Saturday, December 3, 2011

Merry Christmas Everyone!

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Saturday, September 17, 2011

Are Your Child's Behaviors or Emotional Reactions of Concern?

Are your child's behaviors or emotional reactions a serious problem?  Truly this is a question that comes up many times a day in my office.  Mostly I find that I can offer reassurance and guidance on what to do and what to expect next.  Many concerns simply represent normal and predictable parts of a child or adolescent's development.  Sometimes I must dig a little deeper.

Keep in mind that I am a general pediatrician and a mother, not a psychiatrist or psychologist.  I received the education a board-certified pediatrician is exposed to during her training and ongoing maintenance of certification.  My experience has developed over the years, as I have interacted and provided health care for many children.  I have a few validated assessment tools I can use when I need a more objective point of view.  However, to get an idea of what is going on, mostly I talk to parents and children and observe children in my office. 

Now, having properly oriented you, I want to let you in on some of the big things I consider when trying to help parents figure out if their child has a behavioral or emotional problem beyond the range of normal variation or development. 

1.  HAPPY?
I want children generally to be happy and able to participate in school and the activities they usually want to do.   Certainly a child will have ups and downs, good days and bad, temper tantrums, mood swings, and upsetting things that happen to them.  However, overall, a child will normally stay interested and have some enthusiasm for family, activities, friends, and at least some parts of the school day.

I don't want a child's behaviors or emotional reactions over time to significantly limit their participation in family life, the school setting, friendships, and individual interests.  Again, this doesn't just mean having a bad day, or week.  The overall arc of a child's day-to-day life should allow them have the experiences they need to develop meaningful relationships, independence, confidence, and self-esteem.

We have to get to know our children.  Different temperaments respond better to various forms of discipline and structure.  A frown and slight shake of the head may bring one three-year-old to the point of tears, while another won't respond until they have had several time-outs and a toy taken away!  Still, unless it is necessary because of a child's young age or special needs, a family should not have to adjust everything they do around a child's behavior or emotional reactions.  If, because of their child, parents find themselves usually quite limited in the places they can go, food they can eat, and people they can visit, this might be a concern.  Or, if a time-consuming amount of planning is necessary to get out the door, get a child to school, stay on a schedule, make sure the right snack and drink is available, etc. then this could be a red flag.

Can I generalize and say that if a child is usually happy, participates willingly in life, and fits into the family then there is nothing to worry about?  Probably it's not that easy!  However, if one or more of the above three questions starts to reveal a persistent problem, then I know I will have to look into it further.

Your personal pediatrician is a resource for you in helping to figure out what is normal for your child.  Other pieces of the puzzle may be filled in by talking to your child's teacher or daycare provider, other parents, relatives, or a school administrator or counselor. 

Answering the question of what to do about a particular behavior or emotional reaction will always involve trying to determine if it is a major or minor problem, if it is a part of normal and expected development, and if it is affecting multiple areas of a child's life.  I hope, as you struggle through the ups and downs of parenting, this gives you some ideas about how to think clearly about your child.

Wednesday, September 14, 2011

Help Your Child Remember "You are Loved!"

It's the early weeks of the school year and the excitement and novelty is wearing off.  You might start hearing some comments like "I want to stay home with you," or "I don't want to go to school."  Little bits of the school day are revealed at odd times in the evening--sometimes sending a jolt of panic through the center of your chest.

"My teacher never calls on me when I raise my hand."  "When I got back from the bathroom everyone was doing a new assignment and I didn't know what to do."  "No one would play with me at recess."  "I didn't have time to eat my lunch."

You can't be with your child all the time any more, and that can be hard for her and for you.  Some children, and parents, have to be very brave to make it through each school day.  It's time to remind yourself that an appropriate amount of independence and successful, gradual, separation from you will help your son or daughter become more confident, with higher self-esteem.  However, as you ponder these theories, you still need a way to get both of you through the school day.

I don't have all the answers, but I do have some ideas.  Some books for children address this topic in an appealing, caring way.  I found the following books amazingly helpful:

The Invisible String, by Patrice Karst, describes in a touching simple way how we can be connected to each other by an invisible string of love, even when we are apart.  Two children are woken by a thunder storm and run to find their mother.  On each page the family explores how they are linked to different people they love.

The Kissing Hand, by Audrey Penn, stars a baby raccoon who doesn't want to go to school, but would rather stay home with his mommy and familiar toys.  His mother kisses the palm of his hand and tells him that if he puts his hand up to his cheek he will feel her love any time he wants.  The story is sweet, and concept easy to understand at almost any age.

Wemberly Worried, by Kevin Henkes, is about a little mouse who can't go anywhere without his special blanket.  His mother comes up with a creative solution so he can secretly take his blankie whereever he goes.

After the first week of school my youngest daughter and I read The Invisible String together.  We made red construction paper hearts, exchanged lipstick kisses imprinted on the hearts, and put them onto necklaces of string to wear the next day.  In this way we can carry a tangible symbol of love, that hopefully will carry us through until we can be together again.  Maybe some of you will see me with my "heart on a string" tomorrow in the office.

I would love to hear comments on book suggestions or ideas you have to help with separation anxiety, or other special traditions you have that help you feel closer when you have to be apart!  Maybe you can find some books about children and their fathers, too.  Good luck.

Monday, September 12, 2011

What to do with a Fever

Fevers are common in children.  They are probably the number one reason for after hour phone calls to the doctor.  Many parents feel panicky when the thermometer indicates fever.  So what should you do? 

First, and most important, don't panic!  Keep trying to think logically and stay calm.  Your sick child needs you to be able to make rational decisions.  Understand that if the temperature is under 100.5 F, then it is not actually a fever, and you should simply monitor the situation.  Also remember that fever can be helpful in fighting some infections. 

Fever is a sign that your child's body is reacting to an infection.  When there is a fever we try to figure out if the infection is a serious one.  The fever itself won't hurt your child, but a serious infection can be a cause for concern.  If your child has a fever, but is older than three months of age and is looking and acting just fine, you do not automatically need to call the doctor.  Fairly normal behavior and energy level often mean the fever is caused by a more minor infection.

Here are some things to think about.  If your child is under three months of age and has a rectal temperature of 100.5 or higher, you should probably call the doctor.  You could consider unwrapping your baby, making sure that too many blankets isn't the problem.  In general, though, for an infant under three months old with a fever, you should call.

If your child is over three months of age, then her behavior and appearance are important in evaluating how serious of an infection it is.  There is no automatic temperature at which you should "panic" and rush to the ER.  103, 104, and 105 F are all "high" fevers.  When the fever is high you also need to consider how sick your child looks.  If they are very irritable or lethargic, it is more concerning.

When I am called about a child's high fever I frequently ask parents to give a dose of ibuprofen or acetaminophen, and then reassess their child in an hour.  If she feels and looks much better with such a simple intervention, then it may be ok to wait until the next day before bringing her in.  The goal of using anti-fever medicine is not to bring the temperature back down to normal, but to temporarily bring it down a little and to make your child feel better.  It is a good sign if something basic like acetaminophen or ibuprofen can make a big difference in how your child feels.

Giving a cold bath is kind of dramatic and old-fashioned.  I don't usually recommend it because I don't think it would be very soothing to already feel awful with a high fever and then get plunged into icy water.  Cool wet washcloths on the forehead and back of the neck will be much more comfortable for your child.

106 F or higher makes me think of heat stroke, so at that level you should call or take your child to the hospital.  103 F and higher, in addition to a lethargic or irritable child who does not improve with acetaminophen or ibuprofen, would be another reason to call or have your child evaluated right away.
In addition, with any level of fever (that's 100.5 or higher) when your child is also very irritable or lethargic and not improving with anti-fever medicines, you should consider calling or taking your child in.

A child who is lethargic and irritable is usually not smiling, not eating and drinking, is very sleepy or won't stop crying or moaning.  The child can be very restless or almost impossible to comfort and console.  When the doctor asks about "lethargic" she does not mean that your child just wants to sit around and watch TV, or that they seem a little more tired than usual.

