Toilet training can be a prolonged and frustrating experience for both parents and children.
Most children potty-train by 3 years of age, with an average training time of 6-7 months. Daytime continence (urinating in the toilet) with dry pull-ups or underwear precedes night-time continence. Most of the developmental skills necessary for toilet training success begin at about 2 years of age. Certain physiologic signs should be present before successful training: voluntary bladder control (usually starts at 12-18 months), awareness of urge to go (15-24 months) and ability to maintain dryness for more than a 2 hr period (usually 25-30 months). Children should be able to follow commands and communicate that their diaper is wet/dirty. Children with developmental delays may need extra time/attention especially if communication skills are an issue. Children also need the motor skills necessary to get to the bathroom, remove their clothing and sit on a potty chair or the toilet. In the early stages, a child will also need to understand what the potty is for; imitating or watching adults or older siblings go the the bathroom is useful. Some children continue to need pull-ups at night until 5-6 years of age, so being completely dry at night is not necessary to begin the toilet-training process.
Toilet training may begin when children start to show readiness and interest, either by imitating adults or by attempting to remove soiled or dirty diapers. This may begin anywhere between 18-24 months; however, some 2 year old children are not showing readiness signs, and shouldn't be pushed. Buying a potty chair and talking about the potty can occur, and children can "practice" by sitting on the chair fully clothed, then with pants off and only wearing a diaper, etc. when the parents are using the bathroom. This imitation of parent activity can be a positive and enjoyable experience for kids. As children develop urge, it is important to notice this and associate urge with voluntary release of urine or stool. Constipation is a frequent issue with children, especially at toilet training age, and can definitely interfere with the toilet-training process. Family pressure and stress, a change in environment, new baby in the family, or a change in family dynamics may retard the process.
Tips:
1. Focus on ownership of the process - recognize what skills your child has and what they can do. Start with small steps and work up as children show success. For example, take off dirty diapers in the bathroom, have the child help with clean up/new diaper. Once this is established, you can work up to potty-sitting (with or without a diaper) if the child is not resistant.
2. Eliminate stress - talk about the potty, make it a positive experience and don't push; if a child shows regression (was previously interested, now is not) - back off, put them back in diapers or pull-ups and try again in a few weeks. You can still have them come in the bathroom with you or talk about peeing/pooping, even if they won't participate.
3. Schedule potty time - regular times that your child can sit on the potty with or without actually going; the gastrocolic reflex leads most people to go 30 min. after a meal. Sitting time should be about 10 min.
4. Reward systems work - star charts, M and Ms, stickers, etc. Have the chart in the bathroom and reward kids for sitting on the potty - even if they do not actually go. Heap praise on your child when he does go in the potty. Talk about how proud you are of them learning to go potty.
5. Stay positive, and be flexible - adjust tactics if needed, and don't get discouraged for children who regress or take longer
6. Address constipation and stool withholdiing if this interferes with the process. For many children, constipation needs to resolve before they can truly have good urinary continence. Address constipation issues with your child's medical provider.
7. Seek out books that are age-appropriate that discuss children learning to go potty. Point to the pictures, and talk about what is going on. This will reinforce the normalcy of the process, and repetition will breed comfort with the activity of sitting on the toilet.
Wednesday, December 12, 2012
Monday, August 27, 2012
Hand, Foot and Mouth Disease - update
We are starting to see more local cases of Hand, Foot and Mouth disease, a viral illness usually caused by a virus called Coxsackie. Typically, summer and fall are the seasons in which we tend to see more Hand, Foot and Mouth disease. Several years ago, a more severe form of Coxsackie started showing up in various locations around the U.S, and this new variant was identified as "Coxsackie A6".
In the past, Coxsackie A6 patients with Hand, Foot and Mouth disease tended to be sicker and younger (63% less than 2 years old), with some children needing to be hospitalized. The classic rash of Hand, Foot and Mouth tends to be pink or red vesicles on the sides of fingers, hands, toes and feet. The hands are involved more often than the feet. Some children will have small red dots and vesicles on the back of their throat lateral to the tonsils or on the back of the palate.
The current cases we are seeing also have vesicles on the buttocks, lower legs and the perioral (around the mouth) area. These lesions around the mouth may be mistakenly diagnosed as impetigo (a bacterial skin infection).
Hand, Foot and Mouth disease is most common in children under the age of 5; in rare cases, older kids and adults can get it (I have seen parents and older school age children with cases in the last month). Most often, the disease is caused by coxsackie viruses, though a virus called enterovirus 71 can also cause a similar illness. In Asia, enterovirus 71 has caused a cluster of severe neurologic symptoms and encephalitis. Thankfully, what we see here in the U.S. is usually limited to rash and fever - sometimes the fever can be quite high.
Hand, Foot and Mouth disease has a short incubation period - usually about 4-6 days, and will resolve spontaneously in about a week. The virus is transmitted through contact with infected saliva, respiratory secretions, the skin vesicles themselves, or contact with stool of someone who has the infection.
You can prevent the spread of Hand, Foot and Mouth disease by:
covering coughs, washing hands often (especially after changing diapers), disinfecting dirty surfaces, and avoiding close contact such as kissing and sharing eating utensils with infected persons.
In the past, Coxsackie A6 patients with Hand, Foot and Mouth disease tended to be sicker and younger (63% less than 2 years old), with some children needing to be hospitalized. The classic rash of Hand, Foot and Mouth tends to be pink or red vesicles on the sides of fingers, hands, toes and feet. The hands are involved more often than the feet. Some children will have small red dots and vesicles on the back of their throat lateral to the tonsils or on the back of the palate.
The current cases we are seeing also have vesicles on the buttocks, lower legs and the perioral (around the mouth) area. These lesions around the mouth may be mistakenly diagnosed as impetigo (a bacterial skin infection).
Hand, Foot and Mouth disease is most common in children under the age of 5; in rare cases, older kids and adults can get it (I have seen parents and older school age children with cases in the last month). Most often, the disease is caused by coxsackie viruses, though a virus called enterovirus 71 can also cause a similar illness. In Asia, enterovirus 71 has caused a cluster of severe neurologic symptoms and encephalitis. Thankfully, what we see here in the U.S. is usually limited to rash and fever - sometimes the fever can be quite high.
