hour pharmacy.

By going through a list such as the one above before you call your child’s doctor you will be able to organize much of the information you will be asked to provide. Having the answers to these questions when you speak to your pediatrician will enable you to give a better description of your child, which will allow your child’s doctor to give you the most appropriate advice.

Tummy Time - How Early Can It Start And How Do You Make It Fun For Your Infant?

2008-12-08T09:17:00.000-08:00

Now that infants are put to sleep on their backs to reduce the chance of sudden infant death syndrome (SIDS), a new activity for parents and infants has been created -- tummy time. Previously, when infants slept on their stomachs, they had plenty of time to squirm and push. This exercise allowed them to develop their muscles that are needed to roll over and crawl. Infants who spend their days going from sleeping on their backs, then into a car seat, then hanging out in a bouncer or a swing, do not get sufficient time to exercise their muscles; thus, the birth of tummy time. Tummy time is a period of time during the day while the infant is awake and supervised that he is placed on his stomach.

For a child who has never been put on his stomach and who spends his whole day on his back or sitting up, being placed face down on his tummy can be frightening and frustrating. He may not like being in a new position and having to work so hard to see around him. The earlier you introduce tummy time the less likely your child will react adversely to being put on his stomach. Tummy time can start any time after the child is born. Starting the first week home from the hospital is absolutely appropriate. It is a misconception that you have to wait until the infant is strong enough to be able to push himself up before it is safe for him to lay on his stomach. As long as the infant is supervised, there is no danger to placing him on his tummy.

Whenever you introduce tummy time, do it slowly. Place the child on his stomach on a soft rug or blanket for about 3-5 minutes at a time. This can be done a couple of times a day. When first initiating tummy time, get down on the floor with your infant in order to make him more comfortable in this new situation. Play and interact with him while he is on the floor. Mirrors and toys that he can lift his head to see will also make hanging out on his stomach more enjoyable. As he gets more accustomed to the position he may enjoy spending more time on his tummy and not need any encouragement from you.

For children who are more adverse to this position, start with shorter periods of time and allow the child to quit before he gets too frustrated and hysterical. If even short periods of time seem too much for him, you can try getting him used to the position while laying on your chest. This allows him to have the comfort of your warmth, scent and proximity while allowing him to get accustomed to being in a new position and using his muscles. Another trick to make tummy time more enjoyable is to prop up your infant's chest with towels or a nursing pillow in order to give him a better view when he lifts his head. For more tips on how to incorporate tummy time into your baby's day checkout this website.

New parents should not be afraid to allow their infants to see the world from a new prospective -- their stomachs. With a little bit of time on their stomachs each day, it won't be long before they are enjoying being able to explore the world on their tummies. For a summary of the American Academy of Pediatrics' recommendations regarding tummy time, see their pamphlets "Back to Sleep, Tummy to Play."

Fever In A Newborn -- What to Expect When Your Infant Has A Temperature

2008-11-30T21:55:00.000-08:00

A frequent reader of my blog may have noticed last week's post was published a day late. This was unfortunately due to our daughter spending the weekend in the hospital. Our daughter spiked a temperature of 101.1° F, which for a newborn requires a trip to the ER and a mandatory 48-hour hospital stay. In a way, I guess it is only fair that I should have to endure as a parent what I have inflicted on multiple mothers -- the ER work-up for a newborn with a fever. It was eye opening to be on the other side; although, I don't think I felt the same level of anxiety a typical mother feels when bringing her newborn to the hospital. Unlike most parents, I knew exactly what was going to happen. I knew the protocol for the work-up and the reasoning behind it.

Most parents probably think we, as pediatricians, are overly cautious when they call their on-call doctor because their newborn has a low-grade fever and are told to go to the ER. When they get there, they must be appalled by all the poking and prodding, the multiple cultures and the mandatory hospital stay by what can only seem like overzealous doctors.

But all this poking and prodding is the standard of care and it should be followed no matter what doctor or ER you bring your newborn, and for good reason. Any temperature of 100.5° F or greater in a newborn warrants a visit to the ER for a comprehensive work-up because a baby's immune system is not yet fully functioning. This is the reasoning behind not giving infants vaccines until they are 6-8 weeks of age and why new parents are encouraged to keep their newborns away from public places and sick relatives. Newborns cannot mount a mature immune response. In order to fight an infection, they depend on the antibodies that they received from their mothers' while in utero which will circulate in their bodies for a few months after birth. Breast-fed infants have the additional benefit of continuing to receive their mother's antibodies through her breast milk.

The only sign of a severe infection in a newborn may be a fever, increased irritability, poor feeding, or lethargy. For this reason, these symptoms are taken very seriously. The other concern is that newborns cannot compartmentalize infections very well. This means that an infection that starts in one place can quickly spread. Thus, the work-up for a fever is actually a work-up for sepsis (an overwhelming bacterial infection). There are three locations that must be checked for the bacteria -- the blood, the urine and the cerebral spinal fluid, CSF, which flows around the brain and down the spinal column. An infection of the CSF is called meningitis. Therefore all newborns with a fever need a blood culture, a spinal tap for a culture of the CSF and a catheterized urine culture. A urine culture collected with a bag instead of a catheter has a much higher rate of contamination and therefore can be more difficult to interpret. This could cause an infant to be diagnosed with a urinary tract infection when in fact there is none. When the blood culture and labs are drawn, an IV is placed so that the infant does not need to be stuck a second time in order to receive antibiotics.

