Goodby

     After writing this blog for over three years, I've decided to end it. I thank the people who have followed it. If it has been beneficial to you or if you have any comments, I'd love to hear them. You can contact me at: jandtoc@msn.com.                 John O'Connell

Stuttering

     Between the ages of 3 and 4, about one in 10 children will begin stuttering.  It is more common in boys than in girls and occurs in all races and cultures.

     The majority of early childhood stuttering is normal and will resolve by itself, but parents need to watch for signs that the stuttering may be a more severe and persistent problem.

     Normal stuttering most often involves short words at the beginning of the sentence. More severe stuttering often involves the first letter of words and can happen any place in the sentence. A child saying, “Mom…mom…mom…I want to go” is less worrisome than a child saying, “M…m…m…m…mom, I want to g…g…g…go”.

     There are other factors that increase the risk that the stuttering may be more severe. If another family member continued to have a stutter through adolescence or into adulthood, the risk is greater. If the child begins to stutter after age 4 or stutters for longer than 12 months, the risk of severe stuttering increases. Severe stuttering involves more than 10% of the child’s speech with the stuttering lasting longer than 1 second. Children with normal stuttering don’t seem embarrassed or upset about their stuttering, but children with severe stuttering may raise the pitch of their voice and become frustrated while struggling to speak.

      There are many support resources for stuttering that can be found online and there are a variety of treatments used by speech therapists. With mild stuttering and no other risk factors, waiting and watching for a while may be a parent’s best choice of action. A report in Pediatrics in 2013 found that waiting a year before beginning therapy did not seem to have any effect on the child’s development or emotional state. However, if parents are very concerned or if any of the risk signs mentioned above are present, referring a child earlier should be considered.

When Eyes Are Pink

     Because it is one of the most common problems of childhood, there are some basic facts that parents should know about “pinkeye”.

     “Pinkeye” simply means that the eye has a red discoloration. There are different medical problems that can cause the eye to be red – some don’t need any treatment and some need immediate care.

     The most common cause of a red eye is a viral infection. This usually comes along with a viral cold – fever, runny nose, congestion and cough. The eye is mildly red and has lots of tearing. Older children will complain that it feels like “something is in my eye”. (If there are no cold symptoms, check – there could be something in the eye!) Usually the eye is not sensitive to light and there should be no pain. A viral infection of the eye can cause the eye to be “pink” for a few weeks. The major problem is that this kind of infection is very contagious and can easily spread through a day care or classroom. Unfortunately, there is no effective treatment for a viral pinkeye. Even more unfortunate is the fact that many day care centers insist that the child be on antibiotics before they are allowed to return even thought the antibiotics do nothing to treat the infection or prevent its spread.

     Allergy can also cause a child’s eyes to be red. This pinkeye comes on seasonally and is accompanied by other allergy symptoms. The eye has lots of tearing and itches – you will always see the child rubbing his eyes. A thin, clear bubble can appear on the white area of the eyeball or bumps may develop on the inside of the lower lid. This pinkeye can be treated with antihistamines, just like the other allergy symptoms.

     A more serious infection is a bacterial infection of the eye. Sometimes a viral infection of the eye can change into a bacterial infection and sometimes bacterial infections occur spontaneously. A blocked tear duct in a newborn can also sometimes develop into a bacterial infection. This infection causes the eye to be really red. There is usually a thick, colored discharge from the eye and the eye may not be sensitive to light but may have some pain. This infection needs to be checked right away and treated with antibiotics.

     There are two other lumps near the eye that can cause the eye to be pink. A sty is a little pimple-like bump with pus in it that appears at the edge of the eyelid just at the base of the eyelash. There is usually some tenderness, swelling and redness around the bump. This is treated with warm compresses and antibiotics.

     A firm bump can also develop under the center of the upper or lower eyelid. This can cause some irritation and redness in the eye itself. This is called a chalazion and is also treated with warn compresses and, sometimes, with antibiotics.

     Finally, even if the eye is not pink, any child who complains of pain in the eye or vision problems needs to be seen by a physician right away.

Things To Do When the New Baby Arrives

     The August issue of Pediatric News has an excellent article by Barbara Howard M.D., assistant professor of pediatrics at Johns Hopkins. The article discusses things that new parents (and parents-to-be) need to discuss.

     The newborn period is a time of stress and also a time of huge changes. How a couple interacts during this period can have long-term effects on their relationship. Difficulties that arise when a new baby enters a family can have both positive and negative effects on the marriage that can last for years.

     Mothers need to feel that the father of the baby is a true partner. He needs to be sympathetic to the fear and pain she endured in labor and delivery and also to the complete exhaustion she will be dealing with in the first weeks at home.  Fathers need to listen closely to their partner and remember how important it is to ask up front, “what can I do for you”.  A loving husband may bring home flowers and then be hurt when the wife is bothered by the smell and actually wanted him to give her a foot rub.

     Fathers and mothers both have to realize that their relationship has changed in a very fundamental way now that a new person has been introduced into it. Things are never going back to the way they were. It is important that parents have honest discussions about their sexual relationship, breast/bottle feeding, how to handle sleep problems, how to handle relatives who want to visit and how to share the everyday workload. Parents need to be absolutely open about both their emotions and their beliefs. If there are differences in religious or cultural beliefs, these also need to be discussed. If the parents are able to engage in this kind of discussion early, they will probably be able to continue as the child grows older and issues like discipline, feeding, and school arise.

     For second-time parents, Dr. Howard also recommends being realistic and honest with the baby’s older siblings. Parents should avoid the “you’ll have a new brother to play with” attitude because babies aren’t much fun for a long time and all the sibling will see is how much the baby takes away time that they used to have with the parent. They’ll see how, when the baby screams and cries, the parents drop whatever they were doing and go to interact with the baby, so, the logical conclusion is that if they act the same way, the parent will spend more time with them. Potty-trained siblings may want to be in diapers again. Parents can ease the situation by allowing the sibling to openly express any feelings they have – especially the negative ones – and by making special one-on-one time every day with the sibling that cannot be interrupted by the baby.