Hand, Foot and Mouth disease has a short incubation period - usually about 4-6 days, and will resolve spontaneously in about a week. The virus is transmitted through contact with infected saliva, respiratory secretions, the skin vesicles themselves, or contact with stool of someone who has the infection.
You can prevent the spread of Hand, Foot and Mouth disease by:
covering coughs, washing hands often (especially after changing diapers), disinfecting dirty surfaces, and avoiding close contact such as kissing and sharing eating utensils with infected persons.
Wednesday, July 25, 2012
Handling Childhood Emergencies - part 2
When to call 911: Conditions that require immediate attention
Child is unconscious or is choking/turning blue or struggling to breathe
A seizure that lasts longer than 5 minutes, or any seizure if your child has never had one before
Fall from a height of 10 feet or more, or if you child cannot move or talk following an injury. In this case, it is important not to move your child - wait for an ambulance to arrive.
Injury to an arm or leg with: bone protruding through the skin, limb is awkwardly bent or child cannot move the injured extremity.
Burns that are blistered, severely swollen or appear white or charred; any electrical burn
Uncontrolled bleeding from a wound; animal bite from a potentially rabid animal or bite accompanied by difficulty breathing
Fever with a stiff neck (possible meningitis)
Unexplained rash accompanied by shortness of breath or chest tightness
Severe vomiting or diarrhea and dehydration -- signs may include no urine output for several hours, no tears when crying, skin or lips look purple
When to call your pediatrician or doctor's office:
Child has mild asthma symptoms (shortness of breath or wheezing)
Seizure that lasts less than five minutes, if the child has had previous seizures
Fall from a relatively short distance - off playground equipment or down a short flight of stairs; child is conscious and can move/walk
Swelling, tenderness and pain at the site of an injury, but child can still move injured part
Burns with slight swelling or redness
Cuts that are more superficial, but not bleeding profusely; cat or dog bites with minor bleeding and no other symptoms
Unexplained rash without other symptoms
Vomiting and diarrhea without obvious signs of dehydration
Child is unconscious or is choking/turning blue or struggling to breathe
A seizure that lasts longer than 5 minutes, or any seizure if your child has never had one before
Fall from a height of 10 feet or more, or if you child cannot move or talk following an injury. In this case, it is important not to move your child - wait for an ambulance to arrive.
Injury to an arm or leg with: bone protruding through the skin, limb is awkwardly bent or child cannot move the injured extremity.
Burns that are blistered, severely swollen or appear white or charred; any electrical burn
Uncontrolled bleeding from a wound; animal bite from a potentially rabid animal or bite accompanied by difficulty breathing
Fever with a stiff neck (possible meningitis)
Unexplained rash accompanied by shortness of breath or chest tightness
Severe vomiting or diarrhea and dehydration -- signs may include no urine output for several hours, no tears when crying, skin or lips look purple
When to call your pediatrician or doctor's office:
Child has mild asthma symptoms (shortness of breath or wheezing)
Seizure that lasts less than five minutes, if the child has had previous seizures
Fall from a relatively short distance - off playground equipment or down a short flight of stairs; child is conscious and can move/walk
Swelling, tenderness and pain at the site of an injury, but child can still move injured part
Burns with slight swelling or redness
Cuts that are more superficial, but not bleeding profusely; cat or dog bites with minor bleeding and no other symptoms
Unexplained rash without other symptoms
Vomiting and diarrhea without obvious signs of dehydration
Handling Childhood Emergencies - part 1
Many parents feel ill-equipped to handle household injuries and emergencies. With some preparation and training, you can start to feel equipped and ready for some common emergencies that may happen in your household.
When emergencies happen, parents have to be ready to make quick decisions: whether to call 911 for emergency aid/ambulance, whether to take their child by car to an emergency room, or call their child's regular doctor for advise. If a child is not in a life-or-death situation, their physician's office should be able to see them sooner than an overwhelmed and busy emergency room. It is important to know, however, what the pediatrician's office can handle -- asthma flare-ups, injuries, etc. Most physicians are equipped to see you on a same day basis if the office is open, and give medications (like breathing treatments or steroids) and order X-rays if needed. Some doctors' offices do not do stitches, so if your child has a laceration that may need to be repaired, an urgent care center or emergency room is more appropriate. Find out the closest emergency room and urgent care center to your home, and which hospitals or after hours clinics your physician prefers. Once you know where to go, write down the directions and keep them easily accessible in your house.
When visiting an ER or urgent care center, be prepared to answer the following:
Proof of insurance coverage if any, regular doctors' name, address, phone number
Time of your child's last meal (in case anaesthesia is needed)
List of your child's medical conditions (if any), regular medications taken, and date of last tetanus shot
Consent form for someone else (grandparent, babysitter) to seek emergency care for your child; it should read "I hereby grant [name] permission to seek emergency medical help in the event that my child [name] is injured or otherwise in need of medical care. I will assume financial responsibility for treatment rendered during this time". This can be handwritten. Place a phone number (such as a cell number) where you can be reached if needed.
Emergency room physicians also like to remind parents to bring any medicine or cleaning substance that children have swallowed to the ER with them. In a panic, most parents forget this and then cannot recall exactly what their children have ingested.
It is wise to keep these written instructions together near the kitchen refrigerator or phone in case you need to grab them quickly.
A list of emergency numbers should also be posted by a central telephone, including: pediatrician's phone number, phone number for the local ER or after hours clinic, phone number for poison control.
The local poison control center can be invaluable in the case of an accidental ingestion, and can direct you in home treatment vs. the necessity for an emergency evaluation. Give poison control any specific information that you can - oftentimes, it is necessary to estimate how much a child has ingested, especially with medications.
When emergencies happen, parents have to be ready to make quick decisions: whether to call 911 for emergency aid/ambulance, whether to take their child by car to an emergency room, or call their child's regular doctor for advise. If a child is not in a life-or-death situation, their physician's office should be able to see them sooner than an overwhelmed and busy emergency room. It is important to know, however, what the pediatrician's office can handle -- asthma flare-ups, injuries, etc. Most physicians are equipped to see you on a same day basis if the office is open, and give medications (like breathing treatments or steroids) and order X-rays if needed. Some doctors' offices do not do stitches, so if your child has a laceration that may need to be repaired, an urgent care center or emergency room is more appropriate. Find out the closest emergency room and urgent care center to your home, and which hospitals or after hours clinics your physician prefers. Once you know where to go, write down the directions and keep them easily accessible in your house.