When there is a fever, this is what you should do:

Before you call the doctor, take a few seconds to think clearly about your child and his fever.  What other symptoms does he have? What illnesses was he exposed to?  How long has he been sick?  Can you help him cool off by undressing him, using cool cloths on the forehead and neck, and giving him anti-fever medicine?  Did you give the right amount of ibuprofen or acetaminophen, and did you give the medicine enough time to work?  Was there improvement in his appearance, mood, discomfort, and energy level? 

If you are reassured by improvement in your feverish child's appearance, then you may be able to manage this at home for the time being.  You could make an appointment in the next day or two if the fever doesn't go away.  If you continue to be quite concerned and worried about your child even after trying some things to help them feel better, then don't wait to check in with the doctor.

Disclaimer:  As usual, my advice in this blog is general and may not apply to your specific situation, or to your child's special circumstances.  This blog is not intended to be a substitute for the personal attention your own doctor can provide.

Saturday, June 11, 2011

Raw Milk? You're kidding, right?

Drinking "raw" or unpasteurized milk has become popular in some groups whose members believe there are significant health benefits in raw milk which are destroyed in the pasteurization process.  Actually you and your children are far more likely to become seriously ill from germs in raw milk than you are to improve your health.

Pasteurization of milk is a fairly simple process that involves heating milk to about 160 degrees for 20 seconds.  This important step in processing milk  kills serious, disease-causing bacteria such as Salmonella, E.coli, and Campylobacter jejuni.  Yes, E.coli is the same bacteria causing serious illness and death in Europe right now from contaminated bean sprouts.

Before milk was routinely pasteurized (in the 1920s) it caused many illnesses in our population, such as tuberculosis, typhoid fever, streptococcal infections, diphtheria, and more.  In the early 1900s some smart mothers realized the dangers of raw milk and pasteurized it themselves by boiling it before feeding it to their children!

As a Peace Corps Volunteer in Honduras in the 1980s I noticed the villagers where I lived always boiled their milk before consuming it.  We ate our cornflakes with hot milk!  Although they lived in mud huts, with dirt floors, thatched roofs, and chickens and pigs running in and out all day long, these people would not touch milk that had not been heated properly.  At the time I didn't understand the significance of this practice.  Now I do.

Why would anyone want to drink milk that has potentially been contaminated with serious germs like E.coli?  Good question!  Those who do consume raw milk believe it comes from healthy animals, and is handled safely enough that it won't contain disease-causing bacteria.  This is actually very difficult to guarantee.  Even if the animal is healthy, its fecal matter can get into milk.  This can be because it is on the udders, in the barn, on the hands of the farmers, or on insects or rodents living where the animals live.  The germs are microscopic.  Testing the milk is not comprehensive enough to ensure its safety.

Some people believe there are healthy enzymes and vitamins in the raw milk that are destroyed when the milk is heated.  While it is true that heating does inactivate some enzymes and reduce vitamin C content, these are not important nutrients for humans to obtain from cows or animals other than humans.  Raw milk has not been shown to reduce diabetes, asthma, or allergies.  Nor does it improve your immune system.  Raw human milk given directly from a mother to her child is completely different.  We are not cows or goats.

Some people may believe that raw milk has helped their own individual health, but this is what is called testimonial or anecdotal evidence.  It is a claim made by a few, and it is not supported by scientific, or research based evidence.

The images that come to my mind when I think about drinking raw milk are the following:  eating strawberries without washing them, using the toilet or changing the kitty litter box and then preparing a meal for your family without washing your hands, simply cutting up the lettuce for a salad without thoroughly rinsing it first, changing a poopy diaper and then sitting down to lunch, eating bean sprouts in Germany... It nauseates me, repulses me, and makes me shudder to think about taking a sip of milk that has not been pasteurized. 

The diseases you can catch from raw milk are serious.  E.coli can kill.  Certain types of E.coli can cause kidney failure, damage to the red blood cells, and stroke.  In my pediatric training I cared for a preschool aged child who died of a stroke that occurred from complications of an E.coli infection.  It was devastating.  Since I have been in private practice I have had entire families become seriously ill from Campylobacter jejuni that originated in raw milk. 

I don't think drinking raw milk is a smart decision for an adult, but it is certainly their choice to consume it.  When it comes to our precious children I don't think we should putting them at risk by taking our health practices back a CENTURY and giving them raw milk.  I don't think my pediatric practice would be very successful if I practiced 19th century medicine, so I have to recommend against the antiquated and dangerous fad of consuming raw milk.


Here are some links to give you more details.  One link will take you to some testimonials that share experiences some people have had getting sick from raw milk, rather than typical anecdotes that tout the benefits of raw milk.

Monday, May 30, 2011

Treating and Avoiding Seasonal Allergy Symptoms

This is what is in my medicine cabinet at home
It's spring and, in my office, we've been dealing with seasonal allergies for weeks. My nine year old daughter has them every spring. She can be just miserable with itchy, watery, puffy eyes, an itchy throat, a stuffy nose, sneezing, and congestion. For her, the eye symptoms are the worst.

This all started for her when she was about four. I came home after work and she was running frantically around the house rubbing her eyes and bumping into things. Her eyelids were so puffy she could hardly see out of them. It was then I realized I needed to take a more pro-active approach toward her allergies. I needed to keep them under control, to not allow things to get so bad again.

Sometimes I have families come in to the office season after season, surprised that their children have allergy symptoms again! Parents sometimes don't want to keep their children on medication all the time. They don't like medication, and don't think it's healthy for their child to take "so much."

I think, if these parents had allergies themselves and knew what it was like, they would just go ahead and give the medicine and never allow things to get so bad for their child. It is simply miserable to be itchy, sneezy, congested, with a constant runny nose or post-nasal drip.

You can do some simple things at home to help your child with seasonal allergies:

  1. Keep their bedroom windows closed during allergy season so the pollen doesn't get into their bedding and clothes.
  2. Bathe them and wash their hair in the evening if they have been playing outside all day during allergy season. This will wash off some of the pollen so they don't breathe it all night.
  3. If you have air conditioning consider using it during allergy season.
  4. Give your child a simple over the counter antihistamine such as loratadine (Claritin) or cetirizine (Zyrtec). Either of these will last 24 hours, have few side effects, and work great especially to prevent allergy symptoms. Even fexofenadine (Allegra) is now available without a prescription, but it is still pretty expensive and must be dosed twice a day. These medications will work best if you give them regularly during your child's allergy season.
  5. If eye symptoms are really bad you can rinse your child's eyes gently with some saline solution, and then use over the counter allergy eye drops regularly to prevent symptoms. Two of the drops I know you can buy without a prescription are Zaditor and Patanol.
  6. An occasional dose of diphenhydramine (Benadryl) can go a long way if things get out of control and you have to get the symptoms calmed down for the night.

So, don't be surprised if the allergy symptoms your child had last spring come back again this year! The same holds true for fall allergies. Go ahead and treat your child's symptoms and help prevent the symptoms during the entire season your child usually has trouble.

Allowing your child to suffer through the allergies does NOT make their immune system better able to fight the allergies! It just makes them feel terrible.

If you want to do something to try to actually reduce or eliminate the allergies you will have to talk to an allergist about immunotherapy. This is a long-term (2-5 years?) endeavor of year-round weekly or biweekly allergy shots. To many kids (depending upon their age and tolerance), this treatment would be worse than taking some antihistamine for a few weeks or months each spring (or fall).

Monday, May 23, 2011

Why Do Doctors Run Late Part II

This is part two on why doctors run late in the office—more specifically, why I might run late some day while you are waiting for me! The same scenarios I presented in the blog last week are explained here in more detail. I am trying to make you understand why things aren’t always simple when it comes to keeping to a schedule.

Please understand, I am not trying to excuse myself for running late. Hardly anything causes me as much stress as getting behind on my schedule and forcing others to wait for me. I always strive to keep to my schedule by having appointments scheduled in a way that allows enough time for the problem and number of patients to be seen in a time slot. I try to be efficient during the appointment. I even ask people to reschedule—especially if they are so late for a check-up (or similar non-urgent appointment) that almost all of the allotted time has gone by before they arrive.

