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Daily Dose

Preschool Nutrition Can Be Challenging

1.30 to read

Does your child eat three meals a day with healthy snacks along the way? I often find myself talking to parents about establishing healthy eating habits especially when you have a preschooler. Preschool children, specifically the two to five-year-old set are notoriously picky eaters, and parents need to recognize that this is developmentally appropriate, although frustrating for parents.

This is an appropriate time to begin teaching children the importance of healthy eating habits to encourage a lifetime of good health and prevent obesity. A good place to start to get information is “MyPyramid for Preschoolers”, a website sponsored by the U.S. Department of Agriculture. This website not only covers what your children should be eating, but also is full of good advice on handling picky eaters, how to monitor your child’s growth and ideas to encourage physical activity.

The website encourages parents to lead by example and let your children see you eating a wide array of foods including fruits, vegetables, and whole grains throughout the day. There are ideas for healthy snacks that can be eaten on the run, as you get back into carpools and after school activities. Even the toddler set is busy after school!

Remember: do not let food choices become a battle or an issue. Do not make negative food comments around your children, and keep trying new things. It may take up to 20 attempts or more before your child will try something new, but if you don’t keep trying you will never know if they might really like broccoli.

Also, no “yucky faces” for the adults and older children while at the table and eating their meal. That will only discourage your toddler from trying unfamiliar foods. Put on that happy face, even if it is not your favorite food, it might be your child’s.

The most important message is to make mealtime and snack time pleasant and healthy. Even a toddler can help with planning and preparing a meal. This website is really quite good and interactive as you can enter your child’s first name, age, gender and typical amount of activity and the site will generate a plan just for your child! Can’t be easier than that.

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

 
Daily Dose

Breaking Bad Habits

1:15 to read

Do any of your children bite their nails or suck their thumbs? If so, are you always saying, “take your fingers out of your mouth, they are dirty”, or “if you keep biting your nails you will get sick due to all of those germs on your fingers”!  I was guilty of saying those very things to my own children, and I also remember being a nail biter and my mother saying the same thing to me.

Well, who would have thought that a study just released today in the journal Pediatrics might make us parents eat our own words (it wouldn’t be the first time).  The study, “Thumb-Sucking, Nail-Biting and Atopic Sensitization, Asthma and Hay Fever” suggests that “childhood exposure to microbial organisms reduces the risk of developing allergies”.  Who knew that there might be something so positive coming from a “bad habit”.  

This study was done in New Zealand and followed over 1,000 children born between 1972-1973 (dark ages) whose parents reported that they either bit their nails or sucked their thumbs at 5,7,9 and 11 years old. The participants were then checked at ages 13 and again at 32 years old to look for an allergic reaction ( by skin prick testing) against at least one common allergen.  And guess what…at 13 years of age the prevalence of an allergic reaction was lower among those children who HAD sucked their thumbs or bitten their nails.  Incredibly the the findings persisted almost 20 years later!  This study even looked at cofounding factors including sex, parental history of allergies, pet ownership, breast feeding and parental smoking… none of which played a role. 

So, while not advocating for children to suck their thumbs or bite their nails (which unfortunately I did until high school when I decided to have nails to polish) there may be a silver lining….a protective effect against allergies that persists into adulthood. 

Lemonade out of lemons!!!

Daily Dose

Epi Pen Controversy

1;30 to read

I have more than several patients who have had serious allergic reactions (anaphylaxis) to a variety of things…including insects (fire ants, bees) as well as foods (peanuts, tree nuts, fruits, shellfish). All of these children need to have epinephrine auto injectable pens (EpiPen) on hand in case of “accidental” exposure to the allergen and a subsequent life threatening allergic reaction.  These medical devices are seldom used ( thank goodness), but need to be replaced every 12-24 months and should always be readily available in case of an emergency.

For the longest time it was not a “big” issue (cost wise) to write prescriptions for these allergic children and to make sure that they had several EpiPens on hand. This included having them available at home, school, in the mothers purse or in the car or in the gym bag…many people also wanted “extras” to have at the grand- parents house or at the lake house…etc.  So….I would write a script for the EpiPen 2 pack and the family might get 4-5 sets to disperse to the appropriate people. Prior to 2009 the cost was less than $100/two pack. 