In addition to the three cultures, a CBC (complete blood count) will be done in order to get an idea of how the infant's body is responding to the infection. The CBC may also help to predict whether the cause of the infection is more likely a virus or a bacteria. There are some preliminary tests that are done on the urine and CSF that are a good indication of whether or not there is an infection in either of these locations, but the definitive test is the culture. All three cultures are then watched in the lab to see if there is bacterial growth. It can take up to 48-hours for bacteria to grow. Until it is certain that there is no bacterial growth, the infant is treated with antibiotics. Thus, all newborns with a fever are admitted to the hospital for a minimum of 48-hours to receive IV antibiotics. If after 48-hours, there is no bacteria growth, the cultures are considered negative and it is conclude that the fever was due to a viral infection. Since antibiotics don't help with a viral infection, the antibiotics are stopped and the infant is sent home. If the cultures do grow bacteria, then the infant must stay in the hospital to receive a full course of antibiotics. This can be as long as two weeks.

When making that call to the pediatrician for a fever of 100.5° F, most parents don't expect that this will lead to a 48-hour hospital stay and multiple tests to ensure that the fever is not a symptom of a severe infection. But knowing what to expect takes a little of the fear out of the experience. And even though the work-up is mandatory, it is important to remember that most fevers in newborns are not caused by an overwhelming bacterial infection. Most infants will be just fine and will go home in 48-hours with no memories of the ordeal and with parents that are exhausted from the 2-day vigil.

Two Short Thanksgiving Blogs: Cooking Tips to Reduce Food-borne Illness and Sharing The Meal With Your Little One

2008-11-25T14:20:00.000-08:00

Some Thanksgiving Tips to Avoid Food-borne Illness During the Holidays:

With all the wonderful food on Thanksgiving, it would be a shame to have a food-borne illness ruin the feast. Here are some quick tips that will help to reduce your family's risk of getting sick over the holiday. Of course the basic premise is to keep cooking surfaces as clean a possible and to avoid cross-contamination of uncooked meat with cooked food. The easiest way to do this is to designate one cutting board and knife to be used only with raw meat and poultry.
It is also important to make sure that meat and poultry are cooked to the proper temperature to destroy disease-causing bacteria. This starts with properly defrosting the turkey. Most people may be surprised to know how long it takes to properly defrost a frozen turkey. 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." When the turkey is done, a food thermometer should read 180 F. When checking the temperature, be sure the thermometer is not touching a bone, which will give you an artificially elevated temperature. Although it is safest to cook stuffing outside the bird, if cooking stuffing inside the turkey be sure that the stuffing reaches a temperature of 165 F.
Lastly, any food that is being made in advance and refrigerated should be refrigerated immediately after cooking. Allowing the food to cool to room temperature before putting it in the fridge, although a common practice, in fact, allows bacteria to grow. For a complete guide on safe holiday cooking tips visit the FDA's website. Have a happy and healthy Thanksgiving.

Letting the Little People Partake In the Feast:
This Thanksgiving keep in mind that your older infants may be able to take part in some of the food festivities. Gone are the days of food restrictions for infants over 4-6 months of age. The American Academy of Pediatrics (AAP) has revised its stance on delaying the introduction of eggs and other highly allergic foods beyond 4-6 months of age. All foods should still be introduced one at a time over the course of a few days to monitor for allergies. But it is no longer believed that delaying the introduction of eggs, nuts or fish will decrease the likelihood that a child will have an allergic reaction to that food. So this Thanksgiving your youngest family members may be able to partake in a mashed up Thanksgiving tasting if they have already pre-tried and have had no adverse reactions to any of the individual ingredients. Please see April's blog: No More Egg-less Meatballs for a full discussion on the new Infant Feeding Recommendations.

Potty Talk: When and How to Initiate Potty Training

2008-11-17T19:41:00.000-08:00

Toilet training is one of the most anticipated accomplishments of a toddler but when to begin the training is more controversial than one might realize. In 1947, 92% of US children had begun toilet training and 60% had completed toilet training by 18 months of age. Compare this to 1975, when only 45% of 18 month olds had begun and 2% had completed toilet training. The trend of later toilet training has continued and currently most US children are toilet trained between 2-3 years of age. Interestingly, worldwide more than 50% of children are toilet trained by 1 year of age. So why is there such a wide age discrepancy?

It may, in part, be due to the difference in cost and accessibility of disposable diapers in different parts of the world. Another major influence in the US may be attributable to Dr. Spock, who in the 1950’s advocated not toilet training younger children. He believed that toilet training before 18-24 months could lead to a rebellion later on by the child and that the child would begin to bed-wet.

However, considering that over half the world’s children are potty trained well before 2 years of age, it seems safe to say that it is probably not too detrimental to a child’s psyche to begin toilet training earlier than the standard 2 years.

Beginning to potty train prior to 2 years of age may have some advantages developmentally as well. As most parents can tell you, 2 year olds can be very willful and this independence is appropriate for their developmental stage. That being said, it might not be the best time to ask them to cooperate in learning something new. Developmentally, it may actually be easier to introduce potty training at a younger age when the child is still more cooperative and looking to please the parent.

So how is a parent to decide when to potty train? There are some groups that advocate potty training in infancy. The New York Times did an interesting and informative article on infant potty training in 2004.
If starting to potty train prior to your child being able to walk seems a little aggressive, then you can use the following as cues to your child’s readiness for toilet training. First, the child should be able to understand the purpose of the potty. Second, the child should be able to walk to and get on the potty by himself.