When visiting an ER or urgent care center, be prepared to answer the following:
Proof of insurance coverage if any, regular doctors' name, address, phone number
Time of your child's last meal (in case anaesthesia is needed)
List of your child's medical conditions (if any), regular medications taken, and date of last tetanus shot
Consent form for someone else (grandparent, babysitter) to seek emergency care for your child; it should read "I hereby grant [name] permission to seek emergency medical help in the event that my child [name] is injured or otherwise in need of medical care. I will assume financial responsibility for treatment rendered during this time". This can be handwritten. Place a phone number (such as a cell number) where you can be reached if needed.
Emergency room physicians also like to remind parents to bring any medicine or cleaning substance that children have swallowed to the ER with them. In a panic, most parents forget this and then cannot recall exactly what their children have ingested.
It is wise to keep these written instructions together near the kitchen refrigerator or phone in case you need to grab them quickly.
A list of emergency numbers should also be posted by a central telephone, including: pediatrician's phone number, phone number for the local ER or after hours clinic, phone number for poison control.
The local poison control center can be invaluable in the case of an accidental ingestion, and can direct you in home treatment vs. the necessity for an emergency evaluation. Give poison control any specific information that you can - oftentimes, it is necessary to estimate how much a child has ingested, especially with medications.
Wednesday, July 11, 2012
Vaccine Studies: Examine the Evidence
I usually don't cut and paste or forward too many medical spam articles, but this is a great synopsis of the articles that have addressed concerns regarding immunizations (specifically MMR) and autism. The consensus of multiple medical studies is that there is NO link between vaccines and autism.
Most physicians believe that vaccines have been associated or thought causal in the lay press solely because of timing -- many childhood vaccines are given in the 6-12 months prior to the development of classic signs and symptoms of autism.
If parents remain overly concerned about autism, they can choose to delay some vaccines (such as MMR or Varicella) until their children are 18-24 months old, the age at which symptoms of autism usually become apparent.
HealthyChildren.org - Vaccine Studies: Examine the Evidence
Most physicians believe that vaccines have been associated or thought causal in the lay press solely because of timing -- many childhood vaccines are given in the 6-12 months prior to the development of classic signs and symptoms of autism.
If parents remain overly concerned about autism, they can choose to delay some vaccines (such as MMR or Varicella) until their children are 18-24 months old, the age at which symptoms of autism usually become apparent.
HealthyChildren.org - Vaccine Studies: Examine the Evidence
Friday, July 6, 2012
Help! My baby/toddler won't stay asleep!
This is a common topic that we address with parents -- probably because sleep issues are common AND distressing to parents, who are sometimes at a loss when it comes to solving the issues surrounding sleep and nighttime for young children.
Waking during the night is normal at 3-6 months old, and 30% of babies are "signalers" who cry and expect a parental response to their crying. By 8-9 months old, 60-70% of infants can self-soothe when they wake at night, giving them the ability to put themselves back to sleep. 20-30% of toddlers are night wakers. When problems are not addressed at this age (and self-soothing behaviors taught), sleep problems will continue for many children -- into early elementary school.
The goal when approaching any sleep issues is to help your infant/todder or child be able to fall asleep on their own without "props" or excessive parental strategies. All children need a bedtime routine, and this can be started and maintained from a young age. It is important to be consistent at bedtime - doing the same things every night, putting children to bed at the same time every night. We often refer to the "bedtime routine" and this is family specific - it may include a bath, bottle or feeding for young infants, cuddling, story time or soft music. It is very important to put your child to bed while sleepy BUT not completely asleep. I repeat: sleepy but NOT asleep. This is important. Do not let your baby or child fall asleep somewhere else and move them. Learning to fall asleep on their own is the most important skill your child needs to acquire.
Dr. Charles Zeanah, a professor of Pediatrics and Psychiatry at Tulane University, recently spoke at a pediatric meeting and outlined his approach which he called a "hardball strategy": Leave your child in the bed at bedtime. If they continue to cry, go in the room after 5 minutes, soothe the child by using words or gentle touch, but do not get them out of the bed. Leave again -- and repeat at 5 minute intervals if the child keeps crying. As your child adapts, these intervals can gradually be lengthened -- 10 min., then 15 min, etc. In my practice, this "crying it out" strategy takes 5-7 days to work. As a parent, you have to be "all in" and invested in this strategy and follow it to the letter for it to work. It is also very important that both parents (or caregivers) be consistent in the approach.
A more gentle strategy is to respond to the crying but to sit next to the child's bed soothing them - but again, not getting them out of the bed. You can sit next to the bed until your child falls asleep. The next night, sit farther away and gradually move farther away each night -- letting your child see you is important in alleviating some fear. I know personally that this strategy works - especially for toddlers who can either get out of the bed (and love to come to their parent's bed - if they can get away with it) or who continue to call out/cry/cajole for parents to come back in the room. My husband and I tried this approach when my daughter was 2 years old and bedtime avoidant. I tried to be as boring as possible in the 5-10 minutes I stayed in her room - I didn't engage with her, and spent the time lying on the floor reading. Eventually, she gave up needing us in her room in order to fall asleep.
Remember -- your goal is to help your child fall asleep without you :)
Waking during the night is normal at 3-6 months old, and 30% of babies are "signalers" who cry and expect a parental response to their crying. By 8-9 months old, 60-70% of infants can self-soothe when they wake at night, giving them the ability to put themselves back to sleep. 20-30% of toddlers are night wakers. When problems are not addressed at this age (and self-soothing behaviors taught), sleep problems will continue for many children -- into early elementary school.
The goal when approaching any sleep issues is to help your infant/todder or child be able to fall asleep on their own without "props" or excessive parental strategies. All children need a bedtime routine, and this can be started and maintained from a young age. It is important to be consistent at bedtime - doing the same things every night, putting children to bed at the same time every night. We often refer to the "bedtime routine" and this is family specific - it may include a bath, bottle or feeding for young infants, cuddling, story time or soft music. It is very important to put your child to bed while sleepy BUT not completely asleep. I repeat: sleepy but NOT asleep. This is important. Do not let your baby or child fall asleep somewhere else and move them. Learning to fall asleep on their own is the most important skill your child needs to acquire.