It was several years ago that a few families started talking to me about the expense of these devices and also how quickly they seemed to expire…in fact we started asking the pharmacist to look at the expiration dates and to try and dispense the ones that had the longest expiration, in hopes of saving some expense.  At that time there were also two companies that were making the epinephrine devices.  

Then in the last year parents started calling me complaining that the EpiPens were becoming cost prohibitive and “did they really need to keep filling them?”….especially seeing that they had never needed to use one?  Of course I replied that “by the grace of God” and their vigilance they had not needed one, but YES, they indeed needed to continue to have them on hand.  In many cases families reduced the number that they bought and tried to make sure that they handed them off if their child left home….terribly hard I would think to keep up with.

This issue came into view most recently as parents across the country started complaining to not only their physicians, but to the pharmacy, their insurers and the drug maker Mylan Pharmaceuticals….why in the world had the price jumped to over $600? In retrospect, the price had been raised 15% twice a year over the past 2 years!  ( It was also pointed out that this was a 6 fold price increase in the past decade).

I do know that epinephrine has been around for a long time and the drug itself is not that expensive, and is used everyday in hospitals around the country….but the EpiPen auto injector which allows “anyone” to inject the medicine into a muscle without any measuring etc. has become cost prohibitive for many families, even some of those with insurance. It seems that Mylan Pharma  is setting prices “based on whatever the market may bear” and not on the fact that the drug is new or expensive to produce…

This is one of the times that all parents with children who need to carry an EpiPen need to contact their representatives in Congress, as well as their insurers to see if the public can be influential in trying to remedy this situation.  The public will have to let their concerns and voices be heard…

Just as I am writing this, Mylan has announced an “instant savings card” for those people who are paying out of pocket and help for those who do not have the means to buy the EpiPen….but this does not correct the problem as a whole. While the discount may be helpful for some, but not all, it is not the answer to the ever growing problem of exorbitant drug costs in this country. I have several families who are going to try and buy the EpiPen while on trips to Mexico and Canada. I have no idea of the costs there…but worth a try.  

Daily Dose

Drowning Is Silent!

1:15 to read

Summer is coming to an end, and many families will create memories this holiday weekend 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

A Better Night's Sleep

1:15 to read

What is it about sleep and parenting? Babies never sleep enough and teenagers sleep too much!! Why can’t “we” get this right? While sleep patterns definitely do change with the age of the child, good sleep habits can begin in infancy and continue throughout adolescence.

Even from the beginning,  you should try to teach your child to fall asleep on their own and to self-console by either sucking on their fingers or a pacifier. But remember, this sleep thing is new and babies really do have to learn how to do this.  Think of it as if you were teaching your child to read, it doesn’t happen overnight, but evolves with practice, patience and repetition. Sleep is the same way.

After the early years of teaching your child to fall asleep on their own, the toddler, preschool, and elementary years are usually fairly easy to establish good sleep patterns if you follow a routine, with a set bedtime, reading to your child before bed and hugs and kisses and lights out. This is the age for occasional nightmares, or fears, but also for regular nights of uninterrupted sleep.

With the tweens and teens and hormone changes of adolescence comes a new sleep clock that is set to stay up too late and not wake up in the morning. Even teens need a good nights rest, so a bedtime should be encouraged and enforced unless there is a test of special event. There is not a reason I can think of for teens to be up past 11 pm on a school night, homework should be finished, and all of the accessories such as cell phone, computer and all other electronic gear put up before bed. The older you get the more you understand a good night’s sleep , but someone has to teach the basics along the way and before you know it the whole house will be on that schedule too. That's your daily dose for today.  We'll chat again tomorrow. Send your question to Dr. Sue now!

Daily Dose

Tummy Aches

1:30 to read

School is back in session and I am already getting phone calls and texts with concerns about new tummy aches. I have even started seeing patients in the office with complaints of “my tummy hurts”, and we are just in the first week of school. I know that school nurses are dealing with this common complaint as well.   Amazingly, I don’t see very many complaints of tummy aches during the “lazy days of summer”…but once school starts they seem to become more prevalent.

Don’t get me wrong…while the tummy aches are real and painful, they are usually not due to anything serious.  In many cases I see,  the abdominal discomfort may be due to a bit of anxiety and stress that often comes as children get back into the classroom.  While the child may not be aware of “stress”,  their body does sense it and the gut responds with abdominal pain. 