I have had people give me analogies such as getting their muffler fixed, oil changed, or brakes replaced on their car—for these procedures they are given an appointed time, and apparently their mechanic sticks to the schedule. My first response to this is that people aren’t cars! People talk back to me, and have opinions and feelings about what is happening to them. Secondly, it is unlikely there would be an emergency repair a mechanic would have to make immediately (when they thought they would just be simply replacing the muffler). And finally, in my experience, mechanics haven’t been very good at sticking to the schedule when it comes to fixing any of my cars. Or what about any other appointment you have had scheduled, such as getting your hair cut? Your stylist can keep to her schedule, right? Again, a doctor’s appointment isn’t the same as getting your hair cut. Much is known ahead of time about what will happen in the salon (making scheduling more accurate), but the flow of an appointment with your doctor is often unpredictable.

So here are my scenarios—with more detail to give you an idea of why I often must just deal with the problem as it comes up, instead of cutting people off or making them reschedule an appointment. And I’m not even including the little things—such as the newly potty trained three year old who has to go to the bathroom in the middle of the appointment, or the child who vomits everywhere as soon as I walk in the room, or the adolescent who faints after her immunization, or the poopy diaper that goes up the back and onto the exam table.

1. My first patient of the morning is seven minutes late. She is sick and there are no other appointments available until after hours. The child cannot drive herself to the office and I don’t feel right about penalizing her because her parent did not make it to the office on time. It turns out the reason the parent was late is because the child was vomiting all over the place before getting in the car—the best laid plans to arrive at the office on time went awry due to unpredictable circumstances. Or, there was an accident and traffic was re-routed, causing the drive to take longer than usual. Or, the roads were icy. Or, they were just late—but it really isn’t the fault of the 5 year old with the high fever.

2. An appointment was given for one child, but it turns out the sibling is also ill and needs to be seen. Mom is looking stressed and near tears, she won’t have a car that afternoon to bring the sibling back. I don’t have the chart, and have to request it. This is a really common scenario. I am asked to see siblings, or “just take a quick look in the ears,” or “just answer a quick question about brother’s potty training” many times throughout the day. How would you feel if you were in this Mom’s position? I don’t think you would be very happy if your pediatrician said “No, I’m sorry Mrs. Smith, next time you should think ahead and schedule another appointment for little Johnny. Have a nice day.” It would help me if parents could alert my nursing or front desk staff ahead of time so I could have the sibling’s chart, and so I could be aware from the onset that I must divide my time between two kids instead of using all the time for one. But it’s not very likely that I am going to refuse to see a sibling if it is for a simple illness such as a potential ear infection. Adding on another child (or even just a conversation about another child) at the end of the first child’s appointment may take an extra five to ten minutes. If I know about it ahead of time I can be more efficient.

3. A middle-school student is in the office for a sore throat. I do a brief history and physical exam, get a throat swab, and step out while the test runs. I return to inform the family the child has strep, discuss the illness, and write the prescription. I write a note to excuse the student from school, and another to explain the parent’s absence from work. As I get up to leave the parent asks their child to step out because they want to discuss something privately with the doctor. At this point I had thought we were finished with the appointment. But the conversation reveals that the patient is having some serious mental health problems and the parent needs some advice TODAY. This part of the visit turns out to be more important than the strep throat, and yes, it will put me 10 to 15 minutes behind in my schedule. Again, if I had known ahead of time I could have planned better—perhaps having this discussion while we waited for the strep test to run—but I can’t turn this person away just because the problem wasn’t scheduled into my day.

4. A teenager was given a ten minute appointment for the primary complaint of a sore throat. When I get to the room she tells me that she was too embarrassed to say anything to the receptionist, but actually she is having problems with her periods. By the way, she has also recently become sexually active, and is worried about STDs and pregnancy prevention. Obviously we could have allotted more time if we had known all of these issues, but isn’t it understandable why she had trouble telling this to the receptionist? Maybe her dad made the appointment for her, and he is sitting in the waiting room right now wondering if she has strep throat or mono. Meanwhile I am having a completely different conversation with his daughter. And then I will have to reach an agreement with the teenager about how we are going to talk about this with her dad, then dad has to come in and we have another conversation. This will add 15 to 20 minutes to the scheduled 10 minute appointment.

5. A two year old is in the office at 2pm because of two to three days of fever and fatigue. The usual ten minute time slot was allotted for this basic, acute illness. During the exam it quickly becomes apparent she will need to be hospitalized. She is so pale and lethargic that it is clear something is seriously wrong. Now it is 2:12pm (her appt. technically ended at 2:10). I must arrange for her hospital admission. This will involve conferring with my office staff (five minutes), possibly collaborating with another doctor at my office to inform them of the admission and get their opinion (five to ten minutes), talking with other doctors and nurses at the hospital (minimum of ten minutes, may involve more than one phone call), and discussing the possible diagnosis with the child’s family and explaining the diagnostic and treatment plan to them (ten-twenty minutes). Now I am ending this child’s appointment at least 30 minutes (up to 50 minutes) after it had been scheduled to end. To those who are waiting, and feeling frustrated and annoyed, all I can say here is that I would give your child the same time and attention if they were seriously ill.

6. Another scenario is the “by the way, doctor” that is added on as I am walking out the door. This could be a list of questions from the patient who hardly ever comes into the office, is here today, and needs some answers. Or, it could be a behavioral question about a preschooler, or a potty training question for a two year old. It could be questions regarding when to think about ADHD, school problems, how to handle a child’s grief over their grandparent’s death, how to help a child through their parents’ divorce, what to do about bed-wetting/constipation/soiling the underpants, how to get a child to sleep better, etc. Many parents wouldn’t think of making a separate appointment for these questions, but they are important topics that will take at least a few minutes of my time. It is always helpful if a parent can help me plan the time in the office visit by saying at the beginning of the appointment something like: “We are here because we suspect an ear infection, but I also wanted to ask you a question about potty training.” Or, “we made the appointment for back pain, but we have seven other things on our list to ask you about.” For those with a long list I will probably then ask them to prioritize in order of importance, and tell them at the beginning that they have a ten minute appointment and we may have to reschedule to discuss some of the other problems. If I don’t know about the list until I am finished evaluating the primary complaint it affects my schedule more.

I think there were at least four more scenarios in my original blog on this topic. There is enough here, however, to give you a general idea of how and why I can get off schedule. There are also some things you can do to help me stay on schedule. These would include providing accurate information to the scheduler about the main reason, and any other secondary reasons, for the appointment (including how long the symptoms have been present), letting me know at the beginning of the appointment about everything you want to discuss, and informing my office staff that you are planning to have me check a sibling in addition to the child who originally was scheduled for an appointment.

To those of you who simply cannot tolerate waiting, or who have such a tight schedule that it isn’t possible to run late, you might consider booking your appointments as early as possible in the morning or first thing in the afternoon. In general it is more likely I will be running behind as it gets to be later in the day. And my pledge to you is that I will continue to work on staying on schedule and being efficient during my office day—while still striving to treat each patient as an individual who may have important and unexpected needs. Ultimately I will try to treat each family as I would want someone to handle my own.

Saturday, May 21, 2011

Why Do Doctors Run Late?

You know how it is, right? You’re sitting in the waiting room with your child, bored out of your mind, while snotty nosed toddlers cough, sneeze, and wipe their boogers on every imaginable surface, including you and your previously healthy baby. You wonder if you have been forgotten, it has been 20 minutes, then 30. Finally you are escorted to an exam room, told the doctor will be with you shortly, and the door is closed. Claustrophobia sets in. It’s warm and stuffy, and there is no window. Your children turn into unrecognizable beings that must belong to someone else. They open drawers, pull out tongue depressors, rip off exam table paper, and spill crackers on the floor. Someone has to go potty. You’re not sure if you have time to make it to the bathroom and back—what if the doctor comes in right then? Finally you open the door to make sure they still remember you are here, take a step into the hallway to find the potty, and there I am—it’s your turn!

I have looked at my own schedule many times. While I can’t answer the question of why other doctors run behind on their schedules I have thought a lot about why I might get behind. I do understand it better, and have made improvements, but as many of you know, I have not solved this problem after fourteen years in private practice!