Dr. Charles Zeanah, a professor of Pediatrics and Psychiatry at Tulane University, recently spoke at a pediatric meeting and outlined his approach which he called a "hardball strategy": Leave your child in the bed at bedtime. If they continue to cry, go in the room after 5 minutes, soothe the child by using words or gentle touch, but do not get them out of the bed. Leave again -- and repeat at 5 minute intervals if the child keeps crying. As your child adapts, these intervals can gradually be lengthened -- 10 min., then 15 min, etc. In my practice, this "crying it out" strategy takes 5-7 days to work. As a parent, you have to be "all in" and invested in this strategy and follow it to the letter for it to work. It is also very important that both parents (or caregivers) be consistent in the approach.
A more gentle strategy is to respond to the crying but to sit next to the child's bed soothing them - but again, not getting them out of the bed. You can sit next to the bed until your child falls asleep. The next night, sit farther away and gradually move farther away each night -- letting your child see you is important in alleviating some fear. I know personally that this strategy works - especially for toddlers who can either get out of the bed (and love to come to their parent's bed - if they can get away with it) or who continue to call out/cry/cajole for parents to come back in the room. My husband and I tried this approach when my daughter was 2 years old and bedtime avoidant. I tried to be as boring as possible in the 5-10 minutes I stayed in her room - I didn't engage with her, and spent the time lying on the floor reading. Eventually, she gave up needing us in her room in order to fall asleep.
Remember -- your goal is to help your child fall asleep without you :)
Tuesday, June 12, 2012
RIsks of CT scans in Children
I just recently read two articles on the risks of radiation exposure through CT scans in children - one on-line via Fox News, and one in the local Washington Post newspaper.
A 20 year study was recently published combining data from the US, Canada and Great Britain. The results show that exposure in childhood to the radiation equivalent of 2-3 Head CT scans can triple the risk of developing brain cancer later in life, and a child exposed to 5-10 CT scans is three times as likely to develop leukemia than a child who had no scans done.
Children are more sensitive to radiation than adults due to growing bones and tissues, as well as their relatively lower body weights.
This is sobering information that doctors have been alerted to for awhile -- I have been to several conferences at which childhood radiation exposure was discussed, from X rays to CT scans. A CT scan gives great definition, and is useful in looking for bleeds (in the case of head trauma) and solid tumors. Many emergency rooms use CT scans as part of an evaluation of abdominal pain, when the diagnosis of appendicitis is entertained, but not clear cut. Yes, doctors do sometimes practice defensive medicine, but no one wants to miss the appendicitis, the brain tumor or a devestating bleed from a case of head trauma in an otherwise healthy child.
There are alternatives: ultrasound exams do not expose one to radiation, and an MRI (Magnetic Resonance imaging) exam may give great definition of some structures without radiation. An MRI is typically more expensive, may be denied by your insurance company, and requires your child to remain motionless for a more prolonged period of time.
Many experts have weighed in on either side. Per Dr. Raymond Sze at Children's Hospital in Washington DC, "If the benefit to the child is greater than the theoretical risk, then (the CT scan) is appropriate".
A campaign called Image Gently is designed to alleviate concerns of providers and parents, and reduce radiation exposure through greater education. In addition to recommending that scans only be performed when medical benefits are clear, it also recommends limited scanning -- only the area of the body absolutely necessary. Image Gently also recommends evaluation of other imaging modalities like ultrasound and MRI. Donald Frush, chairman of the American College of Radiology's pediatric radiology commission, has said "People need to ask: Is it necessary? Can you do another test, such as an MRI? Can you wait a couple of days?"
Doctors suggest parents discuss CTs with the ordering provider and act as advocates for the children by asking if facilities take steps to reduce radiation exposure in children.
As a parent, I do understand the concerns of exposing one's child to radiation unnecessarily. At the same time, I am a doctor, and need to weigh the risks and benefits with my parents whenever I am ordering studies of any kind.
A 20 year study was recently published combining data from the US, Canada and Great Britain. The results show that exposure in childhood to the radiation equivalent of 2-3 Head CT scans can triple the risk of developing brain cancer later in life, and a child exposed to 5-10 CT scans is three times as likely to develop leukemia than a child who had no scans done.
Children are more sensitive to radiation than adults due to growing bones and tissues, as well as their relatively lower body weights.
This is sobering information that doctors have been alerted to for awhile -- I have been to several conferences at which childhood radiation exposure was discussed, from X rays to CT scans. A CT scan gives great definition, and is useful in looking for bleeds (in the case of head trauma) and solid tumors. Many emergency rooms use CT scans as part of an evaluation of abdominal pain, when the diagnosis of appendicitis is entertained, but not clear cut. Yes, doctors do sometimes practice defensive medicine, but no one wants to miss the appendicitis, the brain tumor or a devestating bleed from a case of head trauma in an otherwise healthy child.
There are alternatives: ultrasound exams do not expose one to radiation, and an MRI (Magnetic Resonance imaging) exam may give great definition of some structures without radiation. An MRI is typically more expensive, may be denied by your insurance company, and requires your child to remain motionless for a more prolonged period of time.
Many experts have weighed in on either side. Per Dr. Raymond Sze at Children's Hospital in Washington DC, "If the benefit to the child is greater than the theoretical risk, then (the CT scan) is appropriate".
A campaign called Image Gently is designed to alleviate concerns of providers and parents, and reduce radiation exposure through greater education. In addition to recommending that scans only be performed when medical benefits are clear, it also recommends limited scanning -- only the area of the body absolutely necessary. Image Gently also recommends evaluation of other imaging modalities like ultrasound and MRI. Donald Frush, chairman of the American College of Radiology's pediatric radiology commission, has said "People need to ask: Is it necessary? Can you do another test, such as an MRI? Can you wait a couple of days?"
Doctors suggest parents discuss CTs with the ordering provider and act as advocates for the children by asking if facilities take steps to reduce radiation exposure in children.
As a parent, I do understand the concerns of exposing one's child to radiation unnecessarily. At the same time, I am a doctor, and need to weigh the risks and benefits with my parents whenever I am ordering studies of any kind.
Thursday, May 10, 2012
Sports Physicals
It is the time of year that we Pediatricians start seeing more kids for school and sports physicals. Here in Virginia, any sports physical done after May 1st is good for the following school year (so fall, winter and spring sports are covered). I admit that I have a bias toward having your regular pediatrician do your child's physical. I have seen too many kids go to "Urgent Care" facilities or "School Physical day" at various schools (staffed by volunteers) in which important things were missed or possible medical problems were not addressed.