The children that I am already seeing are all healthy and growing well. They do not appear to be “ill” when I see them, but will complain that their tummy hurts. When I have them point to where the pain is, they typically point right around their belly button (periumbilical).  If asked to point to the one place where it “hurts the most”  they typically still cannot localize it…it’s just all over! Having generalized pain is typically a good sign, rather than having point tenderness in one area.  Upon further questioning they do not have a fever, have not had vomiting or diarrhea, DO NOT wake up in the middle of the night with abdominal pain and often cannot remember if they “pooped“ today or yesterday but usually swear that their “poop” is “normal” . (I am not always sure about that - stool history in kids is quite hit and miss!) 

A few of the children say that eating makes their tummy ache worse while others report it feels better if they eat. They typically are not having issues with a specific food.  (It also depends what they are given to eat - often they will eat their favorite food if given the opportunity).  

For some of the children the pain is “bad enough” that they come home from school, but once home their parents report that after an hour or so they seem better.  Other children stay in school, but the minute a parent picks them up they start saying “my tummy hurt all day at school”!  

I remember that one of my sons often had tummy aches during the school year and we were talking about it the other night (he is now an adult).  He says he remembers being worried about school and “hiding” in the morning when it was time to go to school (I would be looking all over for him as his older brother was already out the door, and anxious that he would not get to school on time,  while I had the younger brother on my hip as I searched the house).   Talk about getting a stomach ache…mine was in knots by the time I would get to work.  It would only be several hours later when I would get the phone call from the school nurse that he was there with a tummy ache.  He now says that he remembers that by the time he was 8 years old it all just changed and it went away. 

Many times all it takes is a little reassurance that the tummy ache is not serious. I tell the children that everything on their exam is normal which is a good thing. Sometimes it seems to help a tummy ache if I prescribe the child some extra fiber and maybe a Tums  a good source of calcium too). Who knows if it is placebo effect… but just by doing something they feel a bit of relief. The one thing I do know…they need to keep going to school and it usually gets better once they are settled back into a school routine.  

 

Daily Dose

Summer Skin Infections

1:30 to read

I have been seeing a lot of skin infections and many of these are due to community acquired methicillin resistant staph areus (caMRSA). The typical patient may be a teen involved in sports, but I also see this infection in young children in day care, or summer camp. The typical history is “I think I have a spider bite” and that makes your ears perk up because that is one of the most common complaints with a staph infection, which is typically not due to a bite at all.

The poor spider keeps getting blamed, and how many spiders have you seen lurking around your house waiting to pounce? The caMRSA bacteria is ubiquitous and penetrates small micro abrasions in the skin without any of us every knowing it. The typical caMRSA infection presents with a boil or pustule that grows rapidly and is very tender, red and warm to the touch. The patient will often say that they “thought it was a bite” but the lesion gets angry and red and tender very quickly and typically has a pustular center.

For most of us pediatricians, you can see a lesion and you know that it is staph. It is most common to see these lesions in athletes on exposed skin surfaces such as arms and legs, but lesions are also common on the buttocks of children who are in diapers in day care. The area is angry looking and tender and the teenage boy I saw the other day would not sit on the chair, but laid on the table on his side as he was so uncomfortable. If the lesion is pustular the doctor should obtain a culture to determine which bacteria is causing the infection, but in most cases in my office the culture of these lesions comes back as caMRSA or in the jargon Mersa. When I say Mersa, I often cause widespread panic among my patients, but in most cases to date these infections may still be treated with an oral antibiotic that covers caMRSA, such as clindamycin or trimethoprim-sulfa. Many of the lesions improve dramatically once the site is drained and cultured. I will reiterate that if possible you want your doctor to obtain a culture to identify the bacteria that is causing the infection.

To prevent caMRSA remind your student athlete not to share towels, clothing or other items. Make sure that common areas are disinfected and once again encourage good hand washing. The closure of schools or disinfecting an entire football field or area with turf is not recommended. Lastly, this is a good reminder that you only want to take an antibiotic for a bacterial infection and that overuse of antibiotics leads to resistance. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

School & Infectious Disease

1:30 to read

I received an email this week from a patient…subject line: “potential exposure to Herpangina”.  In the body of the email was the following:

Dear Parents,

We want  to inform you that a case of Herpangina disease has been reported for a child at ….. room #112.  This is a contagious disease that  is spread by direct contact with another person or contaminated objects.  Herpangina is an illness caused by a virus, characterized by small blister-like bumps or ulcers that appear in the mouth, usually in the back of throat or the roof of the mouth. The child often has a high fever with the illness. We have attached further information about this common childhood illness published by Children’s Hospital in Boston. Our teachers are carefully disinfecting their room to help prevent further spread of the disease.

