Category Archives: Health

The Runt of my Litter. Why I Worry About my Smallest Child and When You Should Worry about Yours.

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CharlottesWebEvery day in the office at least one parent expresses concern over their smallest child: “His siblings were so much bigger at this age”; “Why is she sick all the time?”.

I can completely relate to their concerns. My 4 year old daughter is a runt1. Like Wilbur the pig2,3, she is sweet and brilliant, but small and often sickly. My husband and I are both tall, athletic people. Her sister has always been in the 95th percentile for her height and weight. Little E is taller than average, but she is scrawny, and she gets sick… a lot. Her sister didn’t have a cold until she was 2 years old. E had her first cold at a few weeks of life and seemed to be sick constantly for her first 3 years.

Why do I worry? Since I first entered medical school 18 years ago I have studied everything that can go right with a child’s health and everything that can go wrong. I have seen innumerable children who have suffered from accidents, cancer, infections, genetic disorders, and autoimmune diseases. When I was in training we used to say “the sweeter the child, the more horrific the diagnosis will be”. There was no truth in our statement. It was just a reaction to the heartbreak we felt; time after time we had to share devastating news about a child to the family that cherished him.

Unfortunately I have kept that superstition with me. My little E is a cup-half-full kind of girl. She dances around the house singing “Let It Go”, yells “wheeeee” the whole time she is flying down the trail on her bike, and shows more determination and grit than almost any child or adult I know. She is also prone to covering me with thousands of kisses and 10 second bear hugs on a daily basis. I have tears in my eyes when I write this because my overwhelming love and admiration for this child is matched by my overwhelming fear that something bad will happen to her. I try to reassure myself by remembering that many of my friends, and parents I see in the office, share my neurosis about their littlest child.

So when do we really need to worry?

  1. Is my child continuing to grow? Your child may be in the 3rd or 30th percentile on her growth curve. What really matters is if she is continuing to follow that percentile (normal) or if she is continuing to drop off the curve (concerning).
  2. Is my child reaching his developmental milestones appropriately (or is he doing well academically)? Check here for more information on developmental milestones.
  3. Does my child get frequent infections requiring antibiotics or hospitalizations? Frequent ear infections in the first year of life are often due to anatomy (small, flat eustachian tubes that don’t drain the middle ear space well), but frequent ear infections are unusual after the age of 2. Recurring bacterial pneumonia, frequent skin infections, or blood infections are more concerning for an immune deficiency.
  4. Does my child have bloody stools or frequent cramping and diarrhea? These can be signs of inflammatory bowel disease or celiac disease.

So how do you protect your runt? Fortunately there are a few great things you can do to keep your children healthier: good hand washing, proper nutrition, consistent sleep schedules, limiting screen/TV time, regular exercise, and vaccines. We do all of these things in our home but my baby still get sick. If your child is in daycare or preschool (or his older sibling attends school) then he may get 10-12 viral respiratory infections per year. Exposure to second-hand smoke will also significantly increase his risk of frequent infections.

Thankfully now that E is 4 years old, her illnesses are less frequent and less severe. Hopefully her physical composition will eventually match her emotional one. In the meantime I will still snuggle up next to her when she has a fever, and I will hold her all night when she has a cough. It makes us both feel better.

1. runt (definition from

– an animal that is small or stunted as compared with others of its kind.

– the smallest or weakest of a litter, especially of pigs or puppies.

2. E.B. White, Charlotte’s Web, (New York: Harper and Bros, 1952).

3. No children or animals were harmed in the writing of this post. Both Wilbur and my 4 year old can’t read yet. If little E does read this in the future I am fairly certain she will forgive her mommy for calling her a “runt”.

5 Common Questions about Introducing Solid Foods to Your Baby

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baby led weaning, introducing solid foodsTomorrow I am speaking at a Parent Participation class about introducing solid foods to your baby. In preparation I collected the most common questions I am asked about this very fun stage in a baby’s development and I wanted to share them with you. Put down your spoon, grab your mop, and be prepared for the messy fun!


When is my baby ready for solid foods?

Can your baby hold his head up and sit properly in a high chair? Does your baby express interest in food? This typically happens between 4 and 6 months of age. Before this your child’s GI system is not ready to properly handle anything other than breastmilk (or formula) and he has not developed the motor skills to chew and swallow food properly. When you offer him food, if he turns his head away from you, chokes, or lets the food just dribble out of his mouth, then he is not ready. Try again in a few weeks.