Here are some things that are covered by a sports physical:
Growth parameters - weight, height; if your child has lost or gained a significant amount of weight (again, previous weights/heights are important info that your pediatrician's office has in your child's medical record). Children grow quickly, and weight gain may not be worrisome if there is also a corresponding growth in height. We can calculate a Body Mass Index (BMI) that takes both weight and height into account together.
Vision screening - if your child wears glasses or contacts, we may want to know what their vision is both with and without their corrective lenses; we may recommend that your child wear corrective lenses while playing sports, depending on their eyesight.
Assessment of pubertal development, screening for hernias or testicular problems in boys
Assessment of menstrual history for girls
Screening labwork - including blood counts, urinalysis, cholesterol; we may be able to perform these tests in our office.
Blood pressure measurement - If your child has an elevated blood pressure (or high cholesterol), this will be something that we want to continue monitoring
Cardiac (heart) screening for risk factors leading to heart disease including assessment of heart murmurs
Assessment of any sports-related injuries that you may have sustained in the previous year; ideally, a sports physical should be done 6 weeks prior to beginning sports in order to determine if any physical therapy or rehab is needed in the interim; for example, ankle sprains are common injuries, and athletes may need to wear an ankle brace or sports splint to prevent re-injury
Assessment of current diet and nutritional intake - some teens skip meals or do not get enough calcium or iron; we can make recommendations based on our interview with you
This is also the time to mention any issues that you are worried about with your child. A teen who has a relationship with their pediatrician is more likely to be honest with us about sensitive topics, which they may not mention to someone they have never seen before.
Get into the habit of scheduling well visits for your children. As physicians, we feel that this is important.
Here are some things that are covered by a sports physical:
Growth parameters - weight, height; if your child has lost or gained a significant amount of weight (again, previous weights/heights are important info that your pediatrician's office has in your child's medical record). Children grow quickly, and weight gain may not be worrisome if there is also a corresponding growth in height. We can calculate a Body Mass Index (BMI) that takes both weight and height into account together.
Vision screening - if your child wears glasses or contacts, we may want to know what their vision is both with and without their corrective lenses; we may recommend that your child wear corrective lenses while playing sports, depending on their eyesight.
Assessment of pubertal development, screening for hernias or testicular problems in boys
Assessment of menstrual history for girls
Screening labwork - including blood counts, urinalysis, cholesterol; we may be able to perform these tests in our office.
Blood pressure measurement - If your child has an elevated blood pressure (or high cholesterol), this will be something that we want to continue monitoring
Cardiac (heart) screening for risk factors leading to heart disease including assessment of heart murmurs
Assessment of any sports-related injuries that you may have sustained in the previous year; ideally, a sports physical should be done 6 weeks prior to beginning sports in order to determine if any physical therapy or rehab is needed in the interim; for example, ankle sprains are common injuries, and athletes may need to wear an ankle brace or sports splint to prevent re-injury
Assessment of current diet and nutritional intake - some teens skip meals or do not get enough calcium or iron; we can make recommendations based on our interview with you
This is also the time to mention any issues that you are worried about with your child. A teen who has a relationship with their pediatrician is more likely to be honest with us about sensitive topics, which they may not mention to someone they have never seen before.
Get into the habit of scheduling well visits for your children. As physicians, we feel that this is important.
Tuesday, April 10, 2012
Video Games and Kids
I discuss video games a lot when I see kids for well child visits. There are definitely positives and negatives about video games, and I think it is important to know what your kids are playing. I have three kids and a husband that I play games with at home. At our house, we have "game night" every Saturday night. I don't have the manual dexterity of my husband or stepson, but I can sing Journey songs on Rock Band 3 with the best of them :)
I read an article recently discussing Internet/video game addiction by Mike Rich, who runs the Center on Media and Child Health in Boston. This is a link to his website, which is pretty informative:
http://cmch.typepad.com/mediatrician
I read an article recently discussing Internet/video game addiction by Mike Rich, who runs the Center on Media and Child Health in Boston. This is a link to his website, which is pretty informative:
http://cmch.typepad.com/mediatrician
Thursday, March 22, 2012
Is Ground Beef Safe to Eat?
Much ado lately about "pink slime" - ground beef filler found in many brands of ground beef sold commercially. Here is the latest from CNN about chain grocery stores making the decision not to carry ground beef that contains fillers:
http://www.cnn.com/video/#/video/health/2012/03/21/exp-cohen-and-pink-slime-in-ground-beef.cnn
Many years ago, when mad cow disease was a concern, I stopped eating ground beef altogether. The last few years I admit I have slacked. I don't buy ground beef often at the store, and when I do, I tend to choose organic meat. However, my family eats out a fair amount and I admit a nicely done burger can be pretty tasty. The latest information on pink slime has me worried though - think I will stay away from ground beef again. With our children eating at school, and eating out on their own with friends, it makes me concerned about their consumption too.
Has anyone else out there changed their eating patterns based on what they are reading about ground beef? Staying informed makes you more educated about what you choose to eat, and that is a good thing.
http://www.cnn.com/video/#/video/health/2012/03/21/exp-cohen-and-pink-slime-in-ground-beef.cnn
Many years ago, when mad cow disease was a concern, I stopped eating ground beef altogether. The last few years I admit I have slacked. I don't buy ground beef often at the store, and when I do, I tend to choose organic meat. However, my family eats out a fair amount and I admit a nicely done burger can be pretty tasty. The latest information on pink slime has me worried though - think I will stay away from ground beef again. With our children eating at school, and eating out on their own with friends, it makes me concerned about their consumption too.
Has anyone else out there changed their eating patterns based on what they are reading about ground beef? Staying informed makes you more educated about what you choose to eat, and that is a good thing.
Wednesday, March 14, 2012
Allergy Treatment
It is the time of year that brings many people in with questions about allergies and the medications used to treat them. Here is the rundown on available treatments for seasonal allergies:
1. Daily antihistamines (brand names Claritin, Zyrtec, Allegra) - usually the first line treatment; all of these medications are available over the counter, can be given once a day, and usually do not cause sleepiness (unlike our old standby, Benadryl). The exception to this is Zyrtec, which can cause sedation in some children. I usually dose these medications in the evening before bed to minimize this side effect.