The mother of the child that sent me the email was “freaked” out and “worried” about  sending her child back to pre-school.  

My question is this, when did it become a “rule” to notify parents in a pre-school or day care setting that there were viral illnesses circulating?  It certainly seems unnecessary to me to send notification of EVERY childhood illness that occurs and for most of my families only serves to cause anxiety.  Some of the schools in our area post a sign on the entry that says something to the effect:  “there are cases of diarrhea, RSV, hand foot and mouth and fevers being reported in children that attend this school.”  Really, is it that surprising or necessary? Seeing that many of the numerous viral illnesses that children get these days are spread via respiratory droplets and contact with surfaces, such as toys and tables that everyone touches (computers too), children are exposed to things all of the time.  Do you go to work and ask your co-workers in a conference room..have you had diarrhea, a cough or a sore throat in the last day?

I understand notifying parents of illnesses, such as meningitis, measles, mumps…even chickenpox that are infectious and may be serious or life threatening. Thankfully, there are very few cases of these illnesses to report, now that the MAJORITY of children receive vaccines to these diseases. 

By putting these emails, texts and notices out for every parent to become alarmed about…and then to come to the doctor out of concern that their child  “may get sick….even before they have a symptom”,  serves no purpose. Herpangina and Hand Foot and Mouth are very similar viral illnesses, and both are caused by enteroviruses. It is at times hard to distinguish one illness from the other. But, with that being said, the treatment is solely symptomatic. In other words, treat the fever, make your child comfortable and don’t let them go back to school until they are fever free for 24 hours.  

Lastly, your child is going to catch a lot of these viruses, no matter what you do when they go out to play, shop or go to school. Each time they catch a viral illness it actually helps them to build antibody in order that their immune system may get stronger and stronger. I think the better note is….as winter comes children will get more coughs, colds and viral infections…if you think you child is not feeling well or running a fever, please keep them home from school for the day.  It is just a normal part of childhood…we don’t need any more anxiety in this world.   

 

Daily Dose

Too Much Pressure to Play Sports?

1:30 to read

Does your child play a sport “after school”?  It seems children as young as 3-4 years of age are now involved in soccer and even football.  Some children are barely walking before they are signed up for a team.  Parents tell me various reasons for this including, “if they don’t start young they will be at a disadvantage athletically”, “if we don’t get on a team now, there will not be room for our child once they start kindergarten or first grade”,  and “our child wants to play and wear a uniform”. I just see lots of issues with burn out.

It seems awfully early to start “team sports” to me. I am a huge advocate of families and children playing together and learning all sorts of games and sporting skills. Kicking a soccer ball in the yard, or hitting the wiffle ball off of the tee, or having Dad throw a pass with the football all seems pretty “normal” to me. But organized sports with a 3 year old who is still in diapers….really?  Maybe one of the “guidelines” should be you have to be potty trained.  Yes, this is true, I see children in diapers who “will not pee or poop in the potty” according to their parents, but they go to soccer practice?  What is wrong with this picture?

So, while some of these well intentioned parents have told me that they are having fun being the coach, or attending games with other friends, their pre-school children “don’t have time to be potty trained”. They are too busy going to school, followed by organized activities that “it is just easier to let them stay in diapers”. I was even with a 4 year old at a football game and she was still in diapers?

At some point these children and parents will need to skip a practice or two and stay home long enough to get potty trained.  I am noticing that children are getting older and older before they are potty trained. I know there are books written on this topic with the philosophy that “the child will ultimately train themselves”, or “ how to potty train in 3 days, with a child who shows no interest”…or something along those lines.  But really, in my experience, if you watch your child’s cues, spend the time to “talk bathroom habits” and have the “time” to be home to potty train most children are potty trained between 24-36 months of age.  Yes, there are occasional children (none of my own) that just show interest earlier and say things like “I go potty now” and really do it on their own. There are also some who are more difficult to get interested and may be harder to potty train…but again, which is probably a more important life time skill…..getting out of a diaper or trying to figure out how to line up for a soccer game? I’m just saying.

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