Sleep Habits At All Ages

     One of the most common problems encountered by parents of children of any age are sleep problems. Questions about sleep patterns are some of parents most frequently asked questions.

     Sleep affects almost every aspect of our lives - not only our energy level and ability to concentrate, but even our basic physical health, immune system function and metabolism. If a child has sleep problems, the entire family can be affected.

     As every parent knows, newborn infants have very erratic sleep patterns. Up until a year of age, infants can need up to 18 hours of sleep daily, but that often comes in 3 hour bursts. Another problem with infants is that they can go from being happy to being miserably tired in less than a minute. Determining whether an infant is crying because he is hungry, wet or tired can be often be difficult for parents because each seems to come on instantaneously. Sometimes, the infant will give a clue with the rubbing of the eyes or ears, but most of the time a parent simply has to go through the list: first, check to be sure he is dry (and remember, sometimes even a small spot of wet will set an infant off); if not wet, try to feed – if the infant stops crying and starts eating, he was probably hungry. If the infant isn’t wet and refuses food, he is probably tired. Rock him, hold him and read to him for a short time and then put him in his crib and leave – even when the crying starts up again. If he is tired, he’ll cry for a while and then go to sleep. Remember infants often wake themselves up in REM dream sleep, so no matter when he wakes up, if he is crying inconsolably, go through the same list again. He might have woken himself up 2 hours into a 3 hour nap and what he actually needs is to go back to sleep for awhile. 

     As children get older, parents can establish and maintain good sleep habits. Co-sleeping in the parent’s bed should always be avoided. Co-sleeping with infants is dangerous and co-sleeping with older children it a difficult habit to change and results in neither the child nor the parent getting adequate sleep. Maintain the last hour before bedtime/lights out as a quiet time for reading together, baths, talking about the day and making plans for tomorrow. Most experts still recommend no “screen time” during this hour before bed – TV, computers, electronic games or phones. For parents who are both working and feeling like they don’t have enough time with their kids, this hour may end up being the best quality time of the day.

     After elementary school, the child needs to start to assume more control over his own bedtime routine. If parents have established good sleep habits since day one, this transition will be easier. Homework should be done early in the evening and the last hour before bed should still be quieter and more “screen-free”. Even though it is impossible to stop late-night phone calls and computer use, parents need to continue to encourage good sleep patterns.

What Is Causing My Child's Diarrhea?

     Diarrhea is a common problem in children and it is helpful for parents to have some general rules of thumb that can identify what might be causing the diarrhea. Doctors divide diarrhea into three groups: acute (which lasts for 1-2 weeks), persistent (which lasts for 2weeks to one month) and chronic (which lasts for over a month). Of course, when your child has diarrhea, it is impossible to know how long the diarrhea is going to last unless you have a crystal ball but the categories can still be helpful.

     Viral infection causes the most common form of diarrhea: acute diarrhea. This often begins with fever and vomiting for 24 -48 hours and then the child has diarrhea for a week or two. At first, the stools may be very frequent and the child may feel very ill. The greatest risk with this form of diarrhea is dehydration and the only treatment is to give lots of water and electrolytes to keep the child hydrated. This means small sips frequently of a rehydrating solution: a mixture of water, sugar and salts. After a few days the frequency of the stools will slow down, but they may stay liquid for 2 weeks. If the symptoms are more dramatic or there is blood in the stool, a bacteria such as E. coli could be the cause of the diarrhea and the child’s caregiver should be consulted.

     Persistent diarrhea usually doesn’t come on as dramatically as acute diarrhea. The child may have cramping and a few loose stools but continues to have them longer than 2 weeks. This type of diarrhea is most commonly caused by an infection with a small organism called a protozoan parasite. The most common ones are Giardia and Cryptosporidium. These parasites are usually in water and the child becomes infected by drinking the water. Giardia is common in small, natural sources of water such as streams and ponds and wells. Cryptosporidium can survive up to 10 days in chlorinated water, so it is commonly found in swimming pools. Cryptosporidium is also sometimes acquired in petting zoos (so, good hand-washing should always be the rule after being in a petting zoo). With these infections, the child is not terribly sick, but he may have cramping. The stools are not frequent, but they are persistently liquid. Protozoan parasite infections can be difficult to diagnose. Even though there may be many eggs in the child’s stools, they may be difficult to find in a stool sample. There are medications that can kill the parasite and treat the diarrhea.

     If the child’s diarrhea lasts for longer than a month, or if it seems to come and go for longer than a month, it is chronic diarrhea. Strangely enough, one of the most common causes of chronic diarrhea is constipation. The child has recurrent abdominal cramps – especially after meals. Some stools are large and hard but others are explosive and liquid. A simple X-ray of the abdomen will show whether too much stool is the cause of the problem. Other causes of chronic diarrhea are: gluten intolerance, food (especially milk) allergy, lactose intolerance and any of the many forms of inflammatory bowel disease. This kind of diarrhea needs a full work-up by the child’s caregiver. 

Cutting The Umbilical Cord

     For a long time, Nurse Practitioners and Midwives have tried to convince medical doctors to delay cutting the umbilical cord after birth. Historically, the umbilical cord was not cut immediately after birth and in most third world countries cutting the umbilical cord is also delayed for over 1-2 minutes after birth. In contrast, in this country the umbilical cord is usually cut 10 to 15 seconds after birth.

     Not clamping the cord results in the infant getting extra blood that is pumped out of the placenta after birth. Medical doctors have believed that this extra blood was harmful to the infant because it caused the infant to have too much blood and it also increased the risk of jaundice in the first few days of life. Midwives have held that humans have always waited to clamp the cord because the extra blood is helpful to the baby.

     There are two studies in the August, 2014 issue of Pediatrics, the official journal of the American Academy of Pediatrics, which go a long way to support the opinion that clamping the cord should be delayed. The first is a very complex, scientific study that measures stress in the newborn.  The researchers found that not only did the extra blood from the placenta reduce the post-delivery stress of the newborn, but it also gave some helpful elements that helped the infants deal with the stress of delivery. The second study was done in a rural Tanzania hospital and it found that, even in healthy infants who were breathing on their own after delivery, the complication rate for the infants was decreased by 20% for every 10-second delay in clamping the cord after the infant started breathing.