2. Steroid nasal spray (brand names Fluticasone, Flonase, Nasonex) - anti-inflammatory medication that blocks the body's allergic response to environmental allergens; the first choice of many doctors due to their potency and the rapid onset of relief of symptoms. I usually recommend these if patients have not gotten better with antihistamines or if parents want to avoid antihistamine side effects. The major side effects of steroid nasal sprays are nasal membrane dryness and nosebleeds. Steroid nasal sprays are prescription-only, so your child will need to be evaluated by his/her doctor to see if nasal spray would be beneficial. Your child would have to be able to tolerate a nasal spray - this is a drawback for some kids.
3. Mucinex - mucolytic medication that thins nasal mucus to decrease postnasal drip; also helps with cough associated with postnasal drip. I sometimes add this medicaiton for night-time cough associated with allergies.
4. Singulair/ class of medication called leukotriene inhibitors - originally developed as an asthma medication, decreases the inflammatory response in the airways to allergens. These medications are sometimes used as an adjunct to the above allergy medications. I find this most helpful for children who have BOTH allergies and asthma, since it treats both conditions. As an allergy medication alone, it is not as powerful at controlling symptoms as steroid nasal spray or antihistamines. These medications also have side effects including behavior/mood changes, so any use should be discussed with your child's pediatrician.
If allergy medications do not control the symptoms, consider making an appointment with an allergist for an evaluation and possible allergy testing.
1. Daily antihistamines (brand names Claritin, Zyrtec, Allegra) - usually the first line treatment; all of these medications are available over the counter, can be given once a day, and usually do not cause sleepiness (unlike our old standby, Benadryl). The exception to this is Zyrtec, which can cause sedation in some children. I usually dose these medications in the evening before bed to minimize this side effect.
2. Steroid nasal spray (brand names Fluticasone, Flonase, Nasonex) - anti-inflammatory medication that blocks the body's allergic response to environmental allergens; the first choice of many doctors due to their potency and the rapid onset of relief of symptoms. I usually recommend these if patients have not gotten better with antihistamines or if parents want to avoid antihistamine side effects. The major side effects of steroid nasal sprays are nasal membrane dryness and nosebleeds. Steroid nasal sprays are prescription-only, so your child will need to be evaluated by his/her doctor to see if nasal spray would be beneficial. Your child would have to be able to tolerate a nasal spray - this is a drawback for some kids.
3. Mucinex - mucolytic medication that thins nasal mucus to decrease postnasal drip; also helps with cough associated with postnasal drip. I sometimes add this medicaiton for night-time cough associated with allergies.
4. Singulair/ class of medication called leukotriene inhibitors - originally developed as an asthma medication, decreases the inflammatory response in the airways to allergens. These medications are sometimes used as an adjunct to the above allergy medications. I find this most helpful for children who have BOTH allergies and asthma, since it treats both conditions. As an allergy medication alone, it is not as powerful at controlling symptoms as steroid nasal spray or antihistamines. These medications also have side effects including behavior/mood changes, so any use should be discussed with your child's pediatrician.
If allergy medications do not control the symptoms, consider making an appointment with an allergist for an evaluation and possible allergy testing.
Thursday, February 23, 2012
Tips for Reading to Young Children
February is "Reading Month" at my daughter's preschool. They get stars for every book they "read" for the month and they get prizes at the end of the month when they have a special "Dr. Seuss" party. My daughter has decided she wants to get the most books on her list for her class. She is entertainingly competitive :)
In honor of reading month, here are some tips for reading to your young child:
1. If your child has a short attention span, try using your own words to describe what is going on in the book, rather than reading the text. Point to objects on the page to engage your child's interest. Early board books are "sing-songy" which also captivates their interest.
2. Be expressive. Adopt different voices for different characters. Children easily learn to imitate this when they are old enough to read for themselves.
3. Move your fingers around the page if there is movement going on in the story. Show them where the action is in the story.
4. Point out new objects so that your child hears new words and learns to associate them. When they are old enough, use "Show me the ..." to involve them.
5. With older children, ask them to tell you what THEY see in the story, ask things like "What is going on here?"
6. At 12-18 months, teach your child to turn pages. If they turn quickly (which often happens), revert to telling the story rather than reading the text.
7. I recently read this and it is so true: kids sometimes like reading time not for the books but for the bonding experience and cuddle time they get with their parents/caregivers. Just another way that reading to kids benefits us too :)
In honor of reading month, here are some tips for reading to your young child:
1. If your child has a short attention span, try using your own words to describe what is going on in the book, rather than reading the text. Point to objects on the page to engage your child's interest. Early board books are "sing-songy" which also captivates their interest.
2. Be expressive. Adopt different voices for different characters. Children easily learn to imitate this when they are old enough to read for themselves.
3. Move your fingers around the page if there is movement going on in the story. Show them where the action is in the story.
4. Point out new objects so that your child hears new words and learns to associate them. When they are old enough, use "Show me the ..." to involve them.
5. With older children, ask them to tell you what THEY see in the story, ask things like "What is going on here?"
6. At 12-18 months, teach your child to turn pages. If they turn quickly (which often happens), revert to telling the story rather than reading the text.
7. I recently read this and it is so true: kids sometimes like reading time not for the books but for the bonding experience and cuddle time they get with their parents/caregivers. Just another way that reading to kids benefits us too :)
Tuesday, February 14, 2012
Child Car Seat Recommendations
This has come up a lot at work lately. There are new recommendations about child car safety seats - you can find this published at www.nhtsa.gov.
INFANTS should be in a rear-facing car seat; most infant car seats are "bucket-style" and fit into a base which stays belted into your car LATCH system. Newly recommended: keeping your young child REAR-FACING until age 2, even after you switch to a convertible car seat. Be sure to check your manufacturer specifications - I know both Graco and Britax have weight and height recommendations on their websites. Your carseat should have a sticker on it with these listed. Many children reach the HEIGHT limit before they reach the WEIGHT limit. If they get close to the height limit or their head is obviously above the top of the car seat, it is time to buy a new seat.
CHILDREN 1-3 year old: keep rear-facing as long as possible, now preferably up until age 2. When your child reaches the height limit for your car seat, you can convert to a forward-facing car seat with a harness. A five-point or harness restraint is preferred.