Why do I sometimes run behind in my schedule? From day-to-day this is the one thing that causes me a great deal of stomach churning, acid refluxing, and gut flip-flopping, head-aching stress! Often I will think back on my day, and if I have stayed close to my schedule and not finished too late it has been a good day. If I’ve run behind I’ll end the day feeling frazzled and out of breath, apologizing to everyone, and will go home to tell my family what an awful day I had.

One message I would like you to take home from this blog post is that I really do care about your schedule. I hate making people wait for me, and I am thinking about it constantly throughout the day.

I have done audits on myself. I’ll take several days and write down my starting and ending time for each appointment, and then compare it to my schedule. While it is fresh in my mind I’ll jot down any special circumstances that might have made an appointment start or end at a different time than it was scheduled. The first time I did this I was trying to find the one problem I was having that would explain getting off schedule. There must be something simple that could be adjusted, right? Perhaps it is just an improper scheduling issue?

What I have found when I audit myself is that there are MANY reasons I can get behind in a day. Most of them are UNPREDICTABLE. Most of them are UNAVOIDABLE if I am to provide good quality patient care. You must understand that it is my goal to provide the best possible care to each child in my office. I cannot sacrifice good care in favor of staying on schedule. I do set priorities each day, and at times cannot satisfy every need a patient has in one office visit.

Let me give you some examples of where things can go wrong, and why you might end up waiting for me. I, of course, have changed these scenarios to protect the privacy of my patients, but you will understand the general principles. I will use my NEXT blog to go into more detail about why each of these can affect my schedule so much, why I don’t think there are simple answers to each schedule-wrecking situation, what I do to try to keep myself on track, and what parents can do to help me stay on schedule.

1. My first patient of the morning is seven minutes late.

2. An appointment was given for one child, but it turns out the sibling is also ill and needs to be seen.

3. A middle-school student is in the office for a sore throat. After the office visit is completed, and I get up to leave, the parent asks their child to step out because they want to discuss something privately with the doctor

4. A teenager was given a ten minute appointment for the primary complaint of a sore throat. When I get to the room she tells me that she was too embarrassed to say anything to the receptionist, but actually she is having problems with her periods. By the way, she has also recently become sexually active, and is worried about STDs and pregnancy prevention.

5. A two year old is in the office at 2pm because of two to three days of fever and fatigue. The usual ten minute time slot was allotted for this basic, acute illness. During the exam it quickly becomes apparent she will need to be hospitalized. She is so pale and lethargic that it is clear something is seriously wrong.

6. Another scenario is the “by the way, doctor” that is added on as I am walking out the door. This could be a list of questions from the patient who hardly ever comes into the office, is here today, and needs some answers. Or, it could be a behavioral question, potty training, ADHD, a child’s grief, parents’ divorce, bed-wetting/constipation/soiling the underpants, sleep, etc.

7. I was given a ten minute time slot for a patient with apparently just two days of headache, but actually it turns out this problem has been going on for more than a year, and also there has been ongoing problems with abdominal pain.

8. During one office day I received several phone calls from the hospital to tell me urgent things about patients in the hospital. I am interrupted from office visits with patients to take these calls.

9. My eight year old patient won’t cooperate for a strep test.

10. Someone walked in with an injury needing urgent treatment and didn’t have an appointment.

I will probably think of more. On any one day my schedule can probably handle one or two of these without disastrous effects. But some days, especially if there is an admission to the hospital, I just end up terribly behind. I can tell you that when auditing myself I see many different reasons throughout the day to explain how my schedule went awry. Sometimes there is a single thing, such as the hospital admission, that explains everything. But more often it is many different situations throughout the day which add up to put me behind. And I am certainly not just standing around drinking coffee or chatting on the phone with my mother while you are waiting for me.

As a parent there are things you can do to get your questions and needs addressed while still helping me to stay on track. There are times in the day when I am less likely to be behind in my schedule. And if, to you, the above scenarios seem easy to solve—then wait for my next blog and I’ll explain why they might be more complicated than they appear at first glance.

Friday, May 20, 2011

Has your child outgrown her booster seat?

New recommendations about booster seats for children state your child should remain in the back seat, in a five-point-harness car seat until the height and weight limits are out-grown. Then, your child should definitely be in the back seat, in a booster seat until age eight. In general, once your child is eight years old he should be 4 feet 9 inches tall before coming out of the booster seat. This will likely be until age 10 to 12! The front seat is for children who are ages 13 and up.

However, after age eight and before 4’9” tall there may be some car seat belts (in the back seat) that will properly fit your child without a booster seat. There are five steps to determine if the seat belt fits well without a booster:

1. Does the child sit all the way back against the seat of the car (their back and their bottom is up against the back of the seat)?
2. While they are sitting all the way back in the seat do the child’s knees bend comfortably at the edge of the car’s seat?
3. Does the shoulder belt come across the collarbone, between the neck and the arm?
4. Is the lap belt low in the lap, touching the thighs?
5. Is this a comfortable position that can last for the whole car ride?

This information originates from the American Academy of Pediatrics, and was printed in the spring 2011 newsletter (Volume XVI, No 1) of the Michigan Chapter of the AAP. Online sources of information can be found at ,, and

Wednesday, May 18, 2011

HPV Vaccination: Prevent Cancer!

Yes, it’s time to talk about another vaccine. I guess I really love this topic, or perhaps it’s just that I think it’s really important. The one I’m referring to this time is the Human Papilloma Virus (HPV) Vaccine. The purpose of this vaccine is to prevent genital (including cervical) and anal cancers, and genital warts. I recommend this vaccine for all middle school students. My oldest child started the series at age 12 and was fully vaccinated at 13.

One commonly recognized brand of this vaccine is Gardisil, which prevents four types of HPV: HPV 6 and 11, which cause genital warts, and HPV 16 and 18, which cause anal and genital cancer and precancer. A more newly released vaccine is Cervarix. It covers HPV 16 and 18. Neither vaccine covers all forms of cancer-causing HPV, but HPV 16 and 18 cause approximately 2/3 of cervical cancers.

Have you heard of Human Papilloma Virus? Did you know that the lifetime risk of becoming infected with this virus is 80%? Are you aware that approximately 20 million people in the USA are infected with the virus? And 18% of 14 to 19 year-old girls are infected? Did you know the virus causes cervical cancer, anorectal cancer, and genital warts? Yuck, right? It’s a sexually transmitted disease (STD) that causes cancer and is PREVENTABLE.

The vaccine was introduced to the general public in 2006. By 2009 44.3% of adolescent girls in the United States had received at least one dose of HPV vaccine, and 26.7% had received all three recommended doses. In Australia, during the first year of a national HPV vaccination program, 75 to 80% of targeted girls had received all three doses! The vaccine is now recommended for girls AND boys, ages 9 to 26.

The vaccine has a good track record when it comes to side effects. Adverse effects shown to be caused by the vaccine are headaches, low-grade fevers, and a sore arm. Adolescents have been known to faint after receiving the vaccine. This reaction can be seen after any vaccine given to an adolescent, and is not limited to the HPV vaccine. Claims of more serious adverse effects have not been substantiated or shown scientifically to be more common in vaccine recipients than in the general public. You can find complaints about the vaccine on the internet, of course, but much of this is hearsay or linked to attempts at legal action.

Why is the vaccination rate so low? The vaccine prevents CANCER! What I hear from my patients’ parents are comments such as these: “We’re not going to give THAT vaccine.” “It’s too new.” “My daughter doesn’t need it because she isn’t going to have sex before marriage.” “If we give the vaccine then my child will think it’s ok to have sex.” “It hasn’t been around long enough for me to feel comfortable.” “I don’t know how long the immunity will last, so I want to wait until my child is older.”

I would like to respond to these comments.

1. First of all, scientific studies have shown that a fairly high percentage of kids ages 14 to 19 are already infected with the HPV virus (18% of girls in one study), so it is quite possible your child could be exposed to the virus during his or her teen years. Waiting until they are older could mean they become infected with the virus before they receive the vaccine. And you don’t have to have sexual intercourse to become infected. HPV can be transmitted via oral sex (among other ways) too! Also, there is evidence that there is more long-lasting immunity when the vaccine is given at a younger age.

