Acetaminophen

     One of the drugs given to children most frequently is acetaminophen. It is a common drug used to lower fever and relieve pain. Acetaminophen has been in the news recently for two reasons.

     Childrens’ preparations of acetaminophen come in multiple dosage forms. Infant drops have a different concentration than the liquid given to toddlers. Chewable tablets have a different concentration than tablets designed for swallowing. Parents need to be aware of these differences, know how much acetaminophen is appropriate for their child’s weight and age and understand how to figure out how much acetaminophen is in the dose they give to their child. They also need to know how often they can repeat the dosage. This is all information which can be obtained on-line or through your caregiver’s office.

      Because the most common reason acetaminophen is given is for the fever and discomfort of a cold, parents also need to be aware that acetaminophen is sometimes added as an ingredient in cold and cough medications. Fever and cold medications are frequently combined, so it is easy to see how the medication can be overdosed. An overdose of acetaminophen can cause serious liver damage. This is especially worrisome because neither medication to lower fever nor cold/cough medications are necessary when a child has an upper respiratory infection. (See previous articles on “Fever” and “Fever Seizures”)

     A more recent problem with acetaminophen is its association with asthma. More information is coming out relating the use of acetaminophen early in life (perhaps even in pregnancy) with later development of asthma. Doctors aren’t sure the degree of connection or the reason for it, but it does seem that there is an increased risk for children who take acetaminophen early in life to develop asthma later in childhood.

     Ibuprofen is the alternative medication choice for relief of fever and pain. Again, it is important to know the right dosage and dosage schedule for your child and also to know whether any other medication you give your child contains ibuprofen. Too much ibuprofen can sometimes upset the stomach, but it doesn’t seem to have the more serious problems with overdose that acetaminophen has. There have been studies comparing ibuprofen with acetaminophen that suggest that ibuprofen does not have the risk of developing asthma that acetaminophen has.

     The best thing for parents to remember is that fever, cough and congestion are all normal ways that the body fights viral infection and these symptoms don’t need to be treated or reduced. A little medication to help relieve discomfort is O.K., but time and love are always the best cures. If your child or your family has a strong history of allergy and asthma, however, it might be better to avoid acetaminophen until more studies are done.

Sleeping with Mom and Dad

     The best way to deal with a problem is to not let it happen in the first place. Any time we, as parents, allow our children to do a behavior, we need to ask ourselves, “Is this something that I want them to continue?” Our children always learn much more from what we do than from what we tell them.

     Sleeping with Mom and Dad is a behavior that comes easy. Often, the children you had before you had children – your pets – were allowed to share the bed with you. Toddlers all want to sleep with their parents. The exhausted breastfeeding mom brings the infant back to bed “just to lie down for a minute”.

     Under one year of age, having an infant in bed with you is dangerous. The “Back-to-Sleep program (which places all infants in their own crib on their back on a firm mattress without soft things in the crib) has decreased the rate of Sudden Infant Death dramatically in all countries and cultures over the world.

     We don’t understand all the factors involved with Sudden Infant Death, but think about entrapment rather than suffocation. If you tried to hold an infant’s nose and mouth closed, the infant would cry and struggle. But if an infant’s face enters a soft pocket – like in a thick blanket or in a mother’s armpit – the infant doesn’t stop breathing, he just keeps re-breathing the same air – like a miner trapped in a coal mine. He quietly, without struggle, slips away.

    Most infants start out by sleeping in Mom and Dad’s room. Having the bassinette alongside the bed beats walking down the hall for those 3 am feedings. But soon you realize how much noise infants (and grown-ups) make when sleeping and you find that you are waking each other up. Move baby to his own room an never look back. When the toddler climbs out of bed crying and wants to sleep with you, you act as if he has just asked to walk on the moon. He is immediately sent back to his room. Remember that children learn from positive reinforcement. If I, as a toddler, get out of bed and get another hug, another glass of water or get gently tucked back in again, you can certainly expect to see me at 1 am tomorrow wanting the same thing. You don’t have to punish the child, but be sure the experience is not a positive one.  There is a series of children’s books about a badger named Francis which help parents deal with children’s behavior. In this case, “Bedtime for Francis” helps parents with the simple philosophy that says, ”If you think the monsters under your bed are scary, you should see how scary I am at two in the morning!”

