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Daily Dose

Codeine & Children

1:30 to read

I order to keep us all safe, the FDA is constantly monitoring drugs and their side effects.  For many years codeine was prescribed for children for pain relief as well as to suppress coughs.  Over the last few years there has been more and more discussion about limiting the use of narcotics in children, but I continue to see some children who come from seeing other physicians and have received a prescription that contains codeine.

 

The FDA just issued new warnings against using prescription codeine in children and adolescents. The FDA reviewed adverse event reports from the past 50 years and found reports of severe breathing problems and 24 deaths linked to codeine in children and adolescents. Genetic variation in codeine metabolism may lead to excessive morphine levels in some children.

 

The FDA also performed a literature review which noted excessive sleepiness and breathing problems, including one death, in breast-fed infants whose mothers used codeine.

 

Due to these findings the FDA is now recommending that “codeine should not be used for pain or cough in children under 12 years of age”. They have also issued a warning that codeine should not be used in adolescents aged 12-18 “who are obese or have conditions associated with breathing problems, such as obstructive sleep apnea or severe lung disease”. In retrospect, codeine was prescribed to more than 800,000 children younger than11 years in 2011. Amazingly, codeine is currently available in over-the-counter cough medicines in 28 states.  

 

Lastly, the FDA “strengthened the warning” regarding codeine and breast feeding. They now recommend that breast- feeding women do not use codeine…which may change the post delivery pain protocol. Nonsteroidal anti-inflammatories (Ibuprofen) and acetaminophen (Tylenol) are preferred and are effective for mild to moderate postpartum pain. As a pediatrician it is important that I discuss this with new breast-feeding mothers as well. 

Daily Dose

PU: Body Odor

1.00 to read

I received an email from a mother who asked if her 5 year old son, an avid athlete, could wear deodorant?  It seems that his arm pits “smell like a grown man”.  I have actually been asked this on occasion in my office and I have even noticed body odor (BO) during exams on some 5-8 year olds.   

Most children start to “stink” as they begin to enter puberty, but there are occasional children that for unknown reasons, develop BO without any signs of puberty. If it seems that your child is entering puberty at an early age, you do need to talk to your doctor.  If your child happens to be one of those kids who are just odiferous, there are several things that you can do.

Number one, make sure that your child is bathing/showering everyday, and that they wash their armpits well. Some little boys (and I bet a few girls) just pop in and out of the shower without touching soap on most of their bodies.  (I used to smell my boys hair when they came out of the shower, sometimes still smelled sweaty, no soap!).

If daily bathing does not do the trick, it may be time to use a deodorant, which just masks the smell. This often works for younger kids who are really stinky rather than sweaty.  An anti-perspirant actually stops and dries up perspiration and may not be needed until an older age.

There are numerous deodorant products available, some of which are natural as well. Head to the store and read labels to decide which one you prefer.

Daily Dose

Mumps Outbreak!

1:30 to read

The latest infectious disease outbreak is in the Boston area where several colleges have reported cases of mumps. Mumps is a viral illness that causes swelling of the salivary glands as well as other symptoms of fever, fatigue, muscle aches and headache.    Harvard University has been hit the hardest and has now documented over 40 cases this spring.  Boston is a city with numerous colleges all in close proximity, and there are documented mumps cases at Boston University, University of Massachusetts  and Tufts as well.  These Boston area colleges are all in close proximity and are merely a walk, bike or train ride away from one another, so these students, while attending different universities may all co-mingle at parties and athletic events.

Mumps is spread via saliva (think kissing), or from sharing food, as well as via respiratory droplets being spread after coughing or sneezing. It may also be spread via contaminated surfaces that will harbor the virus. People may already be spreading the virus for  2 days before symptoms appear and may be contagious for up to 5 days after their salivary glands appear swollen….so in other words there is a long period of contagion where the virus may inadvertently be spread. It may also take up to 2-3 weeks after exposure before you come down with mumps.

All of the students who have come down with mumps had been vaccinated with the MMR vaccine (mumps, measles, rubella).  Unfortunately, the mumps vaccine is only about 88% effective in preventing the disease. Despite the fact that children get two doses of vaccine at the age of 1 and again at 4 or 5 years….there may be some waning of protection over time. This  may also contribute to the virus’s predilection for young adults in close quarters on college campuses. Something like the perfect infectious disease storm!

In the meantime there are some studies being undertaken to see if adolescents should receive a 3rd dose of the vaccine, but the results of the study are over a year away.

In the meantime, be alert for symptoms compatible with mumps and make sure to isolate yourself from others if you are sick.  Harvard is isolating all of the patients with mumps for 5 days….which could mean that some students might even miss commencement.  Doctors at Harvard and other schools with cases of mumps are still on the watch for more cases …stay tuned.