2. Studies that have examined the rate of sexual activity among teenagers have shown that providing information about STD and pregnancy prevention, and even handing out condoms, has not led to an increased number of teenagers having sex. To me, therefore, it seems unlikely that giving the HPV vaccine will cause teenagers to become promiscuous.

3. Millions of doses of HPV vaccine have been administered to date, with proven safety. The vaccine is not new; it has been given to the general public since 2006.

4. Perhaps your child will wait to become sexually active until they are married. After all, you waited, right? But you don’t get to control the sexual activity of your child’s potential spouse. HPV infection (except in the case of genital warts) is not visible to the naked eye, and there is no test that can tell you if someone is infected with it.

5. I don’t want to offend anyone, here. But you should know that it is fairly common for me to see teenagers in my office who are having sex, and I don’t think most of their parents know they are sexually active. Don’t be naive. A 2002 study showed that by ages 15, 16, and 17 30-50% of teenagers were already having sexual intercourse! Talk about relationships, values and expectations with your child. But protect their health. I, too, don’t want my daughters (and I would say sons, if I had a son!) to become sexually active at such a tender age—but I will take a practical approach when it comes to preventing such a serious disease as cancer.

Sunday, March 27, 2011

Starting Solid Foods

Every day in my office I can see and hear tension in the faces and voices of parents as we discuss the introduction of solids into their baby's diet. Mothers take notes as I give advice on adding cereal and other baby foods. I receive requests for exact amounts a baby should be eating, as well as how to time breastfeeding or bottles with meals of solid food. Sometimes I sense that my answers and general guidance in this area are not specific enough to satisfy parents. An entire well visit for a four or six month old can be taken hostage by this topic, leaving little to no time to talk about anything else!

I can find myself baffled by this outcome. After all, feeding is only one of many topics I would like to discuss at a well visit. What about sleep issues, stooling patterns, infant development, behavior, illnesses, vitamins, safety, and immunizations? I have spent quite a bit of time thinking about this and discussing it with the other pediatricians in my practice. I think I understand why feeding solid foods can be such a source of confusion for parents, AND I want to help make it easier!

To first-time parents starting solid foods can be a complete mystery. Guidelines are vague and often seem to conflict. Lots of advice is given by friends and family members. Parenting magazines offer new suggestions in every edition. There are lots of feeding "myths" out there. Research on the dietary needs of infants is ongoing, which leads to changes in recommendations on when and what to feed. Some recommendations seem to be based on well-researched scientific evidence, while others are based on convention, custom, and experience. Parents often feel weighed down by the responsibility to provide good nutrition for their child. The baby food aisle at the grocery store is vast and overwhelming.

And then there are decisions to be made on whether to make or purchase your own baby food, in what order food should be introduced, and what foods to avoid until a certain age. If we top that off with the fear that one's baby will choke on thicker, textured, or chunky food, parents can be left completely paralyzed by the thought of introducing solid foods.

To first reassure you, I would like help you understand my overriding view on introducing solid foods. The following statements may help:

1. It's really hard to do it wrong!

2. There are many correct ways to introduce solid foods.

3. Even if you do something that you read, or hear is "wrong" it probably isn't really that bad. You can always stop what you are doing if you find out it really isn't advisable.

4. You can't "break" a baby by giving them solid foods in the wrong order.

5. Babies all over the world have been successfully introduced to solid foods since before the time of recorded history. This has been done in all different ways, with many different kinds of foods. Practically everyone was weaned from the bottle or breast and was eventually able to chew and eat chunks of food.

6. The mouths, tongues, throats, stomachs, digestive tracts, and fine motor ability of infants will naturally direct and allow them to consume solid foods.

7. Feeding solid foods isn't a competition between parents or babies. So what if your own mother had you eating steak by the time you were 3 months old? Or cereal, or squash, or prunes... Who cares if your sister's baby has tried all the vegetables and yours has only had green beans? This all will fade away in time, and you will move on to new arenas of competition: potty training success, behavior, reading ability, and athletic skills. But, I digress...

8. It's very difficult to really mess up on feeding solid foods. Try to relax.

9. I actually think feeding solid foods can be fun!

Now, on to specifics. In guiding you on how to introduce solid foods I have tried to take into consideration the available research on dietary concerns for infants. These include vitamin D supplementation, adequate iron intake, obesity, recommendations on exclusive breastfeeding, issues surrounding food allergies, asthma, and eczema, and more. After reviewing the research, policy statements, updates, and revisions on infant nutrition and feeding practices I, too, feel a bit overwhelmed! I have to let it all wash over me to condense it into some practical advice.

For a full-term healthy infant, introduction of solid foods should most likely take place somewhere between the ages of four to six months. Introducing solid food before four months is not recommended as it has been linked with a higher risk of obesity and may not supply a nutritionally complete diet. Formula or breast milk are the only nutrition a baby needs before he reaches four months of age. Contrary to popular belief, feeding solid foods such as infant cereal will not help your baby sleep through the night! Helping your baby sleep is an altogether different topic, and it does not involve solid foods.

As a general rule, to obtain maximum benefits from breast milk, exclusive breastfeeding (without adding solids) is encouraged until six months. Infants who are exclusively breast fed should receive 400 IU of vitamin D as a supplement starting in the first few days of life. In my experience, some individual infants are ready to eat solids before they reach six months of age. Infants who are ready to eat are able to sit (with a little support), hold their head steadily upright, reach for things, and grasp objects. They may show interest in what you are eating. When you put food in your mouth you may see them open their own mouths, or try to grab your spoon or fork. They may like to sit with you at the table, and seem to enjoy being present at a family meal. Even if your baby shows all these signs, if she is happy and content with nursing alone you can wait until six months to start solid foods. Or, if it would be enjoyable for both of you, you could start before six months in a relaxed, low-key way. Once again, how well your baby is sleeping at night should really not factor into your decision on when to feed solid food.

As you can see, except for encouraging you to wait until at least four months before introducing solids, I really encourage flexibility in determining when is best for your baby and your family.

Infants born at 36 to 37 weeks gestation will probably fit into these guidelines, as well. An infant born at less than 36 weeks gestation might need to be a little older, or an adjusted age could be used. Specifics for infants born early or with complex medical illnesses could be discussed with your own personal pediatrician, and are beyond the scope of this blog. Premature infants may need supplemental iron in addition to the recommended vitamin D supplements for breast fed babies.

My usual advice is to start with infant rice cereal. This comes in a dry, almost powdered form, that can be mixed with formula, breast milk, or water. You can find it in the baby food aisle at your grocery store. The rice cereal recommendation is traditional. I think it was originally made because hardly anyone is allergic to rice. Now we know a lot more about food allergies, and far fewer restrictions are in place for infants than in the past. However, traditionally the first food is still infant rice cereal. Probably infant oatmeal or barley cereal would be ok, too. Infant cereal is a good staple, and a good source of iron. Some extra iron is needed at around six months of age.

The nice thing about starting with cereal is that you can mix it to your desired consistency! There is no recipe here--just put a tablespoon of dry cereal into a bowl (not a bottle) and drizzle in some formula or breast milk (water is ok, but won't taste as familiar to your baby). Stir while dripping in the liquid and make the first little bowl of cereal kind of a thick cream soup consistency. Put your baby in a high chair and feed it to her with a little spoon. I generally discourage putting cereal in a bottle. That isn't the same as feeding solid foods, and it doesn't move a baby forward in her development.

This is the fun part! Get out your camera or video recorder. Watch the funny faces, and see the tongue push most of it out at first. Your baby has to learn how to handle the new texture, how to manipulate it with her tongue, and how to swallow it.

After feeding creamy soup consistency cereal to your baby once a day for a few days, if he is taking and swallowing it well, you can thicken the cereal to an applesauce or baby food consistency and continue to give it daily. After a minimum of three days you could think about introducing a new food, while continuing to give the cereal every day. Cereal usually stays in a baby's diet for months, generally twice a day. But there are lots of other foods to try, so after a while you will reduce its frequency.