     Then, as with any of the behavior changes parents deal with, you have to keep the new message up without exception. Children will retest you, but as soon as they are convinced that you mean what you say, they move on to something new. Remember it is not a “power struggle” and not “defiance”. Your child wants your love and approval more than anything in the world – he just wants to do what you do.

Changing Bad Eating Habits

Changing Bad Eating Habits

     The best way to deal with a bad habit is to not develop it in the first place. Once it is established, it is painful to change. I was in school at a time when most doctors and nurses (along with most of society) smoked. We all learned that the only way to quit was to quit and it wasn’t easy.

     Picky feeding begins when a child takes in so much milk, juice, crackers and fruit snacks between meals that he is not really hungry when he comes to the table. There are no picky feeders in Third World countries – they eat anything they can get. Picky feeding is further developed because the child who has been given a diet high in sugar demands high sugar/high fat foods at meals and will loudly protest if fresh fruits and vegetables are presented. A mom who is pressed for time and has other kids is often not able to resist the tantrum and ultimately gives in just to see the child eat something. The child quickly learns that if he just keeps the fight up long enough, he will get what he wants.

   Start the Prime Rule of Feeding: “What you eat at meals determines what you eat between meals”. Most children are hungry shortly after waking up, so that is a good time to start changing the habit. Avoid giving the quick-fix juice or milk before breakfast in the morning and have healthy, non-sugar cereal and fresh fruit available. (The first step in stopping cigarettes was to get them out of the house – the same goes for non-healthy foods.) One glass of milk is allowed with meals, but if the child is a “milk-addict” give the food first. If the child eats, fine. If the child refuses and fights, so be it. If food is refused, the child isn’t very hungry. Allowed him to leave the table. Avoid the “up and down” game – once you are done with a meal, you are done. Also, avoid statements like: “Well, I HAVE TO feed him SOMETHING!” No – you have to give him food – whether he eats it or not is up to him. Tantrums are exhausting for both parent and child, so you just have to last longer than he does. Don’t let his frustration become your frustration. Smile and stay supportive but don't give in.

     Now the Prime Rule applies. If the child ate a reasonable breakfast (not the “clean plate” club) and is hungry in mid-morning, offer a healthy snack and water to drink. Remember that “100% fruit” on a package usually means 100% sugar. When lunch comes along, the only choice you offer is a healthy food. If the child refuses, it means that he got too many calories between breakfast and lunch and he isn’t hungry. Don’t fight or try to force him, just don’t repeat the mistake. The Rule means that if you refuse to eat at a meal, you don’t eat (or drink) anything but water until the next meal. The child can have all the water he wants until the next meal but no milk, juice or snacks. He won’t get malnourished in three hours of not having anything with calories in it but he will get hungry and the peas might look better to him at dinner if he's hungry. Normally, toddlers do snack between meals, but we are trying to change a bad habit. We can always go back to a piece of fruit when he wants to snack once the picky feeding is gone. But be careful to never give anything but water 1 hour before a meal. If the parent can ignore the tantrums, avoid the guilt and stick to The Rule, it won’t take more than a few days for the child to learn that things have changed. Life will get a lot easier – and a lot healthier - for both you and your child.

Urine,Bladder and Kidney Infections

     Infections of what is called the urinary tract – bladder and kidneys, can cause problems for children and parents because they can give subtle symptoms and young children cannot tell their parents what is wrong.

     These infections are common. They occur more often in females and uncircumcised males. They are a frequent source of prolonged, recurrent or undiagnosed fever as well as even more subtle symptoms such a prolonged diarrhea, recurrent vomiting and poor growth.

     As I have mentioned in earlier articles, the most common reason for fever in children is viral infections like colds. These infections have a typical fever pattern: three days of daytime fever and nighttime spikes followed by a couple of nights with nighttime fever only and then resolution of the fever. If a child has a daytime fever that lasts longer than three days or if the daytime fever keeps coming and going, the child needs to be examined by their caregiver. Part of that examination should include a urine examination. If the child is old enough to give a good, clean-catch sample, that is fine, but regrettably, the collection of urine in a bag isn’t reliable and shouldn’t be done. For a younger child, catheterization is the only way to obtain a urine sample. Sometimes, the diagnosis of this infection can be made immediately from looking at the urine, but the real proof of a urinary tract infection is a culture of the urine to see if bacteria grow from it. This can take a day or two.