Prior to your child being ready to begin actual potty training, there are things that parents can do to set the stage for training.
1. Familiarize your child with the toilet and what goes on there. Let your child watch you on the toilet and explain what it is you are doing. Such as “Mommy has to pee, so she is going to go to the bathroom and pee in the potty.”
2. Teach your child the vocabulary for the potty.
3. Read your child books about using the potty. Reviews of some of the more popular potty training books can be found at http://babyparenting.about.com/od/pottytraining/tp/pottybooks.htm

Once you’ve decided that your child is ready to begin potty training, the next step is getting a potty. There are two options. The first is an insert that is placed over the toilet to make it child-size, the second is a miniature toilet. There are many advantages to the miniature toilet. One, children often take ownership and pride in “their” potty. Second, it is portable, so it can be brought to grandma’s house or kept in the room in which the child spends the most time. Lastly, since it is a miniature toilet, it is often easier for the child to sit on by himself compared to the adult toilet with a child size insert.

Consider potty training to be a three-step process. The first step is accompanied trips to the potty. These should be short stints of accompanying the child to the toilet and having him sit there for a very limited period of time. The child should be allowed to get up before he starts to fidget so as not to make potty training a chore in his mind. These trips to the potty are best if timed to optimize success, such as a half hour or so after a meal.

Once the child is comfortable walking to and getting on the potty alone, the second step of potty training begins – verbal reminders for potty time. Parents should no longer walk the child to the potty but rather remind the child to go to use the potty at high yield times or when they see physical cues that the child may need to go to the bathroom. Parents can use these opportunities to teach these cues and signs of fullness to their child, such as “You are holding yourself, is it because you feel like you need to use the potty?”

The last step in potty training is when the child remembers to go on his own. Even when a child is successfully potty trained, expect accidents. When these accidents do occur, positive reinforcement is much more beneficial than making the child feel badly. Parents can say things such as, “Good try, we just got to the potty a little too late.”

If further incentives are needed to encourage children to potty train, parents can make an outing of going with the child to buy new big-boy underwear. Let him pick out underwear that he likes, perhaps with his favorite character on them. These then can be kept as a special reminder of what he is working towards. Another incentive can be a sticker chart placed next to the potty. Every time the child sits on the potty or goes in the potty congratulate him and let him put a sticker on the chart.

In the end, parents should try to keep it a fun activity for their child to master. Always remember that there will be setbacks along the way but eventually everyone becomes potty trained.

The Flu Shot:

2008-11-10T11:20:00.000-08:00

The weather has begun to cool, the leaves are falling from the trees and football is continuously on TV. It can only mean one thing: flu season has begun.

The flu, which anyone who has had it can tell you, is not the common cold or just feeling under the weather for a few days. The season lasts from November to April and each year causes 36,000 deaths and hospitalizes over 200,000 people in the United States alone. The flu is a virus that is spread through the air and affects the respiratory tract. Although there are new anti-viral medications, such as Tamiflu, which can be taken within 48 hours of being infected with or exposed to the flu, it is far more beneficial to prevent the flu by getting vaccinated.

Unlike other vaccines, the flu vaccine changes annually. Each year the vaccine contains three virus strains. From year to year, those strains change depending on which virus strains are predicted to be the most prevalent for that upcoming winter. This year all three strains will be new. For this reason, having been vaccinated last year will not necessarily help you to stave off the flu this year.

Can the flu vaccine give you the flu? If you are getting a flu shot, the answer is no. The flu vaccine comes in two forms: the shot and the nasal spray, Flumist. The shot is an inactive, dead virus and cannot give you the flu. If you get a cold after the vaccine, you were going to get that cold anyway. Contrary to popular belief, it is just a coincidence that you got the flu vaccine and a cold at the same time. The other confusing fact that causes some people to think that the shot gave them the flu is that some of the side effects of the vaccine may make you feel as if you are getting a cold. Side effects of the vaccine include fever, increased tiredness and muscle aches. However for most people, the only side effect from the flu shot is soreness at the injection site.

The second form of the vaccine is the nasal spray, Flumist, which is approved for people 2-49 years old. It is a live vaccine. This means that a live, weakened virus is used. This form of the vaccine can cause a runny nose, congestion and cold like symptoms, but nothing comparable to having the flu. Because it is a live virus it cannot be given to pregnant women, the elderly, or anyone with a compromised immune system. It should also not be given to anyone who has asthma, reactive airway disease, or a history of wheezing. The benefit of the nasal spray is that no injection is required.

Is there thimerosal in the flu vaccine? Thimerosal is a mercury containing compound that has been used as a preservative in vaccines for years. However, in light of recent controversy over thimerosal and nuerodevelopmental disorders, in 1999 and in 2000 the American Academy of Pediatrics and the Center for Disease Control issued joint statements encouraging vaccine manufactures to remove thimerosal from pediatric vaccine preparations. As a result most routine pediatric vaccines are now thimerosal-free. For more information on thimerosal and a complete list of vaccines and their thimerosal content visit www.fda.gov/CbER/vaccine/thimerosal.htm.

There are multiple manufactures of the flu vaccine. Below is a breakdown of which shots contain thimerosal and are thimerosal-free.