Do I start with infant cereal?

Traditionally it was recommended that infant’s start with a single grain infant cereal. It is a nice option because you can mix a very small amount with breastmilk or formula when you are trying solids for the first time. Infant cereals are also fortified with iron and don’t have added sugar. Today we know that there really is not a bad first food to start with. You can choose a vegetable, fruit or even meat. The most important thing is that you are offering a single ingredient in a consistency that your baby can handle, without any added salt, sugar or chemicals. In fact there is some evidence that “baby led weaning” may be a preferable way for some families to introduce solid foods to their infants.

What is baby led weaning?

Baby led weaning is a fancy term for letting your baby feed himself, skipping the spoon feeding stage completely. This is a skill that is typically not found in infants until they are 6 or even 7 months of age, so it is best for parents who are not in a hurry to introduce solid foods. Initially your baby will get most of the food in his hair or on your floor, so it is also best for parents who are not mess-ophobic.

The goal with this method is to offer your child smushy versions of common foods that he can pick up himself (soft, steamed and peeled sweet potato wedges, steamed broccoli, scrambled eggs, etc). You want to avoid honey and anything that he could choke on. Some studies have shown that children introduced to solid foods this way may have lower rates of obesity and tend to be less picky eaters, although you may need to supplement with spoon feeding for a child who is underweight. The theory is that babies learn to pace themselves, chew their food, decide when they are done, and get a greater variety of food. How many times can you really serve your baby pureed peas anyway?

It is also nice to sit down at a table with your family and eat together, instead of spending the whole meal spoon feeding your infant. When my 4 year old looks at me at dinnertime some nights and says “feed me” I wish that we had skipped spoon feeding in her infant days! She does love being the baby some days, and I guess mommy secretly loves it too 🙂

What foods should we avoid?

There is increasing evidence that children introduced to a greater variety of foods before 11 months of age will have a lower risk of food allergy. This means that you should introduce eggs, seafood, meat, cheese, yogurt, wheat and nut products to your infant. You do NOT want to give your infant honey, milk, or choking hazards; no nut butters, grapes, hot dogs, large pieces of meat, hard pieces of fruits or vegetables, popcorn, candy, seeds or nuts. There is also no benefit to fruit juice unless your child’s physician has recommended it for constipation.

Exceptions: If you have severe food allergies in your family then you should not introduce any solid foods to your baby until you have discussed it with your child’s physician.

When do I start to decrease breastfeeding?

Your baby will let you know when she is getting enough solid food and will back off naturally on her frequency of breastfeeding. This shouldn’t happen before 6 months of age, and it will typically not occur until she is 10-12 months old.

My bottom line?

As long as you avoid choking hazards and honey there is no right or wrong way to feed your baby. Eat together as a family and enjoy each other instead of your smartphone. The most entertaining moments of your child’s life are often at the dinner table. Have fun!


Please comment below if you have any questions (or funny baby feeding photos and stories to share).

For more information:

Parenting MD: Guide to Baby’s First Year



  1. Rapley, G. 2006. Baby-led weaning, a developmental approach to the introduction of complementNwaru BI, Takkinen HM, Niemelä O, et al. Introduction of complementary foods in infancy and atopic sensitization at the age of 5 years: Timing and food diversity in a Finnish birth cohort. Allergy 2013;68(4):507-16.
  2. Hourihane JO, Aiken R, Briggs R, et al. The impact of government advice to pregnant mothers regarding peanut avoidance on the prevalence of peanut allergy in United Kingdom children at school entry. J Allergy Clin Immunol 2007;119(5):1197-202.
  3. Du Toit G, Katz Y, Sasieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008;122(5):984-91.
  4. Poole JA, Barriga K, Leung DY, et al. Timing of initial exposure to cereal grains and the risk of wheat allergy. Pediatrics 2006;117(6):2175-82.
  5. Brown A, Lee MD.Early influences on child satiety-responsiveness: the role of weaning style. Pediatric Obesity. Published online December 17 2013
  7. Rapley, G. 2006. Baby-led weaning, a developmental approach to the introduction of complementary foods. In Hall Moran, V and Dykes, F. eds. Maternal and Infant Nutrition and Nurture: Controversies and Challenges. Quay Books, London. pp 275-298.