     When a child is diagnosed as having a lower urinary tract infection involving only the bladder, oral antibiotics usually will cure it. If the child is more ill or the kidney is involved, the child may need hospitalization until the infection begins to resolve. In the past, if a young child was diagnosed as having a urinary tract infection, doctors recommended that, after the infection is resolved, the child have a test called a VCUG which involves putting dye in the bladder. Experts are now questioning whether this procedure is necessary in all cases and doctors have begun to stop recommending it routinely.

Problems with Infant Pooping

     Few things cause more concern for parents than their infant’s stooling habits. I’ve written one article on older children and constipation. This article is about poop in the first year of life.

     Normal infant stooling is from 6 times a day to once every 6 days. It is everything from pure water to rock hard and it can be any color from bright yellow to dark black with all shades of green in between. If your infant is otherwise eating, smiling (except when straining at stool) and acting normally, the poop is probably normal, too.

     Infants’ stool varies from week to week with no real reason.  Even without changes in diet, stool can be liquid or hard, frequent or infrequent. When it is liquid, the infant has a red, raw butt that can bleed from small open areas when you wipe it. When it is hard, the infant can strain, cry and push for an hour and then push out little hard pellets.

     Parents first need to realize that the different pooping patterns are normal. The stools will naturally change over time without any intervention – there is no cure for normal. However, the parent can help the infant get through the pooping phase with less trouble. When the stools are liquid, the cure is to protect the skin with any butt paste that has zinc oxide in it. Use lots of it and use it as thick as possible with every diaper change. If you can see the skin when you open the diaper, the stool can touch the skin and irritate it. If the skin is red or has bleeding spots, it needs even more protection. The baby will cry when you put on the cream, but you have to just do it until the raw spots heal. When the stool is hard and the infant is straining, you can help him by using a glycerin suppository when he is trying to poop. The glycerin suppository will help stretch the rectum and make it greasy. This just makes it easier for the baby to poop when the stools are hard. The parent can also feed the older infant fruit – real fruit – not fruit juice or fruit snacks. It is the fiber in the fruit (not the liquid) that helps pull water into the colon and soften the stool.

     In an infant who is healthy, eating and acting normally, differences in the color, frequency and firmness of poop are usually normal. Just try to make the child more comfortable and remember that the child who has hard stools this week will have runny stools next week.

Croup

     Spring and Fall are times when children get croup. Croup is an infection of the upper airway near the voice box that is most often caused by a virus. It is common in children 6 months to 36 months of age. As with most viral upper respiratory infections, it begins with runny nose, congestion and night fever. In the evening of the second or third day, the child begins to get hoarse and develops a barking, seal-like cough. This comes along with a noise called “stridor” which is a high-pitched noise made when the child breaths in (a “wheeze”, the sign of asthma, is a noise made when the child breathes out). Croup is worse between10 pm to 4 am. The symptoms improve during the day but return at night for about the next three nights.

     Mild viral croup will give the child a barking cough at night and some stridor after a coughing episode, but the child will be alert, responsive and having no other problems. This can be treated with humidified, cool air or a walk in the cool, moist night air common in Spring and Fall. Another common treatment is warm, moist air – sitting in the bathroom with the hot water running in the shower. Encourage the child to keep drinking fluids, don’t allow any smoking around the child and, if the child has fever, you can give fever medication to make the child more comfortable (not to lower the fever).  Avoid decongestants or cold and cough medications.

     If the child is breathing rapidly, seems to be working harder at breathing, has stridor continuously, is agitated or acting more ill, he needs to be seen. Even though antibiotics aren’t helpful for viral infections, there are medications your child’s caregiver can give to help relieve the croup symptoms. Respiratory distress, severe throat pain, and difficulty swallowing can all be signs that a more severe infection may be present and the child needs to be seen immediately.

     There are children who seem to get croup frequently. Doctors argue about what causes this “recurring croup” but it happens more often in families with a history of allergies and asthma. In my practice, I found that if I treated these children more like asthmatics and gave them inhaled medications when they first got cold symptoms, they did not get croup as often.

Temper Tantrums

     When your 16 month-old is lying on the ground screaming, it is a good idea to step back and look at the temper tantrum as a learned means of communication.