One or two meals of solid foods per day is probably enough for the first month of feeding. The second month of feeding you could then go to two to three meals per day. By the third month three meals a day seems reasonable. However, there are no well-established rules, nor research-based evidence to direct you on how many meals a day to give your baby by a certain age. My guidelines here are general. Think about what fits into your schedule, how to work around naps, who will be providing the meals, etc.

Most babies seem to be eating three meals a day by nine months of age. By age one they are usually eating three meals a day, plus a few little nutritious snacks. Nursing or bottles just fit in around the meals. In the beginning just keep nursing and/or giving bottles as you have in the past. At first your baby won't eat enough food to fill himself up and he will still need the same amount of milk. Once solids are well-established and your baby is eating more of them (which might take a few months) you may naturally move to a different routine around nursing or bottles. Try not to feel stressed about this. Remember that, as you are introducing food, your baby's primary source of nutrition is still breast milk or formula.

After cereal has been started, and is being taken well, you can give other foods. These will include strained or pureed vegetables, fruits, and meats. Start only one new food at a time, and give that food to your baby each day for three days in a row. If your baby tolerates it without showing signs of an allergic reaction (hives, which look like welts, repeated vomiting, or wheezing and difficulty breathing), then you can add that food to your baby's list of safe foods and move on to another one. Your infant can have one of the safe foods at any time.

Just move through the single ingredient fruits, vegetables, and meats that are available as "First Foods" in your grocery store. I usually suggest alternating them. But there are no hard and fast rules here. Try a yellow vegetable, then a fruit, then a green vegetable, then a meat. Babies have taste buds that taste sweet things best, so you may find they especially like some of the fruits at first. To develop your infant's palate you should offer the full variety of foods, even the ones you find he doesn't like. Research shows that sometimes it takes 8 to 15 tries to get a baby to be willing to eat a food! Trying a variety also gives you some foods you can use if your baby's stools get too hard or soft. Bananas and rice cereal can sometimes be constipating, while prunes and pears can soften the stool. Oatmeal and barley cereals tend to be less constipating than rice cereal.

If you move through the foods (single ingredient cereal, fruits, vegetables, and meats) at a new food approximately every three days, then in about six weeks you will have tried all of the "First Foods." You can take it slower than this, especially if you start solids before six months of age. A typical meal plan after introducing all the "First Foods" would be cereal (mixed with formula or breast milk) plus a fruit, or vegetable, or meat for two meals in the day. An approximate serving size to work toward is one-half to one of the small baby food containers (2.5 oz.), plus an equal volume of cereal at a meal. I am trying to be quite general here. Your baby may advance more quickly or more slowly than this, and I am sure it will all work out just fine.

If you are making your own baby food (and please, no guilt here if you are buying food, I never made a drop of baby food for my children and I think they all turned out quite nutritionally replete!) then you might consider avoiding making a few foods that could be high in nitrates (spinach, beets, green beans, squash, and carrots) and simply buy these instead. Apparently baby food manufacturers use vegetables that are especially grown to be low in nitrates. According to the research the higher nitrate issue is more important for infants under three months of age, who won't be eating solid foods anyway. A more worrisome source of nitrates is contamination of wells, which makes it important to have your well water tested...another topic beyond the scope of this blog.

Juice can be useful if your baby becomes constipated. A few ounces of pear, apple, or prune juice is quite helpful to loosen hard stools. In that case juice should be given from a cup or sippy cup, not a bottle. Maximum juice intake per day should be 4 to 6 ounces. Other than for constipation, I don't recommend juice. Infants learn to love it, and end up preferring it to milk. There is not much nutrition in juice. It is actually mostly sugar, and even though it is "natural" sugar, the child's body doesn't know any difference. Many toddlers end up preferring it to milk, and their nutrition suffers from lack of calcium and vitamin D. It can cause tooth decay because children like to sip on it all day long. And it can lead to excessive calorie intake, or poor food intake because the child is all filled up on juice. Excessive juice can even cause chronic diarrhea!

Babies get lots of rashes, so how do you know if one is a food allergy? For the three day food trial I have described above you are simply looking for hives. Hives look kind of like insect bites. They are raised welts of various sizes that are lighter in the middle raised part, and red on the flat skin around the welt. They change locations and can be here one minute and gone the next. They can be itchy.

A little red rash around the mouth is a common result of the messy eating process, and is almost always more of an irritation from acidic foods than an allergic reaction. Tiny red dots on the upper chest and back are probably more likely to be heat rash. And a diaper rash by itself is hardly ever an indication of a food allergy. However, lots of fruit or other more acidic foods and drinks can cause stool or urine to irritate the skin in the diaper area. This is an irritation, not an allergy. Eczema can be due to a food allergy, but it most likely won't develop in the three day trial I am suggesting. If your baby has eczema you could talk to his doctor about any possible relationship to food he is eating.

Don't panic if she gags. Gagging is not choking. Gagging is the retching sound humans make when something unexpected hits the back of the mouth or throat. It is protective, and helps keep objects, food, and fluids from "going down the wrong pipe." A baby might turn red, make gagging noises, and have watery eyes or even vomit after gagging--but the presence of the noises and the pink or red color are signs that air is still moving and your baby is not actually choking. It is very unlikely that a healthy infant will actually choke (have airway obstruction) while eating infant cereal or other strained, pureed, or mashed baby foods.

If you are really worried about the possibility of choking then you should consider reviewing techniques to clear the airway of an infant, or take an infant CPR course.

If your baby repeatedly gags on food and doesn't seem to be making progress day-to-day in tolerating solid food then you should talk to his doctor. You may need to just back off for a week or two and then try again, but persistent difficulties should be discussed with your personal pediatrician.

I'm exhausted after covering this topic, so I will have to save the next step for another blog. I hope this information is helpful and takes some of the mystery out of starting solid foods. What I really want is for you to enjoy this next stage of your baby's life, to take lots of pictures, and create wonderful memories of your incredible little person starting to grow up! Have fun!

Thursday, March 24, 2011

Vitamin K at Birth

I'm here to talk about vitamin K deficiency bleeding in the newborn and its prevention. Is this a topic of general interest? Does it even concern you as a parent? Perhaps not, if your child is already two months of age or older. However, if you are expecting a baby, or have a newborn, this is something you should know about.

After birth an injection of vitamin K will be given to your baby. This routine, injected supplementation of vitamin K into the thigh muscle of a healthy newborn is extremely effective in preventing vitamin K deficiency bleeding and its resulting catastrophic effects. This practice is based upon reliable, scientific evidence that has been tested and retested over many years. I fully endorse, recommend, and request that all my patients accept the practice of providing an injection of vitamin K to newborns shortly after birth. My own children received their injection of vitamin K after birth with my full knowledge and consent. I rested easier knowing I had greatly reduced their risk of unpredictable severe hemorrhage or death due to vitamin K deficiency. I still am in awe, and filled with the wonder of a simple vitamin injection's ability to prevent such a terrible outcome.

Vitamin K deficiency bleeding in the newborn was formerly known as hemorrhagic disease of the newborn. There are several forms, which are usually described as "early" (or classic), and "late." Vitamin K deficiency can cause serious, life-threatening bleeding because vitamin K is an essential part of the blood's ability to form clots. Without vitamin K the blood will not clot properly, and the affected person will bleed excessively. Vitamin K deficiency bleeding is usually discovered when something catastrophic happens to the infant, such as bleeding into the brain (central nervous system hemorrhage).

Vitamin K deficiency bleeding has been recognized in infants for decades. In briefly reviewing the medical literature on this topic I found published articles dating as far back as the 1960s (I may have even seen the 1940's!) which deal with this topic.

The incidence (rate of occurrence) of unexpected bleeding due to vitamin K deficiency in apparently healthy neonates during the first week of life ("early") is 0.25% to 1.7% (ranging from 1 in 400 to 1 in 50 to 100 newborns). Late vitamin K deficiency bleeding (ages 2 to 12 weeks) rates have been reported from 4.4 to 7.2 per 100,000 births.