Flumist (nasal spray): Approved for healthy, non-pregnant people 2-49 years of age: Thimerosal-free

FluZone (shot): Approved for people 6 months of age and older.
3 forms -Single dose vials: Thimerosal-free
Single dose pre-filled syringes: Thimerosal-free
Multi-dose vials: Contains Thimerosal

Fluvirin (shot): Approved for people 4 years and older
Contains Thimerosal

Afluria (shot): Approved for people 18 years and older
Thimerosal-free

Fluarix (shot): Approved for people 18 years and older
Thimerosal-free

FluLavil (shot): Approved for people 18 years and older
Contains Thimerosal

Who should get the flu shot? It is recommended that everyone 6 months of age and older get vaccinated. Children under 9 years of age, getting their first flu vaccination, will need two shots separated by at least 4 weeks. Since a majority of those hospitalized with the flu are children less than 5 years old and the elderly, anyone who comes into contact with this population should also be vaccinated. If you have a newborn at home, parents, siblings and care-takers (including nannies, babysitters, and grandparents) should all be vaccinated since it is not possible to vaccinate the infant himself. Pregnant women should also be vaccinated. By receiving the vaccine while pregnant, mothers can impart some protection onto their newborns. The main contraindication to receiving the flu vaccine is an anaphylactic, allergic reaction to eggs.

Flu vaccines are available in most doctors' offices. Many pharmacies also have times when flu shots are available. To find where flu shots are available near you visit Prevent Influenza. ( along with enjoying all the wonderful things of autumn be sure to get your flu shot this year so that come winter, you and you're family will be well protected.

For more information on the Influenza virus and vaccination visit:
The Center for Disease Control: http://www.cdc.gov/flu/

Announcing Payton Cross Whalen!!!!!

2008-11-04T14:08:00.000-08:00

The post below is a little late because, as some of you know, we welcomed our daughter into the world Sunday. Born at 5:59am and weighing 5lb 12oz. Here is a photo =)

BPA - Is it safe?

2008-11-04T14:07:00.000-08:00

A new mom walking down the bottle aisle is confronted with an overwhelming array of choices. Among the vented bottles and the drop-in liners is a new category, BPA-free. Despite the fact that Bisphenol A (BPA) is an extremely ubiquitous compound, with over 6 billion pounds manufactured in the US annually, most non-mothers have probably never thought much of it. BPA is not only in baby bottles but also in many plastic bottles, tupperware and metal cans with plastic liners

In the last few years there have been hundreds of studies done on BPA but the question still remains, "Is it safe?" Unfortunately, it depends on whom you ask. And, if you're a jaded consumer you may start to wonder if a study's conclusion truly depends upon is who is funding the study.

The Food and Drug Administration, FDA, released a report in August declaring BPA to be safe at current levels found in plastic baby bottles and canned foods. This brought an array of criticism especially since the FDA relied solely on industry-funded research and dismissed over a hundred independent studies that suggested the contrary to be true. According to the Wall Street Journal, the FDA then asked a panel of scientific experts to form a subcommittee and review its August report. The panel concluded that it disagreed with the FDA's decision to dismiss many of the other studies on BPA. The subcommittee stated that the FDA's conclusions were not supported by the available data and science and that the dismissed studies "raise additional and unsettling concern."

In September, The National Toxicology Program (NTP) released a report stating that; "The NTP has some concern for effects on the brain, behavior, and prostate gland in fetuses, infants, and children at current human exposures to bisphenol A." In their 1-5 scale of concern, some concern is equal to a level 3. This all comes on the heels of Canada's April ban on BPA in baby bottles.

Members of Congress are now looking into the FDA's original statement and what influence the plastic industry had on the research. Rep. Edward Markey has introduced legislation to ban BPA in food and beverage packaging while Sen. Charles Schumer has said he will file a bill to ban BPA from baby products, dental sealants and any bottle containing food or drink. In addition, according to this week's USA Today, "Attorney generals from Connecticut, New Jersey and Delaware have asked 11 companies to stop using BPA in baby bottles and formula cans. In response to Reps. John Dingell and Bart Stupak's investigation (into the FDA), major baby formula manufacturers have said they are working to take BPA out of the linings of their liquid formula cans."

So what does this mean to you?
BPA is an estrogen-like chemical used in the production of polycarbonate plastic and epoxy resin. A CDC study in 2003-2004, of people six years and older, found that 93% of those surveyed had detectable levels of BPA in their urine. The primary exposure for most people is through the diet, both in plastic containers and metal containers coated with a plastic liner to reduce rust. The NTP report states "Bisphenol A can leach into food from the protective internal epoxy resin coatings of canned foods and from consumer products such as polycarbonate tableware, food storage containers, water bottles, and baby bottles. The degree to which BPA leaches from polycarbonate bottles into liquid may depend more on the temperature of the liquid or bottle, than the age of the container. BPA can also be found in breast milk."

The NTP lists the following suggestions to reduce BPA exposure:
1. Don’t microwave polycarbonate plastic food containers. Polycarbonate is strong and durable, but over time it may break down from over use at high temperatures. (In addition, the American Academy of Pediatrics, AAP, recommends not boiling, microwaving, or putting polycarbonate bottles through the dishwasher as heat increases the leaching of BPA.)
2. When possible, opt for glass, porcelain or stainless steel containers, particularly for hot food or liquids.
3. Use baby bottles that are BPA free. (BPA free plastics and glass bottles are available. There are also BPA free nipples.)
4. Reduce your use of canned foods.
5. Identify polycarbonate containers that contain BPA. These containers usually have a number 7 in the recycle triangle on the bottom of the container.
6. Opt for BPA-free toys.