     The initial way all parents and infants interact is that the infant perceives a need (“I’m hungry”; “I’m wet”) and then cries. The parent responds to the cry by taking care of the need. After a while doing this, the pattern is well set.

     As he gets older, the child perceives needs that the parent may not agree with (“I want to play with the light socket”). So, naturally, the child cries, but the parent doesn’t seem to understand and won’t allow playing with the light socket. Earlier, when a parent didn’t take care of the child’s need, the child just cried louder and harder and then the parent came through. So, the child increases the volume but again, the parent doesn’t allow the behavior. This escalation continues because the child thinks that if he can just get the message across to the parent about how important it is for him to play with the light socket, the parent will allow it. Finally, it ends in a screaming, crying, frustrated puddle on the floor.

     This is a good time for the parent to sympathize with the child.  The parent has changed the rules and the good-old style of communication is no longer going to work. It is frustrating when we have to learn new ways to do things, but that’s life. Don’t let your child’s frustration become your frustration. Responding to the tantrum is the way to teach the child that this is still a valid way to communicate and we have all seen 10 year-olds who have been taught that. The nice thing about temper tantrums is that they are exhausting for the child and, therefore, self-limiting. If you can relax, smile and resist the urge to do anything, the temper tantrum always ends. When it does, it is time for everyone to take what we’ve learned and move on to the next adventure.

Teaching Behavior (1)

       Children learn behavior by watching how their parents behave, by watching how their parents react to the child’s behavior and by what the parents say to the child about behavior. This learning goes on throughout childhood, but there is a critical period between about 9 months of age and 3 years of age when many patterns are set. It is important during this time that parents learn to “wait”.

     When a young child is roaming and exploring, wait until he actually begins doing something that is a “no” before saying “no”(as long as it isn’t dangerous). We often will suspect something will happen and say “no” before it is called for which is confusing for the child because he really wasn’t doing anything. Lots of “no”s dilute the important “no”s.

     When a child is obviously tired but cries when put down, or wakes up a short time after being put down, wait before picking him up.  A little fussing and crying is sometimes all they need to go back to sleep.

     When a child starts to whine because he wants something or can’t do something, wait. Or if the child gets angry in his frustration, wait. If the parent doesn’t respond to whining, crying and tantrums, the child will move on and try something else – often finding a way to do it himself and calm himself down at the same time.

     If a young child isn’t acting hungry, wait until he is. Don’t start a meal just because “It’s dinnertime” or the other kids are eating. Trying to feed a child who isn’t hungry (especially one that has been sucking on juice, milk, crackers and fruit snacks all morning) results in upset for everyone and picky feeding problems.

     If a child is acting inappropriately, let them know in a quiet, respectful way what the correct behavior is and then stop and wait. Don’t keep repeating yourself, don’t let yourself get angry and frustrated, just wait. Make it clear to the child by your behavior that you expect proper behavior from him, you will accept nothing less and the world is going to be put on hold until the child begins acting properly.

     Even for older children, we find many times when we need to wait before stepping in to solve problems our children encounter. Allowing a child or a teenager to sort through the normal anger and frustration of life teaches them self-confidence and self-control. Don’t immediately try to fix things for your child.

     Wait.

Vomiting and Diarrhea

            Spring is the time that “stomach flu” viruses come around. Because they are viruses, they come on suddenly, often late in the day, and can be accompanied by fever and chills. They usually start with vomiting for the first 24 hours followed by diarrhea. The diarrhea gets worse through the second 24 hours. The vomiting is the worst in the first 24 hours and decreases in frequency over 2 days. The fever lasts for about 3 days, especially at night and the diarrhea can last a week or more but slows down after the first 48 hours. Although the child can have the usual aches and rotten feeling that comes along with most viral illnesses there usually is not a lot of stomach pain. If a lot of cramping pain occurs, suspect food poisoning, appendicitis or some other problem.