CHILDREN 4-7 years old: Forward-facing car seat with a harness until the weight/height limit is reached. At that time, you can convert to a booster seat in the backseat. Most of the time, booster seats are recommended until a child reaches the height of 4'9".
CHILDREN 8-12 years old: Keep your child in a booster seat until he or she is big enough for a shoulder and lap belt to fit correctly on the body. The shoulder belt should lie snug across the shoulder and chest and not cross the neck or face. The lap belt should lie across the upper thighs and not across the stomach. Your child should remain in the back seat - it is safer there.
CHILDREN 12-13 and up (depending on size) can sit in the front passenger seat.
INFANTS should be in a rear-facing car seat; most infant car seats are "bucket-style" and fit into a base which stays belted into your car LATCH system. Newly recommended: keeping your young child REAR-FACING until age 2, even after you switch to a convertible car seat. Be sure to check your manufacturer specifications - I know both Graco and Britax have weight and height recommendations on their websites. Your carseat should have a sticker on it with these listed. Many children reach the HEIGHT limit before they reach the WEIGHT limit. If they get close to the height limit or their head is obviously above the top of the car seat, it is time to buy a new seat.
CHILDREN 1-3 year old: keep rear-facing as long as possible, now preferably up until age 2. When your child reaches the height limit for your car seat, you can convert to a forward-facing car seat with a harness. A five-point or harness restraint is preferred.
CHILDREN 4-7 years old: Forward-facing car seat with a harness until the weight/height limit is reached. At that time, you can convert to a booster seat in the backseat. Most of the time, booster seats are recommended until a child reaches the height of 4'9".
CHILDREN 8-12 years old: Keep your child in a booster seat until he or she is big enough for a shoulder and lap belt to fit correctly on the body. The shoulder belt should lie snug across the shoulder and chest and not cross the neck or face. The lap belt should lie across the upper thighs and not across the stomach. Your child should remain in the back seat - it is safer there.
CHILDREN 12-13 and up (depending on size) can sit in the front passenger seat.
Saturday, February 11, 2012
Why is High Fructose Corn Syrup Bad for You?
Everyone knows that obesity is a rising problem in the U.S. When counseling people on their diets, we commonly focus on eliminating extra calories, "empty calories" such as those found in sweetened beverages. Many beverages contain high fructose corn syrup (HFCS) - not just regular soda, but sweet tea, lemonade, fruit drinks, and even some sports beverages. In a NHANES study done from 1999-2004, it was found that US adults consumed 12% of their total daily energy intake from sweetened beverages. For adolescents and children, the numbers were 13% and 10% respectively. Those at higher risk for obesity amd cardiometabolic disease, minorities and those in lower socioeconomic groups, tend to consume the largest amounts of sugar-sweetened beverages. Aside from the actual number of extra calories one is ingesting, HFCS itself is thought to be dangerous to one's health.
HFCS is a corn-based sweetener which has been around since the early 1970s. It currently accounts for greater than 40% of the sweeteners added to foods and beverages. It is the sole sweetener in soft drinks and sodas in the U.S. It is a mix of fructose and glucose, is easily produced and, because it doesn't take much of it to sweeten a food, it doesn't take up much storage space. Additionally, it is relatively cheap -- hence why we find it in so many foods and drinks now.
The fructose in HFCS bypasses the regular metabolism of carbohydrates in the body and is immediately synthesized into fatty acids. What this means is that HFCS is rapidly converted into triglyceride and VLDL (blood fats). Triglycerides are quickly converted into adipose ((fatty tissue) which causes obesity. Fat is also deposited into the liver which, over time, can lead to fatty liver, insulin resistance and eventually, elevated blood cholesterol. Insulin resistance can lead one over time to develop Type II diabetes. Fructose also promotes the synthesis of uric acid, which can contribute to the development of high blood pressure. Fructose ALSO reduces our body's secretion of insulin which is necessary to process the sugar load that we just ingested. A blunted insulin response interferes with the "satiety signal" -- in other words, we don't feel full. Which, of course, leads us to ingest more calories. There is actual science to this -- studies show that adolescents who ingest 8 oz or more of non-diet soda daily ingest more total calories than their peers who drink non-sweetened beverages.
Those of us who drink diet soda shouldn't feel totally left out -- the caramel coloring in colas may increase insulin resistance and inflammation due to the caramelization process.
What does this all mean? We should all be more cognizant of what we are ingesting. If HFCS is one of the first ingredients listed on a food label, we probably shouldn't be eating that. The biggest culprits are sweetened soda and sweetened breakfast cereals. But HFCS is found in lots of other things too - fruit juices, pancake syrup, fruit-flavored yogurt, ketchup, canned pasta sauce and soups, canned fruits.
Limiting processed foods is good, but reading labels is a good life-long habit which will benefit your health. You can find canned fruit and applesauce without HFCS - sugar, brown sugar and honey are also used as sweeteners. You can buy organic ketchup which doesn't have HFCS and use pure maple syrup instead of the heavily processed and cheaper varieties. Read the labels of breakfast cereals and pick those that don't contain HFCS. Thankfully, most grocery stores have an increasing number of all natural and organic options. Of course, eating more whole fruits and vegetables will be better for you than relying on processed foods.
HFCS is a corn-based sweetener which has been around since the early 1970s. It currently accounts for greater than 40% of the sweeteners added to foods and beverages. It is the sole sweetener in soft drinks and sodas in the U.S. It is a mix of fructose and glucose, is easily produced and, because it doesn't take much of it to sweeten a food, it doesn't take up much storage space. Additionally, it is relatively cheap -- hence why we find it in so many foods and drinks now.
The fructose in HFCS bypasses the regular metabolism of carbohydrates in the body and is immediately synthesized into fatty acids. What this means is that HFCS is rapidly converted into triglyceride and VLDL (blood fats). Triglycerides are quickly converted into adipose ((fatty tissue) which causes obesity. Fat is also deposited into the liver which, over time, can lead to fatty liver, insulin resistance and eventually, elevated blood cholesterol. Insulin resistance can lead one over time to develop Type II diabetes. Fructose also promotes the synthesis of uric acid, which can contribute to the development of high blood pressure. Fructose ALSO reduces our body's secretion of insulin which is necessary to process the sugar load that we just ingested. A blunted insulin response interferes with the "satiety signal" -- in other words, we don't feel full. Which, of course, leads us to ingest more calories. There is actual science to this -- studies show that adolescents who ingest 8 oz or more of non-diet soda daily ingest more total calories than their peers who drink non-sweetened beverages.
