Category Archives: Toddler

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 DrCason.org. 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?

5 Things You Need to Know About the New Car Seat Laws

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csl-5step-test-graphic-w-textThere has been a lot of buzz lately about new car seat laws in 2014. This is what you need to know:

1- There is no new law in place right now. There is a proposed law that car manufacturers and car seat makers get on the same page; what we want is consistency. Your child’s car seat may allow your child to be in the car seat until 65 pounds, but your child’s weight plus the weight of his car seat weight may exceed the LATCH system’s weight limit (often 65 pounds or less). In this case, the LATCH may not hold the seat in place if there is an accident.

2- If your child plus his car seat exceeds the safe weight limit for your car’s LATCH you can still secure the car seat with a seat belt. There is no maximum weight limit for the seat belt to secure a car seat.

3- You should always use the top tether on your child’s car seat. There is currently no weight limit for the top tether, and we know they significantly reduce the risk of head injuries if you are in an accident.

4- You should still have your infant or toddler in a rear-facing car seat until she is at least 2  years old or she exceeds the height and weight limit for your particular seat. Rear-facing is so much safer that we just changed our daughter’s car seat to forward-facing at 3 ½ years old!

5- Your child should switch to a booster seat after he exceeds the safe height and weight for your forward-facing seat (typically over 4 years old and over 40 pounds). The AAP still recommends that he remain in a booster until he is 8-12 years old and 4 feet 9 inches tall.

For more information and max weight limits for your vehicle go to Car Seats for the Littles and the Car Seat Lady

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).

References

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: flu.gov

“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.

Would you buy a car without seat belts?

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tvBuy a car without seat belts? Probably not. But this holiday season millions of TVs, appliances and furniture are being purchased without safety straps.

Every 3 seconds a child in the U.S. is injured by a falling TV, appliance, or piece of furniture. Every 2 weeks one of these children dies. Every 2 weeks.

As a pediatrician I once tried (and failed) to save a child who was crushed by a falling TV, and I cared for another child who had permanent brain damage from a falling TV. These two children have been a driving force in my focus on safety education. This holiday season please keep safety in mind in your own home, as well as the homes of family and friends that you may visit.

I live in earthquake country so one of the first things we did in preparation for our new baby was strap everything down (in our house and the grandparent’s). There are earthquake straps available in hardware stores throughout the country because the greatest risk is not an earthquake. The greatest risk is a toddler who climbs everything in her path, a preschooler wrestling with a sibling, or a young child trying to turn on the TV.

You wouldn’t buy a car without seat belts. Why would you buy a TV or dresser without safety straps?

For more information:

TV

 

 

Having “the talk”

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Talking to kids about stranger danger, safety, and sexual abuse

Thankfully my girls are still little enough that “the talk” is not about SEX but rather about SAFETY.  Last week I had a really Bad Mommy moment. Apparently the kindergarteners were getting out of school early and I had missed the memo. Unfortunately my daughter’s teacher released her out into the play yard without noticing that I WAS NOT THERE! She then locked the classroom and left. Although I have played the “what if” game in my head a hundred times since then, it all turned out fine. One of the daddies, a good friend, was out there with his son and noticed her alone. He called me and thankfully grandma was able to rush over immediately and save the day. Yikes. The rest of that day I kept wondering: Was I teaching my daughters enough to protect them from others who may try to harm them?

There are so many safety issues that go through my mind everyday. At the hospital I see babies who have fallen off beds, toddlers who have swallowed grandma’s pills, preschoolers who have been crushed by a falling TV, and helmetless teenagers who have fallen off their skateboards. The list goes on and the memories of these kids have turned me into a neurotic safety freak at home. Thankfully I have not seen or known anyone whose child has been abducted. I would have really fallen apart last week if I did. According to the US Department of Justice “there are about 115 stereotypical kidnappings, defined as abductions perpetrated by a stranger or slight acquaintance and involving a child who was transported 50 or more miles, detained overnight, held for ransom or with the intent to keep the child permanently, or be killed”. More children actually died from  chicken pox in the U.S. each year until the varicella vaccine became available. The news media has not made us fear chicken pox, but watching CNN will give us nightmares about losing our babies to a stranger. The crime numbers that we should probably pay more attention to are the statistics on sexual abuse. Nearly 25% of all girls and 15% of boys in the U.S. will be sexually assaulted or abused. Look around your child’s classroom. That is 1 in 4 of those girls and 1 in 6 of the boys. Depressing stuff.