Baby Safety: The 2 Leading Causes of Death and How You Can Prevent Them

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Safe to Sleep® campaign, baby safety, SIDS

Image courtesy of the Safe to Sleep® campaign

Recently I was asked to speak at a childbirth education class at my local hospital. I love talking to expecting parents as it brings back my own memories of that time: the excitement, hopes, fears…My topic tonight was baby safety.  I want to share this information with you as well.

1- SIDS (Sudden Infant Death Syndrome) and accidental suffocation is the leading cause of death in infants in the U.S. from 1 month to 1 year old.  Your child’s sleep environment is the most important thing you can control to keep your baby safe.  It is important that your baby always sleeps on her back on a firm surface with no crib bumpers, pillows (or breastfeeding pillows), sleep positioners or soft bedding. The safest place for your baby is in a crib that is in your room for the first 6 months. Breastfeeding is also associated with a lower risk of SIDS. If you choose to have your baby sleep in bed with you it is really important to keep in mind the risks and what makes a sleep surface safe.

Our first child was a really fussy baby and we did end up sleeping with her occasionally during her fussiest months (1-3 months). It is not something I recommend to others, but it was a decision we made out of desperation and with all of the risks in mind. We have a firm mattress (pillowtop removed), we slept with no pillows or blankets, and we placed her in the middle of a king size bed. This would have been especially dangerous if there were any other risk factors for SIDS (secondhand smoke, obesity, alcohol or drug use, or pain medications). We never let her sleep on her stomach and we never slept on a couch or chair with her. Sanity trumped absolute safety in our house, but we did our best.

For more information on SIDS prevention and safe sleeping please go to Safe to Sleep.

2- The leading cause of death in infants 1 month to 1 year worldwide is respiratory infections, including pneumonia and influenza. Thankfully in the U.S. we have free access to vaccinations. Unfortunately our vaccination rates in many areas of the country are below 90% and we can’t protect our infants unless everyone they are surrounded by is fully vaccinated. We also have access to clean water. Good hand washing can be very effective in reducing the spread of disease. Unfortunately not everyone (especially young children) does a great job of washing their hands after coughing, sneezing, wiping their noses, or using the restroom.

So what can you do to keep your baby safe from infection?

  • Remind people to wash their hands or use hand sanitizer before touching your baby.
  • Ask people who are sick to visit another time. The first sign of many illnesses that can be dangerous to your baby is just a clear runny nose (whooping cough, measles, RSV…).
  • Make sure anyone who is around your baby is fully vaccinated. This should include a yearly influenza shot and whooping cough (pertussis) booster.
  • Avoid crowded places for the first few months. If you have to go somewhere crowded try to keep your baby in an infant carrier or stroller with a blanket thrown over the top. Carry hand sanitizer and avoid anyone that looks like a grandma! She will want to touch your baby 🙂

For more information go to the AAP (American Academy of Pediatrics)

So I am curious (and maybe neurotically overprotective based on my career choice): Do you ask your friends and family to stay away if they are sick? Do you ask them if they are vaccinated before they come visit your newborn? How do they react?


How to Make the Most of your Visit with the Pediatrician

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This is a guest blog from Sheila Cason, MD. It was previously published on her site Dr. Cason is a photographer, pediatrician, and mother of three. I have great respect for her advice and incredibly compassionate nature.

Photo by Brendan Riley, Flickr Creative Commons

Photo by Brendan Riley, Flickr Creative Commons

Whew! The morning is over and I’m at lunch, preparing for a busy afternoon.

With the ever increasing time crunch, pediatricians are forced to see more patients in less time. Often we are only given 10-15 minutes to get the history, do an exam, make a diagnosis, formulate a plan and then explain the directions to the family.

This may be fine if the chief complaint is ear pain. But what if it’s chronic abdominal pain? Or a seizure? Then it’s even more important to streamline the visit so we can help your child and you get some answers.

Here are some simple ways to make your visit go smoother and get what you need:

1. First off let me know if you are running late for another appointment. I try not to run late but it’s ineveitable sometimes. There have been times when I go into a room and the family is seething! It seems they missed an incredibly important meeting. If I can I will try to adjust the schedule and see you faster. Or I’ll just cut to the nitty gritty and get you out quickly.