            The risk that comes with viral gastroenteritis (stomach“flu” is not influenza) is dehydration. Children get dehydrated more easily than adults because of their body make-up and also because they won’t drink when they feel miserable. The first 48 hours can be especially dangerous because they have both vomiting and diarrhea and feel so bad with fever that they won’t cooperate with anything. This is the time when parents are advised to give small sips frequently of the electrolyte solutions. The reason is not that these solutions stop vomiting; it is because these solutions are rapidly absorbed so that even if the child vomits soon after drinking them, there still will be a little absorbed. The object is to just get a little more in than is coming out. Pediatric websites such as the WHO website have specific directions for rehydrating children using oral fluids and also tell you how to make the solutions at home. The problem is that these solutions taste salty and kids don’t like them. Manufacturers keep working on improving the taste and if you freeze them like popsicles the child will sometimes accept them better. Just keep the fluid going in – even sports drinks like Gatorade are better than soda, milk or plain water. A little pain/fever medication can help the child feel better which may improve your chances of getting him to drink. If the child is cooperating, drinking and responding normally to you in the first 48 hours, keep increasing the amount of fluid as tolerated.  Once the vomiting and fever resolve, the risk of dehydration lessens even though the diarrhea continues. If, however, the child is not drinking or is acting more ill, weak or withdrawn, he needs to be seen. Dehydration develops rapidly and is dangerous but it can be easily cured with fluid if caught in time.

            After the vomiting slows down, go back to feeding the child a regular diet, even though he still vomits occasionally. The diarrhea will last longer, sometimes as long as two weeks, but will decrease to 2 -3 times a day. This is when some Pepto-Bismol can help firm up the stool in older children. Because it has a form of salicylate in it, some doctors don’t recommend using it. Ask your caregiver. A common mistake is to continue clear fluids just because the child has diarrhea. The best way to get back to regular stools is a regular diet. The child’s gut needs nutrition to recover from the insult of the viral infection.

Lastly, the incubation period is within about the same three days as for other viral illnesses. Remember to keep washing your hands, but it is almost impossible to keep the virus from spreading through the family.

Feeding Your One Year-Old (1)

            From birth to six months of age, feed your infant breast milk or formula. Start solids at 6 months of age and gradually advance the consistency up to 9 months. Don’t worry about how or what you introduce or what order different foods are begun. After 9 months, allow the infant to feed himself and allow him to eat whatever the rest of the family is eating at the same time that the rest of the family is eating.

            Up until one year of age, an infant can still have breast milk or formula between meals or before bed. Moms who continue breast-feeding beyond a year of age should still establish regular meals and give breast feedings between meals.

            Start with three meals a day eaten with the family. Don’t teach the child to be a fussy eater. Don’t cater to “likes” or “dislikes” by offering substitutions. The toddler who hates peas on Monday will love them on Wednesday, so put the peas on the plate and don’t worry.  A toddler who is hungry will eat what is in front of him. “Picky feeding” has a lot more to do with a box of fruit juice and a handful of goldfish crackers 30 minutes before dinner than what is on the menu.

            Toddlers are grazers and eat multiple times a day. But that isn’t what leads to obesity and poor eating habits. Many excellent diet plans are based on multiple, healthy, small feedings a day. The problem comes when the parent gives the toddler fruit snacks, crackers and juice all day long. These foods are high in sugar and low in nutritional benefit and have no place in anyone’s diet. (The same goes for soft drinks, sport drinks, energy drinks, vitamin water drinks and all other forms of added caloric, sweetened water) Rather than teaching the toddler that he should eat a constant stream of sugar all day, have breakfast and then don’t give anything to eat until the child acts hungry. When that happens, stop what you are doing, go to the kitchen and have a healthy snack – real fruit and a glass of water. When the toddler starts to play with the food rather than eat it, take him out of the highchair and go back to what you were doing. Teach the child that we only eat in one room of the house and, when we eat, we stop other activities. Conversely, when we are doing other activities, we are not constantly eating. Give one serving of milk with big meals three times a day and nothing but water to drink at any other time of day. That includes nap and nighttime. If you never put cow’s milk into a baby bottle, your child will never know it is possible to get cow’s milk into a bottle and will never ask for it. After a year of age, the only thing that goes into a bottle is water. If you follow that rule, you will never have a problem with bottles. Milk and juice in a bottle after a year of age gives the toddler excess calorie intake, teaches him the habit of sucking on sugar all day and it ruins the teeth.

            As the old song says, poor feeding habits and picky feeding habits “have to be carefully taught”. The time between one and two years of age is the parent’s opportunity to give the child the gift of healthy eating habits for life.