Tips for a Safe Halloween

2008-10-27T01:40:00.000-07:00

As a pediatrician, I should probably not admit that I have a nearly insatiable sweet tooth and so, of course, Halloween is one of my favorite holidays. What could be better than perfect strangers giving you candy? You chat and catch up with all your neighbors as they make the Halloween rounds and the children all have a great time dressing up. What fun! In order to keep it a fun holiday, there are a few things parents should keep in mind.

Most people think that the biggest danger for a child on Halloween is eating candy that has been tampered with. However, the chance of being hit by a car is far greater. Unfortunately, according to the Center for Disease Control, children are 4 times more likely to be hit by a car and die on Halloween than any other night of the year. This statistic underscores the importance of Halloween safety.

An adult should always accompany small children when trick or treating. Before going out, remind children that they should always look both ways before crossing the street and should never run out between parked cars. Consider adding reflective tape either to children's costumes or to their goodie bags to make them more visible to motorists. Check to make sure that children can easily see through any masks they are wearing and if vision is limited consider using face paint instead.

If children are going trick or treating without an adult, such as on their walk home from school, reiterate that they should never enter a home or car for a treat. Although tampering with candy is very rare, remind children that any candy not in wrappers should be thrown out and not eaten.

Discuss with teenagers the difference between "tricks" and vandalism. Toilet papering a friend's car may be harmless but smashing someone's pumpkins or writing mean things on their lawns is not. Let them know that if their friends seem to be getting out of control, or doing things that they are uncomfortable with, they can always call you. This is a good time to remind them that they should never get in a car with someone who has been drinking or doing drugs, and that you would rather have to come and pick them up than have them ride with an unsafe driver.

These are all important discussions to have with your children and Halloween provides an opening to have them. So use the opportunity to discuss age appropriate safety topics such as street safety, stranger safety, or drinking and driving. But most importantly have a Happy and Safe Halloween!

SIDS (Sudden Infant Death Syndrome) -- How To Reduce Your Infant's Risk: AAP Recommendations and Analysis of The New Study on Fan Use While Sleeping

2008-10-20T11:43:00.000-07:00

Sudden Infant Death Syndrome (SIDS) has been in the media again this month as a new study showed a correlation between fan use in the bedroom and a reduction in the rate of SIDS.

SIDS is a horrifying possibility for any new parent. It is by definition a sudden and unexplained death of a previously healthy infant. To be classified as a death due to SIDS, the infant has to have been less than 1 year of age at the time of death and no cause of death found after a thorough investigation. SIDS rates peak at 2-3 months of age and drop off considerably after 6-8 months.

SIDS rates have dropped by over 50% since the start of the "Back to Sleep Campaign," however; it remains a leading cause of death in infants. The "Back to Sleep Campaign was initiated by the American Academy of Pediatrics (AAP) in 1992 to educate parents that the safest sleeping position for infants is on their backs. Despite the wonderful success of lying children on their backs, instead of their sides or stomachs while sleeping, with 1 in every 2000 infants still dying from SIDS annually, research continues to be done to better understand how to further reduce infant's risk.

The most recent study, which was published in the October 2008 issue of Archives of Pediatric and Adolescent Medicine, shows a correlation between using a fan in the room where the infant is sleeping and a reduction in the rate of SIDS. The authors quote a 72% reduction in SIDS risk when a fan is used in the bedroom. However, the study is poorly controlled which may bias the results. When the authors set up the two groups of mothers and their infants (one group of mothers whose infants died from SIDS and one group of mothers whose infants were healthy, called controls) for comparison, they allowed for many differences between the groups.

The infants used for the controls in this study were less often pre-term or low birth weight and more often children of older, married, more educated, non-smoking mothers, who had earlier prenatal care. These infants were more often put to sleep on their backs, on firm surfaces, without bulky bedding and with a pacifier. Since every one of the above is associated with decreased risk of SIDS, the infants who died of SIDS and the controls in this study were not well matched.

That being said, children with risk factors for SIDS did seem to benefit from a fan in the room. These benefits were less pronounced in infants without additional risks for SIDS.
A fan in the bedroom can be used to try to further reduce an infant's risk of SIDS but it should not be done in place of the many other recommendations to reduce SIDS risk.

The following is list of the AAP recommendations to reduce an infant's risk of SIDS:
1. Back To Sleep: Every Caregiver, Every time: It is extremely important for parents not only to put their infant to sleep on his back but also to ensure that every caregiver does the same. That means reinforcing it with relatives, babysitters, daycare and nannies. Infants who are normally put to sleep on their backs who then are switched to their stomachs are at an even greater risk for SIDS during that period.

2. Firm bedding surface: Mattresses for cribs, bassinettes, pack 'n plays etc. need to be firm. Compress the mattresses and sleep surfaces with your hands, it should feel firm. Do not add pillows, blankets, sheets, etc. to the sleep area. Anything that can move up over the infant's head increases the risk of SIDS. Any bedding product that states that it conforms to the back of the infant's head so that it reduces the risk of a flat head, will also conform to the infant's face and is not firm.

In order to decrease the chance of the skull becoming flattened by lying on it for an extended period of time, the position of the infant's head should be varied when he is put down to sleep, so that sometimes he lies on the right side of his head and sometimes the left. Infants should also have tummy time daily; when not sleeping, they should be allowed to lie on their stomachs on the floor. It should be noted that car seats, bouncers etc. also put pressure on the back of the head and can increase the risk of a flattened head.