2. Let your doctor know what you really want. If you really want antibiotics, you’re going to be mad when you spent all that time and didn’t get it. Let them know. Often I’ll compromise. If it’s viral and they really don’t need the antibiotics, I let them know. But if it’s a cold and it has been over a week and a half and it’s tough for them to return for a recheck, then I may give them a script to take with them. I give instructions to start only if the cold hasn’t resolved by two weeks. Surprisingly most people don’t abuse this and both parties are happy.

3. Prepare your child: Tell your child where they are going. If they are old enough then let them know exactly what we are going to do. Encourage the young ones and don’t threaten shots if they don’t behave! It scares them to death and then I have to spend a lot of extra time coaxing them to let me even come close.

4.Know your history: Often I have a grandparent come in and not know anything. We have to guess and muddle through the history. This can take a lot of time. If you can’t be there, write a note or give me a number that I can call to ask you some pointed questions.

5. Don’t have the doctor tackle every thing on the same day. If your complaint is ear pain and a cold then talking about your child’s short stature might be better addressed at their well check or another appointment. You’re only going to get frustrated that the doc is rushing you.

6. If you’re still not happy let the doctor know. Some people still look at me at the end of the visit, all worried. I know something is up. Most parents who have a child with 1. Headache: worry it’s a tumor 2. Bruises: worry it’s leukemia 3. Fever and a cough: worry it’s pneumonia. Because parents have told me their fears I have learned what bothers them. I can anticipate this and talk with them about it.

I hope this helps. I think that most people who are frustrated that the doc didn’t spend a lot of time with them, didn’t get what they needed. Communication is key! A pediatrician’s number one priority is making sure your child is healthy and you’re happy!

Do you have ways that make your visit go smoother and you get what you need?

Do you have tips for the doctor that will make the visit go smoother?

Dr.Raja Live on the Dave Congalton Show

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Natasha Raja, MD on the Dave Congalton ShowIn case you missed the live broadcast, my interview on the Dave Congalton Show is now available as a podcast. You can listen here (my interview starts 37 minutes into the broadcast).

Dave and I discussed my background and reasons for choosing a career as a pediatrician as well as my book, Parenting MD: Guide to Baby’s First Year. We also talked about why the first year of your baby’s life is so challenging, and we ended with a heated discussion on vaccines. It was a lot of fun and I hope you enjoy listening. Please comment below if you would like to continue the conversation.

Thank you Dave Congalton and KVEC for having me on your show!

Parenting MD: Guide to Baby’s First Year

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This book, written exclusively for e-readers, is filled with straightforward and up to date information to guide you from preparing for your baby’s birth to celebrating her first birthday.

The ebook format includes links to useful resources within the book and online.

Quickly access helpful information about feeding, sleeping, development, and common ailments, as well
as a glossary of terms and conditions.

Every day, research continues to expand our knowledge about keeping our children safe, healthy, and thriving. The information and recommendations contained in this book are based on the most current evidence available. Printed books can take years to get to publication, and medical knowledge and safety recommendations often change before the book even hits the shelves. This electronic format allows the reader to have access to the information within days of the final edit. Dr.Raja will also provide periodic updates to the ebook for free. Subscribe to and follow Dr.Raja on Facebook to find out more.

10% of proceeds will be going to St. Jude Children’s Research Hospital


Fiber: It’s Not Just for Pooping

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Photo by Aaron McIntyre, Flickr Creative Commons

Photo by Aaron McIntyre, Flickr Creative Commons

A recent study from the University of Minnesota found that only 3 percent of American children and 8 percent of adults are getting the amount of fiber recommended per day by the U.S. Department of Agriculture and Department of Health and Human Services.

Why do we care?

High fiber intake has been shown to lower risk for heart disease, stroke, high blood pressure, high cholesterol, diabetes, and obesity. It is also great for pooping.

How much should my child get?

This really depends on his age and energy requirements. The basic formula is 14 grams of fiber for every 1000 kcal consumed. This equates to about:

19 grams for a toddler
25 grams for a preschool through elementary school aged child
26 grams for a middle school aged girl
30 grams for a middle school aged boy
29 grams for a teenage girl
38 grams for a teenage boy

This really means feeding your kids at least 5 servings of fresh fruits and vegetables each day, as well as beans, nuts, and whole-grain breads and cereals. Cereals should have at least 3 grams of fiber and less than 10 grams of sugar per serving.