 

 

 

 

Daily Dose

What New Babies Need

1:30 to read

I have many friends whose own children are now having babies and they always ask, “what all do we need to have/buy for a new baby these days?”  While many things have changed since I had my own children, many have not,  and I still think “less is more” is a good adage to follow, especially for a newborn.  We all have a tendency to buy too much, or the “latest and greatest” only to find out that it is not necessary.

Carseat - a rear facing car seat is a must for your newborn!!!  Look at all of the reviews on line and pick which seat works best for you.  Do you want one with a base that you can also clip on to a stroller?  Remember your baby will sit in a rear facing car seat until 2 years. This is one item I would spend my money on!!

The baby needs a place to sleep so buy a crib and a good mattress.  If you are going to have more than one baby I would buy something that will last through several children. I like having a crib (rather than a toddler bed), as your baby will be in the crib for several years and then can move to a regular bed…no need for an “in between”.  Do not use an “old” crib that has drop sides, due to safety concerns. So that means the one that I had kept in the garage (from my kids) was a throw away! I usually move the first child to a bed when I need the crib for the next baby…no specific age. Bumpers are no longer recommended, so that saves money too!

Changing table or dresser for the millions of diaper changes.  It is so helpful to not have to bend over each time. I would also buy a diaper cream (Dr. Smiths, Destin or Butt paste) to have on hand….your baby will probably get a diaper rash at some time during their time in a diaper.

Baby bath tub: while you can bathe your baby in the sink, the newer bathtubs do make it easier for a newborn and you can use it in the tub as well until your baby can sit up alone. Remember, you will NEVER leave your child in the tub alone…even with all of the seats, rings and things  that they sell to support your baby!!  For bathing I like gentle bath wash like Cetaphil, Cerave, and Eucerin products….good for all skin types.  Pick one!

Swaddle blankets: WOW there are a million on the market and they all “claim” to help your baby to sleep better. I don’t think any of the products say “it will also takes weeks to months for your baby to sleep through the night” , no matter what you use.  I do like the thin swaddle blankets as they are useful for a number of things besides swaddling. Once you have your baby have the nurses show you how to swaddle (quick and easy).  The Miracle Blanket, Woombie and Halo also make it easy to swaddle as well. Pick one (or two) and stick with that.  Remember, your baby is going to be put in their crib on their back whether swaddled or not!! NO TUMMY SLEEPING.  

Diaper Bag: again their are a million out there in all shapes, sizes and price points. In the beginning you need to have a pad for changing (you will end up changing that baby all sorts of weird places), diapers, burp clothes, wipes…as your baby gets bigger you will have bottles, cups, toys all shoved in there too. All of my patients seem to have a travel size Purell strapped to the side of the bag as well. I would get a bag that you can wipe out as there will be spills of all sorts of stuff in that bag I assure you!  Somehow, over time you go back to “less is more” and the diapers end up in your purse!!  

So…that is a start. Will do another post on some other products in the future. 

 

 

Daily Dose

Lead Found in Baby Food

1:30 to read

I know many of the parents of the children I care for are concerned about the latest news from the Environmental Defense Fund which showed that about 20% of baby food samples tested over a 10 year period had detectable levels of lead.

 

This non profit group looked at data that the FDA had collected from 2003-2013 which included 2,164 baby food samples. While none of the baby food samples seemed to exceed the FDA’s “allowable” levels of lead, it is still quite concerning. At the same time the FDA is in the process of reviewing their standards to reflect the latest science surrounding the potential risks to young children who are exposed to lead.  

 

While lead testing is routinely performed in young children (1 and 2 yrs), the CDC currently  considers a blood lead level greater than 5 micrograms/deciliter as elevated, but no lead level is “safe”. 

 

Lead exposure has been shown to have neurocognitive effects - which means IQ, the ability to pay attention and academic achievement…and the effects cannot be corrected.

 

The study did not name baby foods by brand.  Root vegetables (carrots are one) had the highest rate of lead detection (65% of samples), followed by crackers and cookies (47%) and the then fruits and juices (29%). Only 4% of the cereal samples contained lead.

 

This report will cause a lot of parental anxiety, but really doesn’t tell us much about what to do?  Lead based paint is still the number one source of lead exposure, followed by water, which may also have contributed to lead in food…. but there is still lots of be determined.

 

In the meantime, the take home message is “feed your babies and toddlers a wide variety of baby foods” and when possible eat fresh foods. One hypothesis is that baby foods are more processed which may contribute to the higher lead content.  It is easy to cook and “mush” up your own food to feed your baby and it really does not require a fancy food processor.  If you can mush it your baby can eat it!!! The only concern about the introduction of food is basically it has to be soft enough not to be a choking hazard. So no whole nuts, chunks of meat, uncooked hard veggies…you get the idea.

 

Just because your baby doesn’t seem to like certain foods, don’t get stuck feeding them just a few foods…but continue to offer a variety of healthy foods..some of which they may eat more of than others. Every day will be different.

 

So…don’t go throw away all of your baby foods but think if you might be able to substitute fresh foods, don’t offer fruit juices to your babies and toddlers and most importantly eat healthy foods. That’s the best thing for you and your child.  

Daily Dose

Drowning Is Silent!

1:15 to read

Summer is here and many families will spend time at the beach, lake, or pool. The first thing that comes to my mind (when I think of water) is safety!!  

Knowing that over 900 children between the ages of 1–14 die each year from drowning, the discussion of water safety is a necessary part of summer routines. Astoundingly, reports show that 9 out of 10 of those children who drowned were “under supervision”. The American Academy of Pediatrics has endorsed allowing children between the ages of 1-4 to take swimming lessons. It was previously thought that encouraging swimming lessons for children under the age of 4 years might actually contribute to increased drowning.   In fact, recent studies have suggested that children ages 1–4 may be less likely to drown if they have had formal swimming instruction. The AAP has not gone so far as to routinely recommend mandatory swimming lessons for this age group, but does endorse swimming lessons in younger children who are frequently exposed to water and are emotionally and physically able to participate.  

The AAP does not recommend formal “infant survival swimming lessons” for children under the age of 1 year. When I discuss water safety with my patients, I emphasize that drowning continues to be the second leading cause of death for children ages 1–19.  I often have interesting discussions with parents who have a backyard pool who do not believe that it is necessary to have a barrier around the pool. They will say, “we never let our child outside alone” or “he or she is always being supervised by an adult”.

As you might expect, these are usually first time parents who have yet to experience the cunningness of a toddler.  Just as our children watch us and learn how to feed themselves, or drink from a cup or climb out of a bed, they too watch us open a door, or take a stool out to reach something. A toddler is more than capable or figuring out how to reach a door handle even with a lock, or climb out a window to go outside and head straight for the pool. Drowning is SILENT!!  It is not like the movies with screaming and yelling. The child quietly goes beneath the water and sinks.  It only takes minutes and the consequences of drowning are devastating.  Even for a child who is found and resuscitated there may be a life-long brain injury and the worst case scenario, death.

All families with a pool should install a 4 sided fence that is at least 4 feet high to limit pool access. It must be difficult to climb and have a self-latching, self-closing gate. The arguments I hear about “landscape aesthetics” fall on deaf ears.  Every family should also know CPR. Sign your child up for swimming lessons, and have fun practicing flutter kicks and arm strokes. Just do it with an adult within arm’s reach of all new and novice swimmers and a fence around the pool!

That's your daily dose for today.  We'll chat again tomorrow!

Daily Dose

The Joy of Fun Summer Activities

1:15 to read

While doing summer checkups and discussing everyone's summer plans I started thinking that I should really be asking about some of the basics like summer and all of the wonderful activities to do. We have talked about swimming and camps and staying abreast of academic work, but what about the basics of summer? The good, old-fashioned leisure time activities that we all used to do. While doing summer checkups and discussing everyone's summer plans I started thinking that I should really be asking about some of the basics.

So here are the things that come to my mind: Basic summer skills for all of us to remember and to teach. All of this is free, easy and are really akin to life skills that all children should probably master at some point in their childhood.

  • Jumping rope
  • Riding a bike (of course with a helmet)
  • Skipping a stone
  • Pumping a swing
  • Blowing bubbles
  • Catching a ball
  • Throwing a ball (don't think I have still mastered this, wonder if it is too late?)
  • Turning a somersault
  • Playing hopscotch
  • Playing four square
  • Learning how to float on your back
  • Fly a kite
  • Catching fire flies

Don't feel pressured to do this all at once, as childhood is a long time. But enjoy the time spent with your children accomplishing these simple pleasures. Why don't you let me know things that you think of and that you feel are essential skills of summer? I am sure I have missed many. That’s your daily dose, we’ll chat again tomorrow.

Send your question or comment to Dr. Sue!

Daily Dose

Dog Bites

1:30 to read

I am a dog lover and we have always had a dog in our house….even before we had our children.  But, some dogs will bite and unfortunately there are more than 800,000 people every year who receive medical care for a dog bite…more than half of these are children.

 

Children are also more likely to be severely injured from a dog bite…and I was reminded of this today when I saw a very serious dog bite to a child’s face.  The child was brought to my office by his nanny after being bitten on his cheek by the family’s dog.  It was one of the worst bites I have ever seen! He was severely injured and should have actually gone straight to the ER….the good news is that he will ok, but he had to undergo surgery to repair the bite and will probably require another small surgery at some later date. 

 

In this case as in most, the dog bite occurs when a child is interacting with a familiar dog, and in this case it was the family pet. The little boy is a toddler with a twin sister and they were playing when he was bitten.  The dog had been around the children since they were born…and it is unclear what precipitated the bite.  Sometimes a dog becomes aggressive if they are bothered while they are eating or sleeping…and you know toddlers, they can “bother” anyone. 

 

One of my “boys” is also a dog bite statistic.  He was raised with dogs (my sweet lab Maggie is at my feet as I am writing), so I was totally caught off guard one night when the phone rang. My son had been spending the night at a friend’s house (he was about 10 years old) and the voice on the other end of the phone was the father of the friend (he too a doctor), informing me that my child had been bitten by their dog.  It seemed the boys were laying on the floor on blankets watching a movie and eating popcorn and for some “unknown “ reason the dog bit my son on his face.  The bite was not precipitated by anything…they had not been playing or rough housing with the dog and the dog had not been known to be aggressive. The next words out of the father’s mouth…”do you know a good plastic surgeon?” Not words you want to hear from another physician.

 

Thankfully, I did know a good plastic surgeon who I awakened after his long day in the OR….and he got out of bed and met us to suture my son’s face with over 20 stitches. Luckily it only involved his nose, cheek and chin, just barely missing his left eye. I am sure I cried more than my son.  He still has a scar across his nose..which only bothers his mother.  Incredibly, he never “blamed” their dog, went back to play at their house, and still loves his own dogs more than anything.  My brother who is a vet still thinks that any dog that bites without provocation should not stay in the home with children…but that is one vet’s opinion. 

 

It is especially important to teach your children never to approach a dog to pet it without first asking the owner if it is okay.  Children should learn to move slowly and let the dog “sniff” them first and to stay away from their face and tail. Teach your child how to gently pet an animal and to always be gentle.  If they are around a dog who is behaving in a threatening manner by growling or barking, they should slowly back away from the dog and try to avoid eye contact with the dog. If they are ever knocked over by a dog they should curl up in and ball and protect their face with their arms.

If your child is bitten and it is superficial it will probably just require care with soap and water. For bites that break the skin you should check in with your pediatrician.  Make sure you know the rabies vaccination status of the dog that bit.  You also need to make sure that your child is up to date on their tetanus vaccination. In some cases your child may also need an antibiotic.

Daily Dose

Brown Spots on Your Baby?

1:30 to read

I was examining a 4 month old baby the other day when I noticed that she had several light brown spots on her skin. When I asked the mother how long they had been there, she noted that she had started seeing them in the last month or so, or maybe a couple even before that.  She then started to point a few out to me on both her infant’s arm, leg and on her back.

These “caramel colored” flat spots are called cafe au lait macules, (CALMs) and are relatively common. They occur in up to 3% of infants and about 25% of children.  They occur in both males and females and are more common in children of color.  While children may have a few CALMs, more than 3 CALMS are found in only 0.2 to 0.3% of children who otherwise do not have any evidence of an underlying disorder.  

Of course this mother had googled brown spots in a baby and was worried that her baby had neurofibromatosis (NF).  She started pointing out every little speckle or spot on her precious blue eyed daughter’s skin, some of which I couldn’t even see with my glasses on. I knew she was concerned and I had to quickly remember some of the findings of NF type 1.

Cafe au lait spots in NF-1 occur randomly on the body and are anywhere from 5mm to 30 mm in diameter. They are brown in color and have a smooth border, referred to as “the coast of California”. In order to make the suspected diagnosis of NF-1 a child needs to have 6 or more cafe au lait spots before puberty, and most will present by 6 -8 years of age.

For children who present for a routine exam with several CALMs ( like this infant), the recommendation is simply to follow and look for the development of more cafe au lait macules. That is a hard prescription for a parents…watch and wait, but unfortunately that is often what parenting is about.

Neurofibromatosis - 1 is an autosomal disorder which involves a mutation on chromosome 17 and may affect numerous organ systems including not only skin, but eyes, bones, blood vessels and the nervous system. Half of patients inherit the mutation while another half have no known family history.  NF-1 may also be associated with neurocognitive deficits and of course this causes a great deal of parental concern. About 40% of children with NF-1 will have a learning disability ( some minor, others more severe).

For a child who has multiple CALMs it is recommended that they be seen by an ophthalmologist and a dermatologist yearly,  as well as being followed by their pediatrician.  If criteria for NF-1 is not met by the time a child is 10 years of age,  it is less likely that they will be affected, despite having more than 6 CALMs.

The biggest issue is truly the parental anxiety of watching for more cafe au lait spots and trying to remain CALM…easier said than done for anyone who is a parent. 

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DR SUE'S DAILY DOSE

It's dog bite season, so parents beware!

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