3. No bed sharing. No couch sharing: Infants should not share beds with adults or other children. It is safe for infants to be brought into the bed to breastfeed or bond, but the safest place for an infant to sleep is in a crib in the parent's room for the first 6 months of life. Sleeping with an infant on a couch has been found to be even more dangerous than sleeping with an infant on a bed.

4. Don't over wrap or over dress infants for bed: Overheating is a risk factor for SIDS. A room temperature of 70 degrees F is optimal. Infants should be lightly clothed for sleep.

5.Offer a pacifier: Pacifiers have been found to reduce SIDS risk, although, the mechanism of this reduction is still unclear. An infant should never be forced to take a pacifier and if it falls out during sleep it does not need to be reinserted. Breastfeeding mothers may want to wait a month until breastfeeding is well established before introducing the pacifier. Pacifier use can, unfortunately, also increase the risk of ear infections; therefore, after 1 year of age, when the risk of SIDS has diminished, it is best to try to decrease their use.

The complete statement from the AAP on SIDS and risk reduction can be found on their website.

New Vitamin D Recommendations for Infants and Children:

2008-10-13T09:44:00.000-07:00

In November, The American Academy of Pediatrics, AAP, will be releasing revised guidelines for vitamin D intake for infants and children. The new guidelines differ from the old in two major ways: 1. the amount of vitamin D that should be supplemented to infants and children and 2. when supplementation should start.

The new guidelines recommend that all infants, children and adolescents have a daily intake of 400 IU of vitamin D, which is an increase from the previous guideline of 200 IU daily. This new recommendation was implemented based research indicating that a growing number of children are vitamin D deficient and that the incidence of vitamin D deficiency rickets is rising. (For more information about rickets visit http://www.emedicine.com/PED/topic2014.htm

Vitamin D is a fat-soluble vitamin that has many health benefits, most notably its role in strong healthy bones. A deficiency in vitamin D can lead to many health problems in children, including vitamin D deficient rickets. The body makes Vitamin D naturally when the skin is exposed to sunlight. With Americans limiting sun exposure and with children drinking less vitamin D fortified milk, children and adults are not getting as much vitamin D as they used to from these sources. One would have to drink 32 oz of milk a day in order to obtain 400 IU of vitamin D from milk. However, we, as pediatricians, advise parents not to give children more than 16 -24 oz of milk a day, as the calcium in the milk can inhibit the absorption of iron, leading to iron deficient anemia. Supplementation through vitamins is, therefore, necessary to obtain adequate daily intake. Tri-Vi-Sol and Poly-Vi-Sol, or their generic equivalents, have 400 IU per 1mL dropper or one chewable tablet. (Tri-Vi-Flor and Poly-Vi-Flor contain the same vitamins as their Vi-Sol counterparts with the addition of fluoride).

The second major change addressed in the new recommendation is when to start supplementing vitamin D to breastfed infants. The new guidelines state that breastfed and partially breastfed infants should start supplementation within the first few days of life. Previously, it had been believed that infants did not need to start supplementation until 2 months of age. This new recommendation is based on research indicating that many mothers are also vitamin D deficient and subsequently are producing breast milk with less vitamin D. Since infant formulas are vitamin D fortified, infants receiving 32 oz or more of formula a day need no additional supplementation.

Parents should check their children's multivitamin to determine the amount of vitamin D it provides per serving. Remember, if the tablet has 400 IU per tablet but the child only takes half a tablet a day, then he is only receiving 200 IU. However, this may be sufficient if he is also drinking 16 oz of milk daily. Parents should discuss these new recommendations with their children's pediatrician.

For more information on vitamin D, it's health benefits and it's sources, visit the National Institute of Health's website, http://ods.od.nih.gov/factsheets/vitamind.asp#h2, but please note that they have not yet changed their "Adequate Intake" table to reflect the new, 400 IU, recommendation.

Don't Take a Vacation From Your Car Seat! AAA and Hertz Join Together to Publicize the Importance of Car And Booster Seats

2008-10-03T14:39:00.000-07:00

The AAP has long advocated the proper use of car and booster seats for the important reason that they save lives. There has been great community support for this initiative from car seat safety checks to a variety of online awareness campaigns. One of the newest campaigns was a recent partnership between AAA and Hertz Car Rental Agency called "Don't Take A Vacation From Your Car Seat," which stressed the importance of properly restraining infants and children in car and booster seats while traveling. Through the program, AAA members were eligible to receive up to two complimentary car or booster seats when renting a car from Hertz.

The need for campaigns promoting the proper and consistent use of car seats is indisputable. Motor vehicle accidents continue to be the leading cause of death in children and the statistics are astounding. In 2005, 1,335 children under the age of 14 died from motor vehicle accidents and another 184,000 were injured which averages to 4 deaths and 504 injuries a day, according to the Centers for Disease Control.

Surprisingly, car seat laws vary widely by state, as illustrated by the following link http://www.iihs.org/laws/ChildRestraint.aspx. To add to the confusion, many parents don't realize that they are required to abide by the laws of the state in which they are driving.