What specific foods are high in fiber?FiberTable

Can I get enough fiber on a gluten-free diet?

Yes, but… gluten-free often means fiber-deficient unless you pay close attention to what you are eating. A gluten-free diet that includes plenty of fruits, vegetables, nuts, seeds, and beans can be sufficient. This can be hard to achieve with a carbo-crazed toddler. Children are better off eating multigrain cereals and snacks instead of gluten-free puffs of nothing (unless they have true celiac disease).


Nutr Rev. 2009 Apr;67(4):188-205. doi: 10.1111/j.1753-4887.2009.00189.x. Health benefits of dietary fiber. Anderson JW, Baird P, Davis RH Jr, Ferreri S, Knudtson M, Koraym A, Waters V, Williams CL.

American Heart Association

Mayo Clinic

7 Signs That You Did NOT Have the “Flu”

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Photo by CMRF Crumlin, Flickr Creative Commons

Photo by CMRF Crumlin, Flickr Creative Commons

Whenever I talk about influenza I am told stories about the horrible stomach “flu” someone had the previous week. I agree the stomach “flu” is horrible, but it is not influenza. It should be called a stomach virus or a stomach “bug”. The term stomach “flu” confuses everyone and likely will for years to come.

You probably did NOT have the real “flu”, meaning influenza if ….

1- you were able to get out of bed

2- your symptoms came on gradually

3- your main complaints were vomiting or diarrhea

4- you did not have a cough or sore throat

5- you did not have a fever (greater than 100 fahrenheit)

6- your body didn’t ache from head to toe

7- you were better in 2 or 3 days

There are over 200 viruses that cause bad colds, and almost as many that cause the stomach “flu”. These are not influenza. Influenza is an illness you remember 20 years later. Influenza hits you like a ton of bricks and knocks you down for at least a week. The influenza virus changes so much from one season to another. Some years it is mild, meaning not as contagious or as life-threatening, and some years it is severe.

This year influenza is severe. It is hitting the young and the healthy. 50 young people have died in California this past week, and 50 more died in the week before that. I have not cared for any kids with influenza on my pediatric unit this season. They all bypassed me and were flown to the nearest pediatric ICU. They were all critically ill.

If you think you have influenza it is best to contact your physician within 24 hours. There are antivirals that can help, but they are most effective if started within 48 hours of symptoms. And remember: It is not too late to get your flu shot. Influenza will likely stick around until April or May.

For more information go to:

“Prevention is better than cure”- Elizabeth Blackwell, first woman physician in the U.S. and the U.K., 1849

Photo by Future Atlas, Flickr Creative Commons

Photo by Future Atlas, Flickr Creative Commons

Naturopathic cures for the common cold?

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opiumAs a pediatrician I have come to realize that I don’t always get the whole story when I see my patients. Teenagers will often deny that they smoke (because pot smoking is not smoking, right?), and parents will often deny that they are giving their toddlers medications (because over the counter meds or homemade remedies don’t count, right?). I have learned to ask the same question multiple ways if I am concerned. Parents, unlike some of the teens, are not trying to withhold information. It is usually because the vaporub or herbal remedy seems risk-free or unimportant. I hope it is never because they believe I will disapprove of more natural remedies.

The truth is I am a “naturopath”. I believe in our body’s natural ability to fight off infections and heal itself. I believe in the power of good nutrition, exercise and balance. I do not prescribe cold medicines or antibiotics for viruses. But I have also lived and worked in places where modern medicine is not available. I have seen many children die. Thankfully, modern medicine (antibiotics, chemotherapy, vaccines, screening labs) continues to save the lives of millions of children around the world. I also get to see this every day.

My own children are fully vaccinated. My own children have had antibiotics (once each) for bacterial infections that would have otherwise put them at great risk. My children have had Tylenol and Motrin when they had a fever or were in pain. But mostly my children have had salt water (saline) for their snotty baby noses, honey for coughs (over 1 year old) and chicken soup for their colds. I have spent many nights holding my babies in my arms while they ran fevers or coughed incessantly for hours, but I knew nothing but time would cure their viral illnesses. I so desperately want to fix every hurt but most importantly I need to …. DO NO HARM.