Those of us who drink diet soda shouldn't feel totally left out -- the caramel coloring in colas may increase insulin resistance and inflammation due to the caramelization process.
What does this all mean? We should all be more cognizant of what we are ingesting. If HFCS is one of the first ingredients listed on a food label, we probably shouldn't be eating that. The biggest culprits are sweetened soda and sweetened breakfast cereals. But HFCS is found in lots of other things too - fruit juices, pancake syrup, fruit-flavored yogurt, ketchup, canned pasta sauce and soups, canned fruits.
Limiting processed foods is good, but reading labels is a good life-long habit which will benefit your health. You can find canned fruit and applesauce without HFCS - sugar, brown sugar and honey are also used as sweeteners. You can buy organic ketchup which doesn't have HFCS and use pure maple syrup instead of the heavily processed and cheaper varieties. Read the labels of breakfast cereals and pick those that don't contain HFCS. Thankfully, most grocery stores have an increasing number of all natural and organic options. Of course, eating more whole fruits and vegetables will be better for you than relying on processed foods.
Thursday, January 26, 2012
Is Organic Food Better For You?
Many patients ask me about buying organic foods, and whether they should buy organic. I tend to buy organic foods for my family whenever possible, and I do recommend it for certain foods. Here is the lowdown: Organic foods have been shown to be lower in pesticide residue, as well as more free from additives. When you are shopping for milk and meat, buying organic means you are not exposing yourself (and your kids) to unnecessary antibiotics and growth hormones. Read labels carefully though - packaging that says that the product is "all natural" doesn't mean that the animals weren't given these drugs.
The "dirty dozen" foods that were highest in pesticide residue in 2011 were: peaches, apples, bell peppers, celery, nectarines, lettuce/kale/spinach, blueberries (frozen blueberries are a good option if you can't find organic - my family loves Wyman's), strawberries, beef, eggs and milk. Potatoes can be higher in pesticide residue, but sweet potatoes are not, and have more nutrients also. Surprisingly, coffee can have pesticide residue - in addition to organic coffees, you can also look for "fair trade" and "shade grown" varieties which have less pesticides and are more "bird-friendly".
The "clean 15" list of the foods lowest in pesticide residue includes onions, sweet corn, pineapples, mango, kiwi, asparagus, eggplant, domestic cantelope, watermelon and grapefruit.
In addition to trying to find organic produce and meats, I am also a strong advocate of farmers' markets where you can buy locally grown produce. My local farmers' market also sells sausage, beef and buffalo which is locally grown and harvested. A good resource for buying local organics is LocalHarvest.org.
Update 1/20/15:
The "dirty dozen" list gets updated periodically, and I have seen mention lately of a pesticide called chlorpyrifos, a particularly nasty substance sometimes used on crops. The top five sources of produce contamination with this pesticide are: grapes, apples, peaches (which includes nectarines and plums), tomatoes and, in addition, dairy/milk products from nearby farms. As mentioned before, here is a list to concentrate on when trying to shop organic.
The "dirty dozen" foods that were highest in pesticide residue in 2011 were: peaches, apples, bell peppers, celery, nectarines, lettuce/kale/spinach, blueberries (frozen blueberries are a good option if you can't find organic - my family loves Wyman's), strawberries, beef, eggs and milk. Potatoes can be higher in pesticide residue, but sweet potatoes are not, and have more nutrients also. Surprisingly, coffee can have pesticide residue - in addition to organic coffees, you can also look for "fair trade" and "shade grown" varieties which have less pesticides and are more "bird-friendly".
The "clean 15" list of the foods lowest in pesticide residue includes onions, sweet corn, pineapples, mango, kiwi, asparagus, eggplant, domestic cantelope, watermelon and grapefruit.
In addition to trying to find organic produce and meats, I am also a strong advocate of farmers' markets where you can buy locally grown produce. My local farmers' market also sells sausage, beef and buffalo which is locally grown and harvested. A good resource for buying local organics is LocalHarvest.org.
Update 1/20/15:
The "dirty dozen" list gets updated periodically, and I have seen mention lately of a pesticide called chlorpyrifos, a particularly nasty substance sometimes used on crops. The top five sources of produce contamination with this pesticide are: grapes, apples, peaches (which includes nectarines and plums), tomatoes and, in addition, dairy/milk products from nearby farms. As mentioned before, here is a list to concentrate on when trying to shop organic.
Monday, January 23, 2012
Homemade Magic Diaper Ointment
As Pediatricians, we often prescribe combination diaper ointments for patients who don't respond to usual diaper ointment remedies. Sometimes, the rash has gotten superinfected with yeast (and needs specific anti-yeast/anti-fungal treatment) or has become superinfected with bacteria (and needs antibiotic ointment or, rarely, oral antibiotic medication).
For years, I have told parents that they can concoct a homemade mixture that works on most diaper rashes. I sometimes hand out urine collection cups for parents to keep their homemade diaper ointment in, to make it easier when applying it to their tots. Here is the formula:
Mix equal parts of:
Zinc oxide diaper ointment (I like Balmex)
Antibiotic ointment (such as Neosporin, Bacitracin, or triple antibiotic ointment)
Hydrocortisone cream 1 % ( with or without Aloe)
OTC Miconazole cream - typically you can find 2% in the womens' section sold as Monistat
If you are treating a diaper rash religiously and it is getting worse, call your pediatrician's office to make an appointment - a yeast or bacterial infection may be the culprit.
For years, I have told parents that they can concoct a homemade mixture that works on most diaper rashes. I sometimes hand out urine collection cups for parents to keep their homemade diaper ointment in, to make it easier when applying it to their tots. Here is the formula:
Mix equal parts of:
Zinc oxide diaper ointment (I like Balmex)
Antibiotic ointment (such as Neosporin, Bacitracin, or triple antibiotic ointment)
Hydrocortisone cream 1 % ( with or without Aloe)
OTC Miconazole cream - typically you can find 2% in the womens' section sold as Monistat
If you are treating a diaper rash religiously and it is getting worse, call your pediatrician's office to make an appointment - a yeast or bacterial infection may be the culprit.
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