For some reason (and fairly often), there are newborns who are born deficient in vitamin K. This is discovered when they have a severe bleeding episode. These are major episodes of bleeding, such as bleeding into the brain. Although attempts have been made to correct this by giving supplements prenatally to the mother, this has not been consistently effective. Vitamin K does not cross the placenta well enough to ensure adequate vitamin K in the baby. In addition, breast milk does not reliably contain enough vitamin K to prevent vitamin K deficiency bleeding. Supplementing vitamin K to a breastfeeding mother will not consistently give enough vitamin K to prevent vitamin K deficiency bleeding. There is no readily available test that can be done on a newborn to tell if the infant is at risk for vitamin K deficiency bleeding. Obtaining a family history does not help determine if an infant is at higher risk for this condition.

The only way to be sure to reduce the risk of vitamin K deficiency bleeding in a newborn is to supplement with vitamin K. The most reliable and effective way to do this is a single injection of vitamin K shortly after birth. Oral supplementation has been presented as another option. However, the evidence shows that it is either less effective than injected vitamin K, or there is not enough evidence to be sure it is effective. Weighing the possible severe damage that can occur from vitamin K deficiency bleeding against unreliable evidence about how effective oral vitamin K will be in preventing it, it is clear that the best way to protect a newborn from early or late vitamin K deficiency bleeding is injected vitamin K.

For a while there was a flurry of concern about a possible link between injected vitamin K and childhood cancer. This evidence has been reexamined, and other studies have been done which show no association between the two. This concern has been put to rest by strong scientific evidence and should not factor into decisions regarding injections of vitamin K.

This is how I see it: A simple, small, one-time injection of a vitamin (vitamin K) into the thigh muscle of a newborn will drastically reduce the real risk of catastrophic, life-threatening, brain-damaging bleeding that can occur due to the fairly common state of vitamin K deficiency that occurs in newborns. Other methods of supplementing vitamin K have little evidence to recommend them, or have been found to be much less effective than injected vitamin K. How can we deny this simple, effective, preventative treatment to the most vulnerable and precious beings on earth, our newborns?

I have included some links which will give you a window into the world of scientific evidence on this topic.

Tuesday, March 22, 2011

New Car Seat Recommendations

Wow! Nine years after the last policy guidelines were released the American Academy of Pediatrics has issued new guidelines for children and car seats: The big changes are to keep your child rear facing until possibly two years old, unless they outgrow the limits of the seat earlier, and to use a belt-positioning booster seat (not a bench style booster) until reaching 4 foot 9 inches tall (between ages 8-12). Here is the link. I'll add more to my blog later--this information just came out and I need some time to review it, as well.

Now back to my post. After reviewing the AAP guidelines (which you can see for yourself using the above links), as well as a helpful algorithm that accompanies the guidelines, I believe I can summarize them more effectively for you. The recommendations are evidence-based, meaning they have been shown in scientific studies to prevent injury and fatalities among children in motor vehicle accidents. The big changes are to stay rear-facing as long as the car seat accommodates until age two, to use a car seat with a built-in harness for as long as possible, and when that seat is outgrown to stay in a booster seat until 4'9" tall! This is a lot to absorb, and many older children will be quite vocal about their opinions of booster seats. However, their safety is at stake here so it is time for parents to take a stand.

Infants under the age of two have relatively larger heads and weaker necks than older children and adults. In a crash this puts them at high risk for a head or spine injury. For this reason they should stay rear-facing in a car as long as possible up to the age of two years.

Many infants under the age of twelve months are in an infant-only rear-facing seat that can be attached or removed from a base that is left in the vehicle, and then carried by the attached handle. A convertible car safety seat is another option. It is a non-removable seat designed for infants that can be used both rear-facing and forward-facing. When an infant outgrows the infant-only seat they are best supported in a rear-facing child safety seat until they outgrow the rear-facing height or weight limits of a convertible car seat. Currently, most convertible car seats have a rear-facing limit of 35 pounds.

A forward-facing car seat with built in harness should be used for children ages two and older, or children younger than two who have outgrown their rear-facing convertible seat. The built-in harness should be used as long as possible, until the child has exceeded the weight and height limits of the car seat. Different brands of car seats allow for different maximum weights, ranging from 40lbs. to 80lbs.

Children who have outgrown the limits of their forward-facing, built-in harness car seat should use a belt positioning booster seat until they are 4 foot 9 inches tall (which is the average, or 50th percentile height for an eleven-year-old girl and boy), and at least eight years old, OR they can safely use their own vehicle's lap and shoulder restraint system. Most children in most cars will need to be 4'9" tall to safely fit into a vehicle's built-in seat belt without using a belt-positioning booster seat.

A properly fitting seat belt will look like this: First the child should be sitting up nice and tall in the seat with their lower back against the back of the seat. While in this position the lap part of the belt will fit low across the hips and pelvis (across the upper thighs is the goal, not on the tummy), the child's knees will bend at the edge of the seat (not stick straight out), and the shoulder portion of the belt will cross the middle of the chest and shoulder (not coming across the neck or face).

Children under the age of thirteen should ride in the back seat.

Saturday, March 12, 2011

Flu and Flu Symptoms

High fever? Chills? Cough? Body aches? Glassy, filmy, reddish eyes? Sore throat? Runny nose? If you have all or quite a few of these symptoms you might have "the flu." Flu, or "influenza" is a respiratory illness that makes people feel really sick. It is not to be confused with gastroenteritis (what many people call "stomach flu"), a completely different kind of infection. Flu shots help protect against influenza, but not against gastroenteritis.

Influenza is "going around" right now. We have seen quite a few cases in our office in the last two weeks. Children look miserable, listless, flushed, and weak. They cough, have high fevers, and complain of sore throats, body aches, and chills. The infection comes on pretty suddenly and hits hard. Most of the cases we have seen in the office have been in children who did not receive a flu vaccine. However, this week I have had two patients with confirmed influenza A who were vaccinated last fall. While this does not seem fair, it does happen sometimes.

The treatment for flu is almost always supportive care, which means making your child as comfortable as possible by controlling the fever and ensuring adequate fluid intake. In addition, monitoring for signs of bacterial complications of flu (such as an ear infection or pneumonia) is important. A high fever can persist for 5 to 7 days. Sometimes there is nausea and vomiting, although these are not the main symptoms of influenza.

Clear liquids, especially Pedialyte given 1 tsp at a time every ten minutes, are the best home treatment to prevent dehydration when a child is vomiting. Acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) will help keep a fever more manageable and a feverish child more comfortable. In my experience these medications often do not bring a high fever down to normal. Remember that the fever is not harmful to your child and is actually helping her body fight the infection. However, it makes the sick person feel awful and look terrible, so it is usually worth the effort to treat a fever.

In general it is safest to use one medication to control a fever--either acetaminophen OR ibuprofen. For a limited period of time (less than 24 hours) and a very high fever (over 103) I sometimes recommend alternating these two medications. However, too much medicine on an empty stomach CAN make things worse (nausea and vomiting, for example).

Cough and cold medications (especially decongestants such as pseudoephedrine or phenylephrine, as well as cough suppressants such as dextromethorphan) are NOT recommended for children under age six because research shows they do not work any better than placebo (fake medication), and because there have been a number of overdose cases due to the use of combination products (medicines with acetaminophen plus cough and cold products) in young children.

I sometimes recommend the night time use of the antihistamine diphenhydramine (Benadryl) alone for a smaller child with a bad runny nose and cough. Even this can cause problems such as irritability and wakefulness. At my own home I am likely to use home "remedies" to clear a congested nose and make sleep easier. These would include a steamy shower, saline nose drops, elevating the head of the bed a bit, and clear liquids to drink.

If your child looks really ill, and ibuprofen or acetaminophen do not "perk him up", then we should evaluate him in the office. Similarly if he is appearing dehydrated, (with a dry mouth, lack of tears, sunken eyes, absent or severely decreased urine output, cold hands and feet) then we should also evaluate in the office. If the high fever persists beyond 7 days, we need to see your child. And if you are very worried about your child, or there are concerning symptoms other than those I have described then you should call or bring your child in to be checked. Please remember that my blog is intended to be informational, and cannot take into account every individual situation, or replace the personal attention of your own doctor.