However, given how common motor vehicle accidents are, it is safest for the child, if parents always follow the AAP car and booster seat guidelines. A summary of the AAP car seat recommendations is as follows; infants should be in rear facing car seats until they are both 1 year old and 20 pounds. Some rear facing car seats have a weight allowance of up to 30 pounds, which allow infants to stay rear facing longer. It is safest to keep infants, over the age of one, rear facing until they outgrow the weight or height allowance of their car seat at which point they will move to a forward facing car seat. Forward facing car seats are then generally used until the child reaches 40 pounds and is around 4 years of age, although some forward facing car seats can accommodate children up to 65 pounds, or around 6 years of age. Once a child out grows the height and weight allowances of their forward facing seat they should ride in a booster seat until the adult seat belt fits them correctly which is usually when the reach a height of 4' 9". The AAP has published a Car Seat Safety Guide for Families, which is a wonderful resource for parents and can be viewed at http://www.aap.org/family/carseatguide.htm.

Given the number of deaths and injuries incurred by children due to the lack of proper car seat use, programs such as the recent Hertz AAA campaign are a wonderful way to eliminate some of the obstacles encountered when traveling that decrease their rate of use. According to Deanna Zagin of AAA, the campaign has been well received by AAA members and feedback thus far has been very positive. Although, the campaign officially ended on September 30, 2008, AAA members, as well as members of other participating associations, such as the American Medical Association, are always entitled to receive one complimentary car or booster seat when renting a car from Hertz.

A version of this article also appears on the American Academy of Pediatrics, Council on Communications and Media website.

DHA – Not Just For Infants:

2008-09-09T12:20:00.000-07:00

With the new wave in infant formulas, most new and expectant mothers have heard of DHA (Docosahexaenoic Acid) the omega-3 fatty acid that is touted as helping with brain development and visual acuity in the newborn. Some pregnant moms may have taken Expecta, the 200mg DHA supplement by Mead Johnson that is marketed as a supplement for both pregnant and breast-feeding moms.

Although it is an accepted fact in the medical community that omega-3 fatty acids are part of a balanced diet and that the average American does not get enough omega-3, this information has not made it into mainstream America. The National Institute of Health (NIH) has stated that individuals should consume more omega-3. With evidence that omega-3 is important not only for maintaining a healthy heart, but can also help with coronary artery disease and reducing triglycerides, the American Heart Association has published a set of omega-3 recommendations. In addition, there have been multiple studies showing an association between lower omega-3 intake and depression including postpartum depression, although additional studies are needed to confirm if there is a causal link between the two. Yet with all this information on the benefits of omega-3 fatty acids, it seems that most mothers stop thinking about their or their children’s intake of these fatty acids once the change is made from formula or breast milk to whole milk at one year of age.

There are three main types of omega-3 fatty acids: DHA, EPA (elcosapentaenoic acid) and ALA, or sometimes abbreviated LNA, (alpha linolenic acid). DHA and EPA are primarily found in fish. ALA is found in some plants such as flaxseeds and walnuts. The body can convert ALA to DHA and EPA but not at a 1:1 ratio.

With new studies coming out regularly regarding omega-3 and the health benefits of including it in a well balanced diet, how to consume enough omega-3 becomes a legitimate question. Eating fish is the easiest and most direct way to get DHA and EPA. Due to the possibility of high mercury content in some fish the Environmental Protection Agency (EPA) and the Food and Drug Administration (FDA) have stated that women who might become pregnant, women who are pregnant or lactating and young children should limit their fish consumption to no more than 12 ounces a week. Yet, all fish are not created equal. When choosing those 12 ounces of fish, it would be best to choose those lowest in mercury and highest in omega-3. Shark, swordfish, king mackerel and tilefish should be avoided altogether by women and young children. Salmon, herring and rainbow trout are all low in mercury and a 4-6oz serving of these fish would provide 1gram of EPA+DHA. A complete list of fish and their mercury content can be found at the FDA’s website, while a list of fish and their omega-3 content is available through the American Heart Association’s website.

There are also many food products that are now supplemented with omega-3, usually in the form of flaxseed or flaxseed oil. They include breakfast cereals, breads, and nutritional bars. In addition, omega-3 enriched eggs are also available. The chickens laying these eggs are fed flaxseeds as part of their diet and therefore their egg yolks have a better fatty acid composition that includes a higher omega-3 content.

While the absolute amount of omega-3 consumed is important, the ratio of its consumption in relation to omega-6 fatty acids may be even more important. Omega-6 fatty acids are generally considered pro-inflammatory while omega-3 fatty acids are considered anti-inflammatory. A proper balance between the two is needed in the body. According to the NIH, the typical American has a 10:1 ratio. What is interesting is that it is believed that primitive man had an omega-6 to omega-3 fatty acid ratio of 1:1. But one might ask, how did our ancestors have a 1:1 omega-6 to omega-3 ratio, they weren’t buying nutritional bars at Wholefoods? Well, as it turns out, cows are supposed to eat grass, not corn. Something most first-graders could probably tell you but something lost on the American ranching industry. Corn fattens a cow up quicker than allowing the cow to graze in an open pasture. But corn also alters the fatty acid content of the cow. Just as we are what we eat, cows are what they eat too. That really comes into play when we eat them, because now we are what they eat. Grass is naturally high in omega-3; but, while we can’t digest grass, cows on the other hand can. By eating a grass-fed diet, cows have a higher omega-3 content in their meat and milk. Therefore by consuming beef as well as milk, yogurt, cheese and butter from grass-fed cows, we can increase the omega-3 in our diet.