     The current practice in most American hospitals is that immediately after birth the cord is clamped and cut and then the infant is given to the nurse, pediatrician, or nurse practitioner who is responsible for the infant’s immediate care. The doctor who is responsible for the delivery needs to concentrate on the mother’s care. Delaying the cutting of the cord would be difficult. The second study suggested that, even if the infant wasn’t breathing at first, delaying the cutting of the cord was still beneficial. But when an infant isn’t breathing after delivery, our current way of thinking is that the infant should immediately be given respiratory support with a bag-mask respirator. Doing this at the foot of the delivery bed would mean a significant change in the procedure.

     Modern medicine improves its care by continually questioning its practices and procedures. If these studies hold to be true, it may result in changes in every delivery room in the country.

When Your Child Turns One Year Old

     Your child’s first birthday is a good time to evaluate a number of issues and, if necessary, make changes that will make the toddler years easier for both of you.

     The first change is in the bottle. After one, the only liquid that goes into the bottle is water – no formula, milk or juice. The child can still have a bottle anytime he wants, but, by only putting water in the bottle, you’ll be helping his appetite, his teeth, his weight and his health in general. In addition, your budget will be improved when you no longer have to buy formula. So, the plan for a one-year old is that he drinks regular milk at meal times, in a non-spill cup, drinks water between meals – especially in the naptime and bed time bottles – and never drinks formula or juice.

     His meal menu now is regular food – no more baby food and no special meals. You chop up whatever you are eating and then put it on the tray in front of him. It is important that you also sit down with him and eat your meal, too – kids eat better when the parent eats with them and they are more likely to try foods that they see the parent eating. No more feeding him, no more “Here comes the airplane”.  Just put it in front of him and let him go – some goes in the hair, some goes in the ears and some gets into the mouth. When more food hits the floor that hits the mouth, remove the tray – he’s done eating. If he refuses everything, think back to what he may have eaten or drunk the two hours before the meal. In most instances, refusal to eat is caused by not being hungry rather than “he doesn’t like it”. Resist the temptation to try other foods that you think he’ll like – this results in hot dogs at every meal and you teaching your baby that you’re willing to be a short-order cook.

     Stranger and separation anxiety are beginning now, so remember that “loveys” – blankets, worn stuffed animals and even special clothes – are all very important now. You may need to carry around an extra bag or two, but he needs them. Also remember how important repetition is for his security as you read the same story for the 16^th time that day. Don’t force Grandma on him if he acts frightened – he’ll warm up to her gradually in his own time.

     He can still have the pacifier, but it never leaves the crib. As soon as he wakes up, he’ll want out of the crib, but when you pick him up, leave the pacifier behind. If he wants to go back to get it, he finds that it has (amazingly) disappeared. But it will reappear again at naptime and at bedtime when he gets back into the crib. If he has been taught that he can have the pacifier all day, this habit may be a little hard to break, but don’t give up. In a very short time, he’ll go with the new program and it will save you a world of trouble.

    Keep the car seat facing the rear of the car for as long as you possibly can. It is always the safest way to transport toddlers, too.

     Don’t worry about buying expensive, hard-soled shoes. His feet will grow fine whether you put him in the shoe or the shoebox.

     Finally, remember how important time together is. You are his teacher, his role model and the source of all his love and security. Spend as much relaxed, non-structured, play time as you possibly can with him. All too soon he’ll be a teenager.

Molluscum - Those Little White Bumps

            Molluscum Contagiosum is a very common rash in children. It is caused by a virus that creates small, flesh-colored bumps with a white cottage cheese-like substance inside the bump. If you look closely, you can see a slight dimple in the center of the bump that resembles a little belly button. You first notice a few bumps and then, over time, there are more and more of them until you finally are tired of looking at them and just want them to go away.                                           
           There are lots of treatments (not cures, because it is a viral illness) for molluscum. When I started practice, the dermatologists told us to pick the center of each one out with a needle. Pediatricians finally revolted against this practice because it was painful and bloody, and, besides, the molluscum just kept coming back. Since then, some dermatologists still use the needle and others use mild irritants like benzoyl peroxide while others use harsher chemicals (acids or  "bug juice" - an insect-derived highly irritating substance), and others burn or freeze them off much like warts. The dermatologists swear that they do all this because it makes the molluscum go away faster (remember that even they don't claim to "cure" molluscum) but in 35 years of practice, I never heard one parent say that they thought anything actually worked - the molluscum just kept coming back until they finally didn't come back. I also never heard one parent say they were glad they did any of the treatments. The molluscum don't leave scars unless they get infected, but many of the treatments leave small scars that are permanent.
            When you go to a dermatologist (or any doctor for that matter), you have paid money, taken time out of your day and waited to see that doctor. The doctor feels obligated to do something "doctor-like". Many (if not most) of the day-to-day problems that we human beings suffer with are self-limited and will go away without doing anything, But most people who go to a doctor don't want to hear the doctor say, "Just ignore it and it will eventually go away", so there is pressure on both doctor and patient to "DO SOMETHING".
            As much as you want the molluscum gone, and as sick as you are of having to answer questions about them, it still is best to just ignore them. If one gets inflamed from the child irritating it or if one looks red and infected, put Neosporin on it and cover it with a band-aid until it heals.
            Or, there are plenty of doctors out there who are more than willing to have you pay them to treat the molluscum and, once you are on that road, they will be seeing you again and again.

Spanking And Discipline

     Spanking works. No doubt about it. It rapidly stops unwanted behavior. The problem is that it has side effects that parents might not want. In the short term, it causes children to be more aggressive towards other children, siblings and even toward the parent. In the long term, it can make the child sneaky and less likely to admit mistakes. It can also give the child the blueprint for becoming a parent who hits their child. A study of white children 0 to 23 months of age found that the children had worse behavior at 6 years old if they were frequently spanked. Finally, physical punishment must be progressively increased to keep working.

     Spanking is especially ineffective in infants. Under a year of age, infants cannot learn to avoid a behavior by being spanked. They only become frightened of the parent and confused because they have difficulty connecting the behavior to the punishment. That is also true for timeouts at this young age. This does not mean that young infants should not be disciplined. The first way to begin teaching discipline to children under one year of age is simply saying “No” in a serious, firm way that causes the infant to stop the behavior, give a startled look and begin to cry. It is important for parents to realize that this does not mean shouting. Many times I’ve talked with a parent who says, “ I shout and shout and they don’t listen”.  The reason, of course, is that the parent really does just “shout and shout” and they have taught the child to ignore them.  When you say “No”, you will know that the message got across if you see the startle and the tear (“fear and a tear”). But that’s the end – you can immediately comfort the child and go on with your interaction with the infant. When the behavior repeats (and it always does), you do the same thing with the same level of intensity but without any escalation (even if you are feeling frustrated because the child didn’t “learn” the first time). You don’t have to do anything more but you do have to be consistent and say “No” in the same way each time the behavior occurs.

     By one year of age, you’ve taught your child that the word “No” means: “stop the behavior and pay attention to Mom”. Between one and two years of age, you can begin to add simple verbal directions – “No, no hitting” Again, consistency in your reaction is the key. Rather than shouting, you can even decrease the volume as long as the child stops the behavior and clearly pays attention and listens to you.

     After two years of age, the parent can begin using time-outs. Time-outs have been proven to be as effective as spanking without the unwanted side effects. Now the parent can start to add more discussion and explanation. Depending on the toddler’s level of understanding, the parent can also help explore alternative behaviors that may not have resulted in the discipline. This is done in a quiet, sensitive, serious way which conveys to the child that the parent is displeased with the behavior but still clearly shows the parent’s love for the child.

     Once you are dealing with the child on a verbal level, I’ve always felt the “Practical Parenting” program was excellent. You can find it online.

Signs That Your Child May Have An Eating Disorder

     We have all heard that eating disorders are dangerous – even life-threatening. They can occur in children, adolescents or adults and they can cause chronic poor health along with an increased risk of early death. They occur more often in girls and women (nine times more common in females), but it is important to remember that they can happen in young boys and, when they do, they can be subtle and hard to detect. Eating disorders can occur in both athletes and in non-athletic obese adolescents. In males, an eating disorder can present with intense body-building and use of muscle-enhancing drugs.

     A common eating disorder is anorexia with food restriction causing loss of weight and distorted body image of being fat when the child is obviously thin.
These children usually have an obsessive fear of gaining weight. Female athletes often can have problems with their menstrual cycle. Another eating disorder is bulimia in which a child’s weight may be normal or even above normal but the child goes through cycles of binge eating followed by trying to compensate for the binge by self-induced vomiting, use of laxatives or diet pills or excessive exercise. Another less common eating problem is food avoidance where the child doesn’t have body image distortion, doesn’t have fear of gaining weight but does severely avoid and restrict themselves from eating many foods because of other fears and concerns.

     One of the first signs of an eating disorder that parents can watch for is a lack of growth or weight gain in a young child or adolescent. At this age, growth should be obvious over a six-month period and, if the child doesn’t need new clothes, is actually smaller, has delayed puberty or has interrupted menstrual periods, the child needs to be evaluated by their caregiver.  A parent may hear repeated comments from the child about weight, eating, or dieting. There may be obsessive exercise or body image distortion (“I’m so fat!” when the child is actually thin; “I wish I had a better build” when the child is already very muscular).

     A child with an eating disorder can also have physical changes. Along with irregular periods, the child may have cold intolerance, dizziness, fainting, or complaints of chronic fatigue. They may complain of problems swallowing, recurring abdominal pain or constipation. They may have hair loss, bones that obviously protrude, swelling of their ankles, or erosion of their teeth enamel from vomiting.

     Treatment of eating disorders can involve not only the child’s physician but also a nutritionist and a psychologist or psychiatrist. Restoring weight by adequate food intake is the first goal. The child may need extra vitamins and minerals in addition to extra calories. Along with restoring weight and health, the psychological healing needs to be addressed. A system called family-based therapy has been proven to be effective and is used by many eating disorder centers in the country. Because these behaviors can be very difficult to treat and can easily recur, it can be important to have contact with a program which specializes in eating disorders, incorporates the necessary specialists and allows the patient to return during times of relapse.

Notes On Vaccinations

       There is currently an outbreak of measles in an Amish population in Ohio. It started when unvaccinated Amish travelers to the Philippines contracted measles and then returned home. Because a significant segment of Amish are not vaccinated for measles, the disease spread rapidly to more than 360 cases. The establishment of rapid vaccination clinics, quarantine and door-to-door visits by public health nurses finally slowed the spread of the disease. The concern of health officials is that an international showcase of horse-drawn equipment is scheduled to be held this week with over 20,000 Amish expected to attend and there is a risk of attendees contracting measles and taking it back to their home communities.

     In my home state, Minnesota, in March of 2011, an un-vaccinated 30-month old child was infected with measles while visiting Kenya and, on returning, infected 21 other people – the largest measles outbreak in Minnesota in 20 years.  Again, an aggressive vaccination program prevented additional transmission.

     Before vaccinations for measles began in the 1950’s, the disease would cause 48,00 people a year to be hospitalized, 500 people a year to die and 1,000 people a year to suffer brain damage or deafness. Vaccination has almost eradicated measles in the United States, but the disease remains common in many parts of Asia, the Pacific and Africa – areas that are only a plane ride away.

     Multiple studies on hundreds of thousands of children have proven that vaccines are safe and effective. The measles vaccine has absolutely no connection to autism or brain damage. The July issue of Pediatrics, the official journal of the American Academy of Pediatrics, has studies showing the safety and effectiveness of both the rotavirus vaccine and the chicken pox vaccine. A recent study found that giving the Tdap (tetanus, diphtheria, and acellular pertussis) vaccine to a pregnant woman protects both the mom as well as her unborn child against whooping cough, a disease that can be fatal to young infants.

    

      Yet, even though the vaccines which protect children from these diseases are safe and the consequences of becoming infected with these diseases can be devastating (even deadly), why do so many parents continue to refuse vaccinations for their children? A study in the March issue of Pediatrics revealed an interesting fact: the more positive information about vaccines that parents who were against vaccination received, the less likely they were to give their child vaccinations. Information about the safety of the MMR vaccine, information about the dangers of the disease, images of children with measles and a dramatic story about an infant who almost died from measles did not increase the parents intent to vaccinate, even though they said that they no longer believed that the vaccine caused autism. In fact, parents who had the most negative view of vaccines said that the information made them less likely to vaccinate their child! Doctors do scientific studies to find out the best way to do things – the safest, most effective medicines and the best treatments. Doctors obviously have a lot to learn about how the human mind works.

Accidents Involving Cars And Kids

In summertime, the risk for accidents increases and many of these accidents occur in and around the car.  A wonderful tool for parents is available online at: www.safercar.gov/parents/home.htm. This site has a wealth of information for parents about how to avoid common accidents.

            One section deals with the danger of leaving a child in a parked car. Every summer, there are reports of children dying of heatstroke because they were either intentionally or accidently left in a hot car. A study of 1000 parents early this year done by Public Opinion Strategies revealed that 7 out of 10 parents said that they had heard about the danger of leaving a child in a car, but 14% of those parents reported having intentionally leaving a child aged 6 or younger alone in a parked, locked car. 6% said that they were comfortable leaving their young children in a parked vehicle for longer than 15 minutes. It is common to think that these parents are neglectful, but in cases of a child dying from heat stroke in a car, only 8% were found to be negligent – meaning there were drugs, alcohol or a previous report of negligence to Child Protection. In 52% of the cases, the parent simply forgot that the child was in the car. In 30% of the deaths, children were left playing in the car and in 18% the child was left intentionally. These were not “bad parents”. They just made a bad decision (“I’ll only go into the store for a minute”) or simply forgot the child was with them – often because they were not used to traveling with the child. The website reminds parents to never leave a child in the car, even if the window is cracked open. Don’t let children play in the car and always check before leaving the car – “Look before you lock”.

            The site also discusses power window accidents, including strangulation caused by a rising power window. These accidents are common in vehicles that have push button power window controls (newer vehicles have “lift” controls rather than “push down” controls). Parents need to teach their children not to play with or around the door armrests. The parents should never leave a key in the ignition or have the key turned to “on” or “accessory”.

            Leaving the key in the ignition can also result in the child moving the car’s gearshift out of park and the car being set in motion with the child in it.

            Earlier this year, there were news reports of a toddler “going missing” at a family gathering and, after a prolonged search, the child was found dead in the trunk of the family car parked right in the driveway. The site talks about how to avoid trunk entrapment and also talks about how to avoid back-over accidents where a driver drives over a child while backing up out of a driveway or parking space.

            Finally, the site gives excellent information about car seats, and all manner of child restraints to keep children safe in cars. It also has articles about bicycle safety and safe teen driving.

The handouts are printable and all the information is free.

An Unusual Cure For Bedwetting

     A recent study of children who wet the bed showed an interesting problem: all of the bedwetting children were found to be constipated. Constipation causes stool to build up in an area behind the urinary bladder. This puts pressure on the bladder and causes the child to have problems holding urine, especially at night.

     When the children in the study were treated for the constipation, 83% of them stopped bedwetting within three months.

     Constipation is a very frequent problem for children. It is by far the most common cause of recurrent abdominal pain, especially after meals. It can cause loss of appetite and even cause recurrent vomiting. When a child is constipated, his stools are usually hard and large, but some stools can also be liquid and explosive and the child can have recurring stooling “accidents” in his pants.

     Constipation is usually a long-term problem for children and even after it has resolved, it frequently reoccurs because it results from habitual stool withholding.

     If a child has severe pain from constipation, enemas can give immediate relief. Children’s enemas can be found in any pharmacy. But constipated children need long-term treatment with daily laxatives. There is a commercial product that is a powder parents can dissolve in water or other liquids. This has no real taste and can be given every day. Parents should give larger doses until stools are very soft and the child has no complaints of cramping. After that, the dose can be lowered, but the child needs to stay on a daily dose that keeps the stool soft and keeps the child pain-free. If the child begins to complain of pain again, the dose should be increased.

     Abdominal pain has many possible causes and a child with severe or recurrent abdominal pain needs to be evaluated by his caregiver before any course of treatment is attempted, but, for children with both problems – bedwetting and constipation – curing the constipation could also cure the bedwetting.

Sugar,Fluoride And Teeth

     The June issue of Pediatrics has a detailed report from the United States Preventive Services Task Force about preventing dental cavities in children. It mentions the importance of fluoridation in drinking water and discusses the benefits of the fluoride treatments given by doctors and dentists. It also discusses problems that can occur with too much fluoride such as staining and pitting of the tooth enamel. It is important for parents to be aware of the different sources of fluoride that their children are exposed to (tooth paste, mouth wash, drops, tablets) and to discuss them with their child’s caregiver to be sure the child is receiving the proper amount of fluoride.

     The prevention guidelines listed in the report discuss the importance of avoiding excess sugar and specifically mentions inappropriate use of the bottle.

     Too often, toddlers carry around a bottle of juice or milk through the day and take a sip anytime they want to. This continuous exposure of their teeth to sugar is a common cause of severe dental cavities. Going to bed with a bottle of milk or juice is another cause.

     Up until an infant is one year old, he can have bottles of formula. After six months of age, he should be given milk in a sippi-cup at mealtime but still given a bottle of formula whenever he wants it. At this age, there is no need for (and certainly no benefit in) juice. When a child hits his first birthday, all bottles should magically become water and, after that time, parents should never put anything but water in bottles, daytime or nighttime. This eliminates the debate about when to stop using bottles because, as long as the only thing in the bottle is water, the child can have a bottle whenever he wants it for as long as he wants to use it (in fact, lots of adults suck from a water bottle with a nipple on it). Milk is always given in a cup, and only given at mealtime.

      A recent documentary film (“Fed Up”) and a book (“The Omnivore’s Dilemma”) both outline the problems our society has with our addiction to sugar. That addiction starts early in life with juice, snacks with sugar and processed foods. When infants begin eating solid foods, parents should give them fresh fruit and vegetables ground up to a proper consistency.  Juice is nothing more than water and sugar and when the package says, “100% fruit juice”, it doesn’t mean “100 fruit”, it means “100% fruit sugar”.  The same is true for the many kinds of processed “fruit snacks”. Fiber and other components of fresh fruit help our bodies digest and process the fruit sugar and, without them, the sugar easily turns into fat.

     When our kids are thirsty, we should give them water between meals and milk at meals. When our kids want a snack, we shouldn’t give them apple juice, we should give them an apple.

Should Baby Cry Herself To Sleep?

          One of the most touchy topics in Pediatrics is whether or not to allow babies to cry themselves to sleep.  A visiting granddaughter recently showed me that sometimes it is not a question of “whether or not” but it is an issue of “need to”.

     Our granddaughter is 9 months old and is a quiet, easy-going baby who hasn’t ever much needed to cry herself to sleep because she clearly advertises when she is tired - suddenly crabby, rubbing ears, rubbing eyes, not wet and not hungry – and goes down with a minimal amount of rocking and singing. Like most 9 month-olds, she needs both a morning and an afternoon nap.

     On the day in question, she went down for her morning nap in the guest bedroom and after she was asleep, her father joined her for a nap. After she had been asleep for only an hour, his cell phone rang and woke them both up.  Because she was in an unfamiliar environment, she woke up totally and wanted to play.

     Later, she again got tired at the time for her afternoon nap. But her parents were going to a wedding that afternoon. I put granddaughter in the car seat knowing that she was so tired that she would be asleep by the time the car reached the end of the driveway. She was. But when we returned home after dropping off her parents, she woke up again when I took her out of the car seat. Once again, she wanted to be up and play.

     When bed-time rolled around, she was beside herself. She had been awakened halfway through each of her daytime naps and she was beyond exhausted. She cried when we gave her her pacifier, when we tried to rock her, when we picked her up and when we laid her down. She was rubbing eyes and ears and yet could not settle herself – crying and screaming no matter what two frustrated grandparents could come up with. All she knew was that she was miserable and nothing was helping her feel better.

     Finally, even though her parents agree with the “no-crying-to-sleep” school, we put her into the portable crib and closed the door. After ten minutes of loud, tearful protest, all was quiet and she was gratefully asleep. She slept through the entire night and well beyond her normal time to wake up. When she did awaken, she was her happy, normal self.

     When you know a baby is tired, it is time to let them go to sleep. If you find that what you are doing (rocking, holding, walking, etc.) is keeping them awake, it is time to give baby a chance to cry off the extra bit of energy that is keeping them awake and let everyone get some much-needed sleep.

 

Acne At Different Ages

     Most parents think of acne as being an adolescent problem, but acne can occur at any age.

     Acne in the first few weeks of life is very common. This “newborn” form of acne is mild with small red bumps but no blackheads and minimal inflammation. No treatment is necessary and it usually just goes away with time. It leaves no scars.

     In older infants and toddlers up to age 2, acne can look more like adolescent acne with inflammation, blackheads and pustules. This acne can result in scaring, so the child should be seen by his caregiver and should be treated. The child should also have a good examination to be sure that the child’s growth and development are normal. Acne at this age is much less common than newborn acne, but it does occur.

     Acne in the age group between 2 and 6 years of age is rare and it should always make the parents and the caregiver worry about a hormonal problem. It is probably best to refer children who develop acne in this age group to an endocrine specialist for evaluation.

     Some preteens can get acne. Puberty seems to be occurring at younger ages in this country and acne is often the first sign of puberty. When a preteen gets acne, the child’s caregiver needs to evaluate the child’s growth and development, but, if everything is normal, regular acne therapy should be started.

     For common adolescent acne, there is a product that is heavily advertized on infomercials and in print that is very expensive. This product’s active ingredient is benzyl peroxide, a common acne medicine that can be purchased in any drug store without a prescription and at a much lower cost. The only benefit of the product is that it gives teens a strictly scheduled way of applying it and teenagers are likely to follow it. If the teen would follow the same regimen with the benzyl peroxide from the drug store, it would be every bit as effective.

     If adolescent acne is mild or moderate, their caregiver has ways of treating it that are very effective. If the acne is more severe, a referral to a dermatologist may be necessary. If a teenage girl gets acne at the time of her periods and then the acne improves when the period ends, regular acne therapies may not be effective and she may need to go on a high-estrogen birth-control pill to control the acne.

    

Immersiion In Water During Labor And Delivery

     Immersion in water has become popular in certain circles and many facilities offer it as an alternative way to give birth. The April, 2014 issue of Pediatrics published a joint clinical report on immersion labor and delivery issued by both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.

     Advocates of immersion during labor and delivery argue that it decreases pain, decreases maternal stress, decreases trauma to the vagina and gives the infant a gentler transition into the world.

     The report in Pediatrics examined the statistical data available for immersion during both the first and second stages of labor and during delivery. They found that immersion in the first stage of labor was associated with a decreased need for epidural, spinal and cervical pain relief. It also reduced the first stage of labor by about 30 minutes. However, there was no difference in vaginal tears and no reduction in the need for cesarean delivery. They found no benefit to the mother with immersion during the second stage of labor. There was no measurable benefit to the infant from immersion during either labor or delivery.

     The report did find that immersion caused an increase in complications for both the mother and the infant. There were higher rates of maternal and infant infections, especially if there had been rupture of membranes. There were reports of infants having severe bleeding from ruptured umbilical cords, infants having hypothermia and infants having episodes of drowning and near-drowning.

     The most serious complications were the drownings and near-drownings. The advocates of immersion birth claim that the infant is protected from inhaling water by the mammalian diving reflex. A Cochrane review in 2009 stated that they found no adverse effects on the infant from immersion, but this study excluded 12% of the infants delivered by immersion who had to be admitted to the Newborn Intensive Care Unit as compared to none in the group delivered without immersion. It also ignored reports of drowning and near-drowning from England in 1995 and a report in 2010 of 4 infants who had severe respiratory distress after water birth. There is a great deal of evidence in both experimental animals and in human infants that the decrease in oxygen which occurs during delivery causes the infant to gasp (which is exactly what Nature intends the infant to do) and the need to take that first breath overrides the diving reflex.

     The conclusion of the 2014 report was that immersion during labor and delivery should be considered an experimental procedure and that the risks involved dictate that it should only be done as part of a closely controlled scientific study.

Super Head Lice

       When I last wrote about head lice in March, 2012, medications that could be purchased over the counter were still effective in treating head lice.  That is no longer true.  The two medications that can be purchased without a prescription, permethrin and pyrethrin, are no longer effective according to an article published in the Journal of Medical Entomology.  The article states that 99.6% of head lice have a gene mutation that gives them immunity to these commonly used medications. Many head lice are also resistant to two other commonly used prescription medications, lindane and malathion.

     There are three new medications that are available by prescription and are effective in treating head lice. Benzyl alcohol comes in a lotion that is applied for 10 minutes to the hair and scalp and then rinsed off and repeated in a week. (“nits” – the lice eggs - hatch in a week). Spinosad is a lotion that is used in the same way.  Both can cause irritation to the scalp. Ivermectin is available in both a hair/scalp preparation and as an oral medication. Ivermectin kills both lice and eggs, so no repeat dose is necessary. Sulfa-based antibiotics are also used to treat head lice, but they can cause serious allergic reactions.

     Wet combing – using a fine-toothed nit comb after lubricating the hair with a substance to make the comb pass more easily – is now considered the best way to make the diagnosis of head lice. If live lice are obtained by passing the wet comb through the hair., the child has an infestation. However, if a parent sees the child itching the scalp and then notices nits or lice on the hair, the child almost certainly needs treatment. However, simple inspection is not adequate to tell whether a child has been treated successfully. It is thought that after treatment, 28% of children still have lice on their hair and 63% still have nits. This is important because schools bar children with lice from coming to school and many schools have a “no-nit “ policy for allowing the child to return to school – if the nurse sees a nit, the child goes home. This results in millions of needlessly lost school days every year.

     Repeated wet combing is also used as a treatment for head lice for people who don’t want to use medications. The lubricated hair is combed for up to 30 minutes every 3 to 4 days until no live lice are found and then continued for about 2 weeks after that to ensure successful treatment.

     There are many other treatments commonly recommended but without any real scientific proof of effectiveness. Smearing olive oil, petroleum jelly or mayonnaise in the hair doesn’t really “suffocate” the lice. Heat applied through an electric comb or a hair drier doesn’t work, either.

     Finally, many of the recommendations about how to clean the house when a child has lice are part of the general overreaction that we all have as parents when we think of bugs crawling on our child’s head. Lice that fall off the head probably don’t live more than 48 hours and any head louse that would crawl off a nice, warm, bloody scalp in order to attach to a stuffed animal probably wasn’t going to live long anyway. It is reasonable to hot-water wash hats and linen that were used for two days before the diagnosis was made, but putting all the stuffed animals in a bag for two weeks or spraying the furniture with anti-lice spray aren’t necessary. Also, don’t blame the family dog or cat – they don’t carry human lice.  

When To See A Doctor For A Child's Cold And Fever

            When babysitting for a niece recently, Grandma and I were told, “If he gets a fever of over 100.3, take him into the Emergency Room”. Her toddler son is perfectly healthy and has no medical problems, but our niece had been told by a medical person that “any fever over 100.3 was dangerous.”

            Toddlers, especially toddlers in day care, seem to catch a new virus about every two weeks. In this era of poor insurance and high co-pays, it is important that young parents know how to tell if a child needs to examined in a medical facility or if observation at home is appropriate.

            Most viral infections start with an evening fever. The child is crabby, tired and has a poor appetite at the end of the day and then develops a fever. The height of the fever is unimportant – fever that comes with a viral infection is never dangerous. If, after an age-appropriate dose of a fever/pain reliever is given, the child seems to feel better, the parents should just watch to see if the child acts any sicker.

            Within the next twelve hours, the virus will declare itself – the child will develop runny nose and congestion or perhaps vomiting and diarrhea if it is a gastrointestinal virus.

            With an upper respiratory virus (a “cold”), the child can feel pressure and fluid build-up in the middle ear because the swelling in the nose causes blockage of the drainage tube out of the ear. The child complains of mild ear pain and pulls on the ear. The child’s eye can develop some crusting mattering from a similar blockage of the tear duct. The ear pain can be treated with a dose of fever/pain reliever and the mattering in the eye treated with cleansing with a warm washcloth. The nose drainage can be thick or thin and can be about any color. The fever will be up and down for three days. The child will be coughing and feel bad, but will not be severely lethargic or ill-appearing. No cold medications or antibiotics are necessary. The symptoms improve over three days, even though the cough can last for two weeks.

            A complication of a cold is that bacteria can infect the blocked fluid in the ear or the eye. These infections usually develop later in the course of a cold. Daytime fever with a common cold should be gone by the third day. If the daytime fever lasts longer than three days, or if the fever goes away and then returns, it could be a sign of bacterial infection. If a prolonged or late fever is accompanied by more severe or continuous ear pain, the ear may need antibiotic treatment. If the mattering in the eye is persistent or becomes pus-like, it also could be a bacterial infection. If the fever returns on the fourth or fifth day and the cough is getting worse, pneumonia could be developing.

            But, if the child continues to act only mildly ill, the fever goes away in three days and the symptoms slowly get better, the child is probably going to be fine and the parents have made it through one more viral infection.

Helpful Rules For Parents Of Picky Feeders

        Picky feeding can develop anytime in childhood. Here are some basic rules for dealing with picky feeders:

#1. Eat Together.  With both parents working, having family meals can be hard, but mealtime should be a time for the family to sit down together with TVs and smart phones off. Fewer distractions can mean quieter, calmer and better meals for everyone. Younger children eat better when they see their parents eating the same thing that they are eating. Sitting a child in a high chair and trying to have him eat while other people in the house are doing other things is rarely successful.

#2. No fights at the table.  No one’s appetite is helped by being upset. Forget “clean-plate “and “one-more-bite” arguments. Don’t coax, plead or try to force (It’s impossible for one human being to force another to eat and your child will be happy to prove that to you!).  Mealtime is the time for families to enjoy each other and to talk about anything other than food and meals.

#3. Presentation is important.   For both adults and kids, how a meal looks (and, for toddlers, how it feels) can help or hurt the appetite. We all like fresh-looking food and bright colors, but remember that, for a toddler, the peas being arranged in a smiley face might help, too. Play with your food and make mealtime fun.

#4. Make a meal and serve it to everyone – avoid substitutions. Approach each meal with a positive attitude. Even though your toddler refused noodles yesterday, he might like them today. Continue to make and serve what you like, but you can experiment – if he didn’t like noodles with tomato sauce, he might like them with cheese. If you are going to discuss menu planning with your older child (every teenager wants to be a vegetarian at some time), have that discussion between meals. Once a meal is made and served, don’t be quick to offer substitutions like bread, hot dogs or extra glasses of milk or juice. If a child eats nothing but potatoes at a given meal, it is not a problem. But saying, “If you don’t like what I made, you can always have a hot dog” is a fast-track way to teach your child to be a picky feeder. If a child turned down everything you served, allowing him to have a dessert is just one more form of substitution.

#5. Picky Feeders aren’t hungry.  Children in third-world countries aren’t picky – they’re hungry. They eat whatever comes their way. Experts talk about children eating 5 small meals a day, but there are meals and there are snacks. Sometimes the snacks can sabotage the meals. Drinking milk or juice between meals is the #1 appetite-killer, especially with toddlers sucking on a bottle. Allow only water between meals and give fresh fruit for snacks. Fruit snacks are not fruit. Neither is juice. And allow your child to actually get hungry before the meal. Don’t give anything but water for 1 hour before any meal. If a child refuses to eat a meal, that means somewhere he got too much to eat between this meal and the last one. Don’t make the same mistake twice. If he turns down a meal totally, he can only have all the water he wants until the next meal. By then, the peas might look a lot better to him.

Nutritional Supplements For Autism

     In the April issue of Contemporary Pediatrics, there is an article written by Mary Beth Nierngarten (a native of my city, Saint Paul) called “Managing autism symptoms through nutrition”. The article points out that a high percentage of parents of autistic children use alternative medical supplements or nutritional manipulations such as modified diets.

     The diagnosis of autism is devastating to parents. What makes it especially difficult is the fact that physicians don’t have a “reason” or “cause” for autism and we also don’t have a “cure”. That results in desperation in the parents and leaves them susceptible to people who will offer “cures” that have no basis in fact.

    Ms. Niergarten’s article lists many of the alternative medicine supplements that parents use in the diets of their autistic children: Vitamin B6 - Magnesium, Vitamin C, Omega-3-fatty acids, cod liver oil and probiotics. It also mentions gluten-free diets, casein-free diets, high-fat/ low carbohydrate diets, and special carbohydrate diets (monosaccharides).  The article uses soft terminology like: “evidence to date does not confirm the rationale” and “evidence insufficient to support efficacy”. The reality is that none of these things have any real scientific evidence that shows that they are actually beneficial and some of the supplements are dangerous if given in high doses.

     There are also many “tests” offered online for “nutritional evaluation”, “allergy evaluation” and evaluation for nutritional deficiencies. As with the people selling supplements, the people who promote these tests are only taking advantage of the parents’ feelings of helplessness. A similar phony market exists for parents of children with Down’s syndrome.

     None of us has unlimited funds. The money spent on these unproven treatments could be better spent on the speech therapy, physical therapy, occupational therapy, special education and psychologic help that has been be proven to help autistic children.

Apology

Dear Readers, I failed to publish this Friday because my granddaughter is hospitalized and I haven't had time to write. A new article will be coming next Friday right on schedule.    Dr. John

Fainting

     Fainting is not lightheadedness or dizziness. It is a sudden, brief loss of consciousness in which the child “passes out” for a short time and then “comes to” and is all right. About one in every six children experience fainting sometime before adulthood. Most fainting in children is called vasovagal syncope (syncope means “fainting”) and is caused by a temporary slowing of the heart rate that causes less blood to flow to the brain and causes the child to faint. Along with having a slow heart rate, the child’s skin is pale, clammy and cold. The child rapidly regains consciousness and has no other problems after he wakes up. A fainting episode is harmless, although the child might sustain an injury from falling when he faints. Fainting commonly occurs when the child rapidly stands up from a sitting or lying position, is under stress or is in warm or crowded conditions (it often happens at church).

    However, there are other causes of fainting that are dangerous and parents should know how to tell the difference. The most dangerous form of fainting is caused by an abnormality of the heart. A study of 106 children who were seen for fainting found that 17 of them had heart trouble as a cause of their fainting. One of the most common heart problems is called hypertrophic cardiomyopathy. This is an inherited tendency for a chamber of the heart to gradually enlarge as the child gets older until it can no longer pump enough blood. This condition is the reason for most of the reports of an adolescent suddenly falling dead while playing a sport. These children often have no symptoms of their problem other than having fainting episodes while exercising. Any child who has a family history of sudden cardiac death during exercise needs to be closely examined before being allowed to exercise and any child who has a fainting episode during exercise needs a full heart evaluation including an electrocardiogram (EKG).

     Fainting can be a sign of other heart problems, too. These can be problems with an abnormal heart rhythm, infection of the heart, abnormal anatomy of the heart or abnormal blood vessels in the heart. Most of these can also be found with a good family history, a good physical exam and, possibly an EKG. This is not the kind of examination that can be done in an “assembly-line” fashion in a gym full of young athletes. If there is any family history of heart problems, a history of someone in the family who died suddenly at a young age or if a child has ever had fainting during exercise, that child needs at least a full evaluation by their physician and probably a cardiology referral.