There are medications to treat influenza (not stomach "flu", remember?). In reality we use these only sometimes, as they carry their own risks of side effects, are not palatable (Tamiflu liquid tastes terrible), must be started very early in the illness, and are not extremely effective. Primarily we use medications like Tamiflu for children with underlying medical conditions (at risk for severe complications of flu) to either treat flu in the early stages or prevent flu in cases of household exposure. Hopefully all of these children with severe underlying illness have already been vaccinated for flu!

How do you distinguish influenza from strep throat? Strep is the other illness that is "going around" right now. The classic symptoms of strep throat are sudden onset of fever, sore throat, headache, and stomachache, usually in the absence of cold symptoms such as cough or runny nose.

I have previously written blogs about both strep throat and flu, so you could check those out for more information. And remember, you are the expert when it comes to your child. This blog is here to be helpful in providing general information to you, it is not designed or intended to diagnose or make treatment recommendations for specific children, illnesses, or situations. That kind of individual attention can only come from your own personal pediatrician!

Thursday, January 13, 2011

Strep throat?

How can you tell if your child has "strep throat?" I'll give you some things to look for, and some information for you to think about in determining when your child should be evaluated by a doctor.

As always, please keep in mind that I intend my blog, and this information, for general and informational use. It cannot, and is not intended to replace the attention of your own personal pediatrician. You should not try to diagnose your child or expect treatment based upon what I am writing in my blog! If your child is ill and you need more information or evaluation then you should contact your child's doctor.

Strep throat is a bacterial infection caused by a bacteria called Streptococcus pyogenes. It is contagious through respiratory secretions or saliva, has an incubation period of three to six days (that's how long it takes to get sick after being exposed to the germ), and is treated with antibiotics. After a person has taken antibiotics for 24 hours they are no longer consider contagious to others. A quick test can be done in a doctor's office to detect strep, or a culture can be done over several days in a laboratory.

The classic symptoms of strep throat are the sudden onset of a sore throat, headache, stomachache, and fever, without any symptoms of a cold such as a runny nose or cough. Sometimes there is a stuffy nose, but it is not usually runny. Some people do not have a fever with strep throat. The location of the throat pain tends to be more in the back of the mouth, not as much in the front of the neck. It hurts to swallow. Sometimes the voice sounds as if there is some swelling in the back of the throat--not like you are losing your voice or have laryngitis, but more of a sound of fullness there.

In strep throat the throat is often very red, with swollen tonsils. Sometimes there are red dots on the back of the palate, near the uvula. Sometimes there are whitish spots on the tonsils. "Glands" (actually lymph nodes) in the neck can be swollen and hurt to touch. If you are checking your child's throat and neck at home it is good to have some experience looking at your child when she is not ill. Healthy children have throats that are normally somewhat red, and many children who are not ill have tonsils that can look big, or lymph nodes that can be felt during an exam.

A sore throat that is pretty significantly associated with cold symptoms such as a runny nose or cough is less likely to be caused by strep. This kind of non-strep sore throat is often located in the front of the neck, lower in the neck, worse in the morning, and is improved after drinking fluids or being out of bed for a while. Coughing can make this kind of sore throat worse.

Infants and toddlers can get strep throat, and may not have classic symptoms. In younger children like these there can be prominent cold symptoms along with the fever. There is often a history of exposure to strep throat from an older sibling or in daycare.

In general I tell my patients' families they should have their child checked at the doctor's office during regular office hours if they think she has strep throat. Antibiotics for strep throat will help your child recover more quickly, and reduce how contagious your child will be to others. Rarely, an untreated strep infection can affect the heart or the kidneys. Antibiotics can help prevent these complications.

Strep throat is not usually an emergency. Treating the infection within seven days of the start of the symptoms is the goal in order to help prevent complications from strep. Confirming the diagnosis with a strep test before treating with antibiotics is best for your child. An evaluation in the doctor's office is the best way to ensure your child is treated properly, that he does not receive unnecessary antibiotics and risk the development of bacterial resistance to antibiotics, that the correct antibiotic at the right dose is chosen for your child, and that there is no other explanation for your child's symptoms that could be better treated in a different way.

Making an appointment for your child to be evaluated for strep throat within a day or two of the onset of symptoms usually "catches" the infection early enough to keep your child comfortable. If your child is very ill (repeated vomiting, appears very ill, is dehydrated, has a "stiff" neck, seems delirious, or has other symptoms that really worry you) then you should not wait to contact the office. It would be unlikely that an antibiotic would simply be "called in" for your child, more likely an evaluation in some type of health care setting will be recommended.

Another interesting tidbit about strep throat is that, even though it is a contagious illness, at least 75% of family members will not become ill from strep throat when someone at home has the condition. For that reason we do not automatically treat exposed family members with antibiotics.

Even if someone has all the symptoms sometimes they do not have strep throat. There is a virus called Adenovirus that can appear very much like strep throat. "Mono" (more correctly termed infectious mononucleosis) can look a lot like strep throat, too. "Mono" is caused by the Epstein Barr virus. You may remember that viruses like these cannot be cured with antibiotics. Instead your child's own immune system will fight off the germ and treatment will involve rest, fluids, and symptom relief--but not an antibiotic.

What does it mean to be a member of your family?

As we counted down to midnight on December 31st my girls got excited talking about New Year's resolutions. Remember those? Usually they are things like exercise, spending less money, going on a diet, saving, or not eating out as much. As the ball dropped on Times Square in New York I still couldn't think of a resolution that seemed very important to me. The result was that I have been thinking about it for the last two weeks.

I want to talk about family values, and I don't want it to be a cliche. I want to reflect on what helps our children figure out what is important, and what it means to be a member of their family. What can they fall back on when times are tough? What thought makes them stand up a little straighter as they walk through the halls at school? What is something they know is true, that can give them more insight into themselves and others?

What I mean when I say family values is probably a little different that the phrase used in the media. I am asking you to think about the principles by which you are raising your children. I want you to consider what kind of person you hope they will be as adults. What would you, or they, say if asked what it means to be a Smith, a Jones, a Roberts?

I really started thinking about this when talking to a friend who had to advocate for his daughter about a school/peer-related problem. When I asked him why he intervened, knowing that there was potential for things to backfire, his answer to me (probably paraphrased) was "What I want my daughter to know is that it means something to be a _________. We stick up for ourselves. We don't take things lying down."

That conversation has stayed with me. It made me think about what it means to be a member of my own family. What kinds of things do I say to my daughters when we are reflecting on the day, or looking forward to a new school year? What will be foremost in their minds when they are in a tricky situation, trying to make friends, watching how others interact with each other, taking a test, behaving in a classroom? If it was at all possible, what influence would I want my daughters to have on others?

One guiding principle that is important to me is that my daughters try to treat other people as they would like to be treated. Without getting all religious on you, I have to tell you that this is definitely based on the "extra" commandment given to us by Christ (Do to others as you would have them do to you, Luke 6:31, NIV) that is also known as the golden rule. My husband tries to help our girls respond to others (and each other) "in a loving way." None of us are perfect at this, but I know we all think about it and talk about it.

Instilling the sense of what it means to be a member of your family also includes the way you live your life each day. What fills your time? What takes priority? How do you spend money? Your children are living it, too. The way they grow up will become their "comfort zone."

I need to think about this part more for my own family. Are we (and I am speaking personally, of my own family, here) living daily (or at least weekly, monthly?) in a thoughtful way that is caring, will foster a healthy mind, body, and spirit, and will help our daughters become responsible, independent adults? I think I might have trouble sleeping now that I have put into words what a huge responsibility this is!

My resolution for 2011 is to think more carefully about what it means to be a member of my family. I want to better define what we stand for, what gives us reason to get up each day, and what will get us through when things don't happen as expected. I want to make sure that my daily life reflects these values, and make adjustments when I find discrepancies. I only have one chance to parent my children, and to live the way I want to be. I want to think about this.

And just to make you smile as you consider these thoughts: