Daily Dose

How is School Going?

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So with everyone back in school, I am already discussing “how is school going?” during my patients check ups. This question is great for kids from 5-18 years of age and you get various amounts of feedback depending on age and gender!  The elementary school set is usually talkative and goes into great detail about their teachers and classmates while most of my high school students just tell me their classes are “hard” and they are “busy and tired”.

The cutest comment came last week from an 8 year old little girl. She had only been in school a few days and when I asked her how it was going she said, “I am nervousited”.  What a great way to sum it all up! Of course she was both nervous and excited. A great way to sum up the start of school.

I think any of us at any age can understand being “nervousited”. The start of any new school year typically comes with excitement about the next grade, or a new school,  and a new teacher.  The start of school also makes many children, as well as their parents and teachers a bit nervous.  New friends to make, new expectations for the next grade level, new lockers....the list is very long for some.

But, I think we parents can help our kids to understand that being “nervousited” is normal and healthy.   Reassurance, good listening to our kids concerns and comments will make the new school year get off to a good start.

I must say I am still “nervousited” with the new TV show each week....but I am hopeful that it gets easier each week, right??  Stay tuned, will let you know if those butterflies go away in the next few months as I get used to this new gig...same as a new class. 

Daily Dose

Grandparenting is Tricky

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I have had the luxury of spending a week with my “new and first” grandbaby and I must tell you I am “learning” a lot.  One thing for sure, it is quite different being a grandparent, but the responsibility at times seems even greater.

I find myself carrying her up and down the stairs while thinking, “what if I fall?”, “maybe I shouldn’t take her upstairs?” Really?  Another time I was “multi-tasking (which my husband tells me I am an expert at doing) by holding her and standing on the porch watering a pot. All of the sudden I thought, “I might slip with this water on the porch, maybe I should just forget about the plants”.  I now check to make sure I don’t hold the coffee cup while holding her, or get her too close to a pillow when I lay her down on my bed (on her back of course) while I grab a diaper. I never thought like this when I was “just the parent!”.  All of these what ifs.

While we were traveling with her I found myself up with her in the middle of the night.  I was trying to let her parents get some well deserved rest and put her in bed with me to try and quiet her and play a bit.....suddenly I realized I had fallen asleep (must have been 2 minutes) and I woke up frantic that I might have rolled over on her. She was just laying there gazing up at me...quietly sucking on that pacifier!

Next area to “mess up”;  her feeding!  Her parents left me with strict instructions about when to give her her bottle, which they had made ahead of time.  When they were delayed in returning and it was time for another feeding I did not know the specific “mix” of her formulas as she was coming off premie formula.  I did not know whether it was half and half or one - third to two-thirds....If I was talking to a parent I would have said, “you can’t mess that up, it won’t hurt if it is a bit different”, but as a grandparent I was  anxiety ridden.

My last quandary was her stroller....just a simple walk turned into an exercise in ergonomics, trying to figure out how to get the whole extravagant thing put together....but at least she was fed, not dropped and somehow survived!  The question is....”will I”?

Daily Dose

Is it Appendicitis?

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Last night, a patient called me and wondered if their daughter had appendicitis. I always thought it would be the easiest diagnosis, and that we would call the surgeon and whisk the patient off to the operating room for an appendectomy, just like Madeline (one of my favorite books as a child). Well, over the years have I been taught a few things. At times the diagnosis is easy. The patient has the classic symptoms of a "tummy ache" that starts around the belly button, they may vomit a few times and have a fever and the parent in all of us thinks, "yuk, another one of those tummy viruses". But over several hours the tummy aches worsens, and moves from around the belly button (peri-umbilical) to the right lower quadrant and the nausea and vomiting persist and your child just looks SICKER. At the same time you may notice that they have a funny walk, and won't stand up straight, as they try to get to the bathroom and when possible, they move very little at all, as any movement makes the pain worse. This is classic appendicitis. For a parent, that means a phone call to the pediatrician, day or night, as that child needs to be examined. On the other hand some children just forgot to read Nelson's text book of pediatrics. They don't vomit, they may not have a fever, they are a little nauseated, but when pressed could still eat, and it only hurts in their right lower quadrant, everything else is just okay. These are the difficult cases to diagnose. These children require a lot more history, repeat exams and lab tests and may even need a CAT scan to look at their appendix. But, you don't want to miss an appendicitis, as a perforated appendix is serious and requires a lengthy hospitalization. So as a parent and a doctor, if your child's tummy ache seems to be getting worse, it may be worth a trip to the doctor to feel that tummy, run a few tests and decide how to proceed. It is not always as easy as in a book or on TV. That's your daily dose, we'll chat tomorrow!

Daily Dose

Relief During Allergy Season

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It's the worst allergy season in years and I'm seeing a lot of children complaining of nasal congestion, sneezing, itchy and watery eyes.Achoo!  Yes, it has been a particularly bad allergy season and (I'm afraid to say) it seems like it's going to be like this for a while. I have been seeing a lot of children complaining of nasal congestion, sneezing, itchy and watery eyes. 

The surge in allergies this year has been due to a very wet winter and the weather this spring has brought erratic temperatures and lots of wind. The perfect storm for the "allergic cascade" to inflict itself on everyone's nasal mucosa. The best preventative for nasal allergy symptoms (allergic rhinitis) has been the use of intranasal steroids. These steroid sprays have been used for the past 15 years and clinical studies have shown that intranasal steroids are superior to oral antihistamines. Intranasal steroids function by inhibiting the production of chemical mediators such as histamine and prostaglandin that cause inflammation and mucous production. In other words they are more of a preventative medication, while an antihistamine is treating the histamine that was released once you inhaled the offending tree or grass pollen. Intranasal steroids may also help eye allergy symptoms too. The problem is getting young kids to let you use a nose spray on them. The same holds true for the older tween and teen crowd who complain that they "just don't have the time to use it everyday" (it must take all of 15 seconds to use on yourself!) They have been shown to be effective within 3-12 hours, although will reach their maximum effectiveness after several days to weeks of use, so using it daily and throughout the allergy season is going to give you the maximum therapeutic effect. There are many different brands available and everyone seems to have their favorite. If one spray seems to bother your child due to scent, or intensity of the spray ask your doctor to try another brand. Many times they will have a sample and give you several to try and then prescribe the one that is easiest to get your child to use. It may be trial and error, but finding the right nasal steroid may just change your allergy season. That's your daily dose, we'll chat again tomorrow. Oh, God Bless You! Send your question to Dr. Sue!

Daily Dose

Constipation is a Common Pediatric Ailment

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I received a question from one of our twitter followers about her daughter who was recently found to be constipated. She wanted some information on treating constipation.

Do you know how common constipation is in pediatrics? I must discuss this at least once a day, and I have dealt with “poop issues” in my own home while raising my boys. As a mother, I was really amazed at how much discomfort and disruption of a child’s life simple constipation can cause. Constipation is defined as reduced frequency of or painful stooling in a child for two or more weeks.

The majority of pediatric patients have functional constipation, and rarely have issues secondary to anatomic, physiologic or metabolic problems. It is not uncommon to see children have a change in their stools as they become toddlers with varying eating habits, during elementary school years when children don’t want to use the bathroom at school and even later in life.

Once your child has been potty trained, it is often difficult to get a good history of their “poop” habits, and many children and even teens will report that they have “normal” stools and then on abdominal exam or x-ray are found to have “tons of poop”. There are several ways to treat constipation, and there are several different products that may be used without problems.

For daily management of constipation I recommend using either milk of magnesia (MOM) or Miralax (polyethylene glycol) which may be used safely for long periods of time. MOM is easy to use in an infant and can be started in 1/4 to 1/2 teaspoon daily and may be increased as necessary in order to produce a soft stool at least every 24 to 48 hours.

As children get older they may not be as willing to take MOM in larger doses and Miralax has truly been a “miracle” in that it is tasteless and odorless and may be mixed with juice for easy acceptance.  The starting dose for Miralax is 1/2 to 1 capful (17 grams) per day in a child over the age of one to two years. I tell the parents again to titrate the dose either up or down, to produce a soft stool every day or every other day.

I also advocate using bite sized prunes, prune juice-apple juice “cocktails”, and Metamucil cookies to help maintain normal “mushy” stools. For children who have problems with constipation or resistance in stooling, it is important that they have a dedicated time each day to use the bathroom. Good poop habits often take practice before becoming routine. Treating for many months may not be uncommon, especially in children who have ongoing constipation issues.

That’s your daily dose, we’ll chat again tomorrow. 

Daily Dose

Do Essential Oils Boost Immune System?

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Although it is still hot and officially summer, soon everyone will be heading back to school  and coughs and colds (and eventually flu, another topic) will be just around the corner. I had a patient ask me about the use of essential oils. Her 2 1/2 year old daughter is heading to preschool for the first time and she “had heard from her friends that essential oils help a child’s immunity during cold season”.

Unfortunately, there is very little data at all to confirm that statement. I only wish that rubbing a bit of lavender oil on would help prevent the common cold. While it may smell great and be relaxing....there is no data that I can find to show that there is any reproducible science to the claims that essential oils boost the immune system.  

While I was researching I found many sites stating that “eucalyptus oil is an anti-viral” and “peppermint oil is an anti-pyretic (fever reducer)”.  Tea tree oil is touted as being “both anti -bacterial and anti-fungal” (I don’t know of other drugs that can claim both!).  But, I just don’t see any data to support all of this. 

The word essential refers to the essence of the plant the oil is derived from, rather than being “essential” to your health. While in most cases essential oils (which are highly concentrated) used as aromatherapy are not harmful for adults, it may be a different story in children, especially those under the age of 6. While labels may say  “natural” it may not always mean safe.  Many oils are poisonous if ingested and there have been reports of accidental overdoses in children with several different oils. In one report tea tree oil and lavender oil applied topically have been shown to cause breast enlargement in boys.  Oil of eucalyptus and peppermint are high in menthol and cineole.  These substances may cause children to become drowsy have decreased respirations.  While there are articles stating that the use of menthol (Vicks) on a child’s feet may be helpful during a cold for reducing a cough, do not use this if child is young enough to put their feet in their mouths. 

I must say that I sometime use a few drops of eucalyptus oil in the shower when I have a cold as I think it smells great and seems to help “open up” my head. Whether this is in “my mind” or a response from my olfactory centers which sends calming messages to respiratory center is not clear. But, I am not ingesting it or using it topically. 



Daily Dose

Head Flattening on the Rise!

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A recent study published in the online edition of Pediatrics confirms what I see in my practice. According to this study the  incidence of positional plagiocephaly (head flattening) has increased and is now estimated to occur in about 47% of babies between the ages of 7 and 12 weeks.  

The recommendation to have babies change from the tummy sleeping position to back sleeping was made in 1992. Since that time there has been a greater than a 50% decline in the incidence of SIDS. (see old posts).  But both doctors and parents have noticed that infants have sometimes developed flattened or misshapen heads from spending so much time being on their backs during those first few months of life.

This study was conducted in Canada among 440 healthy infants.  In 1999, Canada, like the U.S., began recommending  back sleeping for babies. Canadian doctors had also reported that they were seeing more plagiocephaly among infants.  

The authors found that 205 infants in the study had some form of plagiocephaly, with 78% being classsified as mild, 19% moderate and 3% severe.  Interestingly, there was a greater incidence (63%) of a baby having flattening on the right side of their heads.  

Flattening of the head, either on the back or sides is most often due to the fact that a baby is not getting enough “tummy time”.  Although ALL babies should sleep on their back, there are many opportunities throughout a day for a baby to be prone on a blanket while awake, or to spend time being snuggled upright over a parent’s shoulder or in their arms.  Limiting time spent in a car seat or a bouncy chair will also help prevent flattening.

Most importantly, I tell parents before discharging their baby from the hospital that tummy time needs to begin right away. It does seem that some babies have “in utero” positional preference for head turning and this needs to be addressed early on. Think of a baby being just like us, don’t you like to sleep on one side or another?  By rotating the direction the baby lies in the crib you can help promote head turning and prevent flattening.  

Lastly, most cases of plagiocephaly are reversible. Just put tummy time on your daily new parent  “to do list”.   

Daily Dose

Your Chid's Fever

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Now that you have taken your child’s temperature, what do you do with the information? As discussed previously, a fever is defined as a body temperature above 100.4 degrees. If you take your own temperature all day long it will be quite variable as will your child’s, and body temperature often goes up as the day goes on.

If your child has 100 degree temperature in the morning, the mother and pediatrician in me thinks that by the end of the day they may be running 101 degrees or higher. I would keep that child home that day to see what happens with the temperature. If you’re wrong and their temperature stays down, back to school or day care the next day. If it goes up you have not exposed everyone else throughout the day. All infant’s under two months of age with a documented temperature (preferably rectally) above 100.4, should be seen by their doctor. That is a phone call day or night, to find out if your doctor wants to see you in the office or go to ER etc. Do not give this age infant any acetaminophen, before talking to your doctor. Many times this age child will be admitted to the hospital, so be prepared for that discussion with your doctor.

Once your child is over two months of age but still younger than six months, it is important to discuss your child’s fever with the nurse or doctor. There are certain things they will ask you that will help determine if your child needs to be seen that day or night. After six months of age it is easier to judge a child’s degree of illness by not only the reading on the thermometer, but by how they are acting. The hardest thing to teach any parent (me included) is that the height of the fever does not necessarily correlate with degree of illness.

During flu and viral season, it is not uncommon to see temperatures in the 103 - 104 degree range. Try not to react to the number on the thermometer, but rather look at your child. Go ahead and treat the fever with either acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) and then watch your child over the next 30 – 40 minutes. Reducing their fever will often improve how sick they look. Whenever a pediatrician walks into a room the first thing we do is look at how the child is interacting with the parent. Whether that is a toddler in a lap, or a big kid on the table, a quick look at a child is really worth a thousand words. If your child will smile (okay just briefly), make good eye contact, responds to the pediatrician by kicking and screaming (a toddler for sure), can play on the Nintendo DS, eat cheerios or candy or chips (I know, they won’t eat well when sick, do you?) and tell you just how crummy they feel, they are probably okay. I describe this as pitiful, and pathetic, but not critically ill. That is what we are trying to distinguish on a busy day in the office, and that is the same thing you want to look for in your own child.

It takes practice, but as a parent, you will be dealing with children and fevers for the next 21 years and you too will get better at dealing with fever. It is always scary the first time you see your child sick, but fever is not the enemy. It actually means that your child’s body is fighting the infection. So remember the mantra: Fever is your friend. I think we will be saying this a lot this winter. More fever topics later.

That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

New Test for Your Baby

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If you recently had a baby (or are getting ready to) you may have noticed another “test” being performed on your newborn before they leave the hospital. Earlier this year the American Academy of Pediatrics endorsed the routine use of pulse oximetry to enhance detection of critical congenital heart disease.   

Critical congenital heart defects (CCHD) are serious structural heart defects that are often associated with decreased oxygen levels in infants in the newborn period. These heart defects account for about 17-31% of all congenital heart disease (or about 4,800 babies born each year in the U.S.)  While some of these defects are found on pre-natal ultrasounds, and some may be evident immediately after birth when the pediatrician hears a murmur or the baby has difference in their pulses, others may not present until a baby is several hours - days of age.  

Using pulse oximetry to measure a baby’s oxygen levels before they are discharged is just another method of screening a child, and if there are abnormalities a baby would undergo further evaluation with an echocardiogram and would see a pediatric cardiologist. 

Pulse oximetry is routinely used in all aspects of medicine these days and requires a simple non-invasive device that is placed on a babies finger or toe to measure the level of oxygen in the blood. (looks a little like ET device to light up a finger). It works by comparing the differences in red light, which is absorbed by oxygenated blood, and infrared light, which is absorbed by deoxygenated blood.  

In a large study just published in the journal Lancet (looking at over 230,000 newborns), simple pulse oximetry detected 76% of congenital heart defects, with only a rate of 0.14% false positive results. The risk of false positives was even lower than that when pulse ox was performed when the baby was over 24 hours of age. Pretty impressive! 

It has been estimated that about 280 infants with unrecognized CCHD are discharged from newborn nurseries each year. Congenital heart disease also accounts for somewhere between 3-7 % of infant deaths. With early intervention and surgery the chance of survival from CCHD is greatly improved. 

So, ask your pediatrician or obstetrician if they are doing routine pulse oximetry in your hospital nursery. 

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


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