The good news is that we can better protect our children from others who may harm them by educating ourselves and educating them. This is what you can do:

  • Talk about it! From the time my girls were toddlers we talked about who should be changing their diapers, and why other people should not touch or look at their “private parts”. I want them to be proud of their bodies. I want them to streak through the house squealing after baths. But I also want them to know that their bodies are their own. No one else has a right to touch them or hurt them. It is important to let your child know that other people should not be asking your child to touch them either.  Using correct anatomical terms will help them explain and understand the concepts better. I talk to every child I see about this in the office before I examine them.
  • Teach your children about good secrets and bad secrets. Good secrets would be something like a surprise party or present. Bad secrets would be anything that makes your child feel sad, guilty, or anxious. These are secrets that have to be shared with a trusted adult.

  • Give them “what if” scenarios. “What would you do if mommy was in the shower and someone knocked at the door?”; “What would you do if someone approached you and said mommy was hurt and they needed to take you to her?”; “What would you do if someone lost his puppy and asked you to help find it?”; “What do you do if an adult you don’t know pulls up in a vehicle to ask you a question?”

  • Read books about stranger danger and safety. We have a Winnie the Pooh book that the girls love. We read it over and over again and talk about what Piglet and Pooh learned from Christopher Robin. If you engage a child’s imagination then she is more likely to remember the lesson you are trying to teach her.

  • More tips: teach your kids your address and phone number, teach them how to call 911, label their clothes with your phone number, do not let your child use a public restroom alone.

Resources

National Children’s Alliance Child Abuse Resources

The National Center for Missing and Exploited Children

Eat your vegetables!

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vegetablesEvery day in the office I have at least one parent expressing concern over their child’s diet. I know I shared this same concern as a new mom, but as I continue to watch my children grow and thrive I have finally relaxed a bit. I wanted to share some facts and tips on starting your infants and toddlers on a path to healthy eating.

Tip #1: Your infant and toddler watch EVERYTHING you put in your mouth. If you are drinking sodas they will want soda too. If you are eating cheese puffs they will expect the same. The best way to ensure your child establishes good eating habits is by eating well yourself.

Tip #2: Variety is the spice of life. A study from researchers at the London Metropolitan University (Wansick, et al.) showed that children are most attracted to food plates with seven different items and six different colors. Adults prefer only three items and three different colors. Using this knowledge can give you an opportunity to diversify your child’s palate and improve their nutrition.

Tip #3: Meal time should not be a battle zone so if you can negotiate a bite of each thing you are a lucky parent. Forcing a child to finish her meal will not help the physical or mental health of you or your child. It is more important to teach her to eat until her tummy is happy.

Tip#4: Children who sit down to eat with their family eat more nutritious diets. This may not be an option every day but when you can, make the most out of this time. Turn off the T.V. (and mobile devices!) and focus on each other. Your infant or toddler will rarely make it through a whole meal without wanting to get down and wiggle, but this will get better as they get older. Just make sure the eating part of the meal only happens when they are sitting down. A toddler eating on the run is a risk for choking (and a risk for ruining your rug). Remember: family mealtime should not be a battle zone so have realistic expectations.

Tip#5: Juice works great for a constipated infant, but has NO role in good nutrition. It can also be helpful when you are introducing a sippy cup or trying to keep a toddler well hydrated on a really hot day. In these cases it is still better to water it down and limit his juice intake to less that 4-6 ounces in a day. Yes, juice originally came from fruit, but after it is processed you are left with a lot of sugar. Unfortunately, you won’t find many of the vitamins or fiber that were in the skin and pulp of the original fruit.

Tip #6: French fries should NOT be considered vegetables! There was actually a survey done about 10 years ago of 3000 kids from 4-24 months that showed the most common vegetable eaten by these kids was….. french fries. I really hope we are doing better now. French fries are really a salty, fatty starch. If you offer your kids fries please do it infrequently and in very small amounts. Dark, leafy green and orange vegetables tend to be the most nutritious. I haven’t figured out how to get my kids to love salad but they do eat a lot of carrots, peas, and sweet bell peppers. I am optimistic though, so every day they get a small offering of our salad and can usually be talked into one bite.

Tip #7: Too much milk CAN be a bad thing. After his first birthday your child can start drinking whole milk, but too much milk will fill his tummy and make less room for solid food. Too much milk (over 24 ounces in a day) can also block your child’s ability to absorb iron from other foods leading to severe anemia (low red blood cells). In my opinion, chocolate milk should not even be considered a dairy but rather a dessert. There is more sugar in a cup of chocolate milk than in most sodas or juices!

Tip #8: Vitamins may make us feel better about our child’s nutrition but they do little to improve your child’s health. I admit it. I gave my picky little toddlers a multivitamin because it made me feel better. That is OK. The truth is a healthy child who is growing well is getting enough nutrients from their food. The exception is vitamin D. We need to use sunscreen to protect our kids from the real dangers of UV radiation, but we are also blocking their absorption of vitamin D. Vitamin D is important for bone growth and immune function. It is therefore recommended that all infants and children receive vitamin D supplementation (400 IU/day for infants less than 1 year and 600 IU/day for over a year).

Tip #9: Snacks should be nutritious too. Did you know that 2 tablespoons of Nutella have as much sugar as 5 Oreos? Wow. Most of our diets are already overloaded with carbohydrates, salts and sugar. It is better to offer veggies, fruits, or protein rich snacks (cheese, yogurt or nuts in older children) a few times a day. Having a bowl of fishy crackers available for them to graze on all day will diminish their interest in real food at meal time.

Tip #10: Try, try again. Kid’s are fickle with food. My daughter will swear she hates avocados and a week later they are her “absolute favorite”. If you reintroduce an unpopular food regularly your child may actually decide she likes it.

The bottom line: If you put everything your child ate in one week on a plate how would it look? One day she may not eat many veggies, another day she may not have much protein. At the end of the week was her overall consumption pretty well balanced?

For more information on what a well balanced plate would look like check out: www.choosemyplate.gov

Do you have any tricks for getting your kids to eat more veggies? Any great kid-friendly recipes to share?

Boogers!

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BoogersDinner conversation at our house last night:
My 3 year old daughter E:”Remember when I was sick that time?”
Me: “Yes baby. You were sick all the time when you were a baby”
My 5 year old daughter M: “I wasn’t. But now I am sick all the time. You want to know why?”
Me: “Why?”
5 yr old M: “It’s because I eat my boogers every night”

Ewwwww. Is there a better way to start a blog then a conversation about boogers? As a pediatrician I thought about how this simple conversation revealed 2 very important points about keeping children healthy:

1-    It is so much easier to keep a first born healthy. My oldest didn’t even have her first cold until she was 2 years old. My youngest was about 2 weeks old! I was able to protect M because I had the luxury of grandparents instead of daycare, and no snot nose siblings to get her sick. We were a little obsessed with washing our hands and we spent a lot of time outdoors instead of crowded indoor places. E was sadly not so lucky. She was born in October (right at the onset of cold and flu season), and her older sister was bringing home every flavor of germs from her preschool and play dates. Poor E didn’t stand a chance. Luckily after a year of constant colds she was a little stronger and her immune system was revved up enough to start fighting back. She has had a much healthier toddlerhood.

2-    Fingers up the nose and in the mouth are loaded with bacteria and viruses. Germs are everywhere, but they especially like to gather in our noses and mouths. In fact the human mouth carries more bacteria than a dog’s mouth (and you know what they like to lick!). There is no better vehicle than a finger to transport those germs from our outsides to our insides. Of course keeping a child from spreading boogers and snot to all of their friends and foes is an impossible quest (and a battle that I don’t choose to fight). I do talk about germs and what is considered polite in front of others, and we move on. We also focus on good hand washing in home and school. I am a proud mama when I hear them belting out the “Happy Birthday song” when they are washing up in the bathroom. If you sing it twice it is about 20 seconds long, which is the minimum length of time recommended by the CDC to reduce the transfer of germs. I may only get one rendition out of them each time, but 10 seconds is better than nothing right? Just don’t peek under their fingernails!

 

Do you have any tricks for keeping your kids healthy this winter?