So the moral of the story is what is good for you as an infant is also good for you as child and an adult. The best way to increase omega-3 in your and your children’s diet is to continue to eat the 12 oz of fish allowed by the FDA per week and if you can find it, buy grass-fed food products. And, if you can’t find what you’re looking for at your local grocery store, ask them to start carrying it.

Cold Remedies

2008-06-18T10:57:00.000-07:00

Cold Remedies for Infants and Toddlers:
Even for children not in daycare, having a cold once a month can be quite common. But, now with infant cold preparations off the market for children under 2 years of age and with new warnings that children’s cold remedies should not be used in children under 6 years old, unless advised by a doctor, what can parents do to ease the symptoms of a sick child?

For fevers, aches and pains, Tylenol, also known as acetaminophen, and Motrin, whose generic name is ibuprofen, is still available and considered safe for children and infants. These can be given according to the directions on the bottle. If your pediatrician advises using a cold preparation medication, make sure when using these medications that they do not contain the same active ingredient as any other medicine you are giving to your child. For example, many combination medications also contain acetaminophen. You cannot give Tylenol for fever and then a combination medication containing acetaminophen or Tylenol within the same 4-6 hours. Make sure to read the active ingredients of all medications you give your child.

For a troublesome cough, honey has been shown to be an effective cough suppressant. In a study published in December of 2007 in the journal Archives of Pediatric and Adolescent Medicine, buckwheat honey was compared with dextromethorphan, the common cough suppressant used in children’s cold medications. Honey was found to be as effective as dextromethorphan. Yet as the authors point out, honey is considerably safer. In addition to its cough suppressant properties, honey is also known to have antioxidant and antimicrobial effects. Honey should not be given to children less than 1 year of age, as it is not safe for them to eat. But, for children older than one year, a teaspoon of honey can be tried to alleviate cough. In the study, it was given a half an hour prior to bed and was found to help with both cough and sleeping difficulty.
For congestion, a bulb suction can help relieve a stuffy nose. When using a bulb suction, it is important not to suction too aggressively. Aggressive suctioning can lead to trauma and swelling of the inside of the nose making it even more difficult for the child to breath and clear nasal mucus. The tip of the bulb suction should be placed right inside the opening of the nose and not up against the wall of the nose. A drop of saline can be used in the nose to loosen up the mucus right before suctioning.

Another way to relieve congestion in children over the age of 1 is with steam. Steam up the shower and then shut off the hot water before getting in with the child, so as to be sure not to burn your child. Do not allow the child to stay in the steam for more than 5 minutes and make sure to keep the child well hydrated once out of the shower. If the child is having trouble keeping down liquids, then do not use steam to help with congestion as he cold become dehydrated. Older children can place their head over a steaming pot of water. It is best to transfer the steaming water to a new pot before placing the child’s face over the water so as to avoid the child burning himself on the hot pot. Do not leave the child unattended while steaming as hot water can also burn and, of course, allow the child to get out of the shower or stop steaming his face at the first sign of discomfort.

In the end, a cold or virus is just going to have to run its course but while waiting for it to do so the above options may provide a little relief for your little one.

Infant Diets: New Feeding Regimen for Infants

2008-04-25T16:33:00.000-07:00

The New Infant Feeding Regimen - No More Egg-less Meatballs:

In January of 2008, the American Academy of Pediatrics (AAP), released a policy statement regarding the introduction of solid foods, including eggs, fish and peanuts into an infant’s diet. This policy statement replaced the statement released in 2000 that had advised delaying the introduction of highly allergic foods until 1-3 years of age.

The delay of the introduction of certain solid foods has become the mainstay for many infant-feeding regimens. The standard feeding regimen for infants had been breast milk or formula, exclusively, for the first 4-6 months, followed by the introduction of rice cereal, then vegetables and fruit, followed by meat, with eggs being introduced after 2 years of age, and fish and nuts after 3 years. However, according to a new policy statement released by the AAP, these restrictions are no longer thought to be necessary.

The new statement still recommends exclusive breastfeeding for 4-6 months, however, there are no longer recommended delays for the introduction of solid foods after this time, including removing the previous recommended delays for eggs, fish and nuts. It is important to understand what the statement says. Previously, it had been thought that some atopic diseases, which include eczema, allergic rhinitis, asthma and food allergies, could be prevented or lessened in severity by delaying the introduction of highly allergic foods into the infant’s diet. The new statement concludes that, after 4-6 months of age, the timing of introduction of solid and highly allergic foods does not change the outcome. That is to say, if a child is going to be allergic to a food or have an atopic reaction (eczema, allergic rhinitis or asthma) to the food, then delaying the introduction of that food does not lessen this chance. The child will still have the reaction when the offensive food is introduced, whether that is at 7 months of age or 2 years. Thus, a certain percentage of infants will have these reactions to a food regardless of when the food is introduced. For these reasons, it is still prudent to only introduce one food at a time and watch for allergies. When introducing eggs, it is still wise to start with just the cooked yolk and if that is well tolerated move on to the whites a week or so later.

These new recommendations should be discussed with your child’s pediatrician. For infants that have already had an atopic reaction or who have a strong family history of eczema, allergic rhinitis, asthma or food allergies, parents and pediatricians may still opt to wait on introducing solids or highly allergic foods as these children are more likely to have reactions. The full statement release by the AAP can be found at http://aappolicy.aappublications.org/cgi/content/full/pediatrics;121/1/183.

Update: AAP Q&A - first foods as of Sept. '08