Shopping Carts Are For Groceries

Don't let your child's head be the watermelon!

My on call weekend is over, and I am enjoying an evening at home when I can just worry about my own kids for a while. Not that I mind doing my job, it's just refreshing to be free of the on-call phone for an evening.

It was interesting this weekend that I was grocery shopping with my 9-year-old daughter while I answered a call about a child who fell out of a shopping cart. My daughter was having a lovely time pushing our grocery cart, standing on the sides or front while I pushed, and at times coasting along for a ride while the cart rolled down the aisle. She was a big help to me, "guarding" our cart while I ran back to get the Italian bread crumbs that were strangely located in the cheese and yogurt aisle.

The child who had fallen out of the cart was in the cart basket jumping up and down while her parents unloaded the cart into their car. Luckily, she was fine except for a bump on her head. 

I have had so many "fall out of the cart" calls over the years that it seemed like a good topic for a blog post. And I learned some interesting information when I did a bit of research:

1. Most shopping cart injuries occur in children under five years of age.
2. Common types of shopping cart fall injuries are fractures and head injuries.
3. Most falls from shopping carts involve children riding in, climbing into, or climbing out of the shopping cart basket.
4. Another important cause of shopping cart injuries are "tip-overs." 
5. Older siblings are often involved in "tip-overs" when they lean or ride on the cart, throwing it off-balance.
6. Parents are near the cart when most of the injuries happen, but most parents step away from the cart several times during a shopping trip.

I am sure the parents of the child who fell out of the cart basket now realize it's not a safe place for a child to ride. However, after reviewing all of this research I had to reflect on what I personally could do to make grocery shopping with my 9-year-old safer. For example, I shouldn't allow her to ride on the sides of the cart OR leave her alone!

What advice can I give you? Don't take your child grocery shopping?

At least don't let them ride in the basket or sides of the cart. Make short, quick shopping trips so your child doesn't get too bored. Keep one hand on your young child at all times. Have an organized list that allows you to get in and out of the store efficiently. Shop when it isn't crowded so it's easier to focus on your child.  And don't let them ride in the basket.

Babies Coughing and Wheezing: Does Your Baby Have RSV?

It's late.  Your baby is coughing and wheezing.  Everything seems worse in the middle of the night.  What kind of cough is it?  What is going around this time of year?  What should you do?

A common virus has really taken off in the last month or two.  You have probably heard of it:  RSV.
RSV stands for Respiratory Syncytial Virus.  For older kids and adults it usually just causes a bad cold.  However, infants and toddlers can be hit hard by this virus.  RSV causes a lot of mucous drainage.  This is hard for babies because they greatly prefer to breathe out of their noses.  The infection causes wheezing and congestion in the lungs of small children.  RSV can cause a fever and may lead to ear infections and prolonged cough.

Sometimes I have called this "baby bronchitis."  Although that comparison helps people understand the condition a little better, bronchiolitis is not actually the same thing as bronchitis.  Bronchitis affects the larger airways in the lungs (the "bronchi") and leads to a significant productive cough.  Bronchiolitis affects the smaller airways, deeper in the lungs.  These flexible, narrow airways are called bronchioles.  They collect mucous and then tend to tighten up with each breath.  This leads to wheezing and a painful sounding, tight cough.

Here are some examples of the symptoms of bronchiolitis.  You will hear wheezing (both with inhale and exhale) and see retractions.  When the skin sucks in above the sternum (breastbone) or between the ribs with each breath, these are retractions. 

This video shows a baby with bronchiolitis who has retractions in her neck (called suprasternal retractions), wheezing with inhaling and exhaling, nostrils flaring with each breath, and a tight little cough (at the end of the video).  Although the dad mentions during the video that she has croup, actually this is a better video of bronchiolitis.




The next video shows a baby with head bobbing.  It is a sign of difficulty breathing in young infants.  Because he is using his neck muscles to help him breathe it pulls his head forward with each breath.




Here is a pretty good example of a bronchiolitis cough.  It starts about 20 seconds into the video.  You might also notice that the baby seems to cough up mucous into her mouth, which she then chews on for a while before she swallows it.  Sometimes babies with bronchiolitis gag on the phlegm and actually throw up after coughing.




RSV bronchiolitis can be mild, moderate, or severe.  Mild bronchiolitis causes wheezing and coughing, but babies can still smile, laugh, drink, and eat.  More severe bronchiolitis can cause rapid breathing, significant retractions, pale or bluish skin tone, prolonged coughing spells, gagging and vomiting with cough.

In another blog post I will discuss some home treatment for RSV bronchiolitis, and what can be done for a child in the office, emergency room, or hospital.  Please remember that my blog is not intended to substitute for the advice of your own personal pediatrician!  Words on a page cannot replace your own observations, or those of the doctor who knows your child.

Merry Christmas Everyone!

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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.

2.  PARTICIPATING IN LIFE?
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.

3.  FITTING INTO THE FAMILY?
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.

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.

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.

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.

Yuck.

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.

http://www.cdc.gov/features/rawmilk/
http://www.cdc.gov/foodsafety/rawmilk/raw-milk-index.html
http://www.cdc.gov/foodsafety/rawmilk/raw-milk-questions-and-answers.html
http://www.cdc.gov/foodsafety/rawmilk/raw-milk-videos.html