This means I do not use vaporubs (menthol and camphor) or essential oils for my kids. I do not give them alcohol baths for fever. I do not give them herbal remedies or teas. I do not give them antibiotics for viruses, and I do not give them cough or cold medicines. These are the risks:

  • Menthol and essential oil rubs can actually worsen respiratory distress in young children.

  • Alcohol baths can lead to alcohol poisoning, seizures, or death.

  • Herbal supplements are not FDA regulated and up to ⅓ of them don’t contain any of the ingredients listed.

  • Numerous studies have found high levels of lead in tea leaves.

  • Thanks to vaccines, the majority of infections today are viral and antibiotics will not help.

  • Over the counter cold medicines have shown no benefit to kids under 6 years old and they can cause dangerous heart arrythmias in young children.

I have an amazing cousin who is the mother of a very cute one year old. She is a wonderful, very intelligent, and caring mother. Thanks to her great questions and Facebook posts, I continue to learn what she and other parents are trying to help their little ones get through the toughest nights with their sick babies. I continue to research every remedy that it is proposed to find out…. what are the risks? what are the benefits?

In the past, people have tried whiskey, cocaine, and opium (called Svapina in the ad above) to relieve a child’s cough. The truth is, medicine is constantly changing and we can all learn together. Talk to your child’s doctor about what you are using for your kids, or what your friends have tried. Give them the chance to learn from you or to teach you about potential risks. We all want our kids to be safe and healthy. There is no better common goal.

To find out more about complementary medicine practices (both safe and unsafe) please go to the National Center for Complementary and Alternative Medicine.

Fever Phobia

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sick childTrue confession: I don’t have a thermometer…. or at least I have no idea where it is. The truth is I haven’t used one since my youngest was 6 months old because I didn’t need it. A fever is many things (uncomfortable, dehydrating), but a fever itself is not dangerous. So why do doctors and nurses always ask you, “how high was his temperature”? Because many times families report a fever when a child’s temperature is 99 degrees fahrenheit. Everyone’s temperature varies greatly throughout the day and the definition of a fever is a temperature of 100.4 fahrenheit or greater. Your child’s doc only wants to know that because a true fever is a sign that your child is fighting a viral or bacterial infection. Here are some facts about fever that you may find helpful:

1- Fever is your body’s way of raising your internal temperature enough to kill whatever virus or bacteria is attacking you. Your body is brilliant and this is a completely normal response.

2- A fever is always an emergency in a child less than 3 months old. Children this age can still have infections that they picked up in the womb (like GBS or HSV). They can also have a urinary tract infection that can quickly travel to their bloodstream or spinal fluid (meningitis). This is because the barrier between their blood and spinal fluid is still very permeable at this age.

3- The only accurate way to check a temperature in an infant less than 1 year of life is using a rectal thermometer. There are NO other thermometers as accurate in this age. It should be digital, not glass and not mercury. Newer studies have shown that temporal artery thermometers can be used in infants over 3 months old.

4- A fever can NOT cause damage to your child’s brain, even at 105 degrees! Hyperthermia (body temperatures over 107) can cause brain damage or death, but extremely hot environments, not infection, cause this.

5- Height of a fever does not help us determine if the cause is viral or bacterial.

6- Teething does not cause fever.

7- Although a fever is not dangerous, it can make a child very uncomfortable and unwilling to drink fluids. Using acetaminophen or ibuprofen at appropriate doses for your child’s weight is the safest treatment. Aspirin and alcohol baths or rubs are not safe. There is also no reason to put your child in a cold bath.

8- Almost 5% of young children will have a febrile (fever) seizure. The seizure itself is terrifying to watch but this type of seizure is not dangerous. Treating a fever will not prevent a febrile seizure.

Bottom line:

If your child is over 4 months old and fully vaccinated, a fever alone is not a reason to worry. Everyone looks and feels crummy when they actually have a fever. If your child is still playful when the fever comes down that is a very reassuring sign. If your child is dehydrated, lethargic, has a rash, seizure, trouble breathing, or scares you in any way call your doctor or seek medical attention immediately. If your child has been running a fever for a few days then you should also call your child’s doctor for recommendations.