Daily Dose

Puberty And Your Child

Email via iPhone App asks when will I go through puberty?I received an email via our iPhone App from Hayden who asked when “he” would see his body changing.  That is a question from a lot of “tweens” as they are often concerned if they are “normal” as there really is a wide variation in pubertal development.

Puberty is defined as the time that physical and sexual maturation occurs and it is based upon hormonal changes in both boys and girls. The interesting thing about puberty is that there is a WIDE variation of normal as to when pubertal changes begin. Most girls will start to see some changes in their body anywhere between 8 – 14 years of age.  The first change is the beginning of breast development which is called breast budding.  Further changes take place over the next 18 – 36 months,  which ultimately leads to a girl’s first menstrual period which is called menarche. Boys will enter puberty anywhere between 9 – 15  years of age, and this too is a gradual process that typically begins when a boy notices that his penis and testicles begin to enlarge.  There will be other changes too as a boy grows facial hair and their voices begin to change.  Later in puberty a young man will notice more muscle development. The pubertal process is pre-programmed genetically, and most adolescents will begin puberty at “about” the same time that their parents did.  In other words, if your parents developed pubertal changes at a younger age then you typically will do the same. If your parents were older when they went through puberty then you may do the same thing, and this is called constitutional delay of puberty. Going through puberty after all of your friends often worries adolescents and if you are concerned speak with your doctor. If necessary there are several easy tests that me performed to assure you that your body is “normal”, and it may help to predict when your body changes may occur. Thanks for writing Hayden. I bet a lot of your fellow classmates have the same questions. That's your daily dose.  We'll chat again tomorrow. Send your question or comment to Dr. Sue!

Daily Dose

Jaundice in Your Bbay

1.30 to read

Newborn infants will often experience an elevation in their bilirubin (one mother thought it was “belly robin”) levels in the first several days after birth. This makes the baby appear to be yellow or jaundiced.  

Parents may hear their nurses discussing a baby’s TcB (transcutaneous bilirubin) level, and some nurses may even show parents the nomogram which the hospital uses to chart bilirubin levels.  It seems there is now a lot of anxiety among new parents about what this all means and in most cases the levels are to be totally expected.  I continue to think, “too much information for a brand new parent may be harmful to their health”. I want parents to be informed, but only if there is a problem. Is a bili of 7.4 really any different than 8.2?  Do you need to be up at night worrying about that? The answer is no - I will be up at night if necessary and let you know.   Knowing your baby’s hourly or daily TcB is not necessary and in fact, in my experience they often do not correlate with actual serum bilirubin levels.  

Newborn jaundice is due to the fact that infants break down red blood cells in the first several days after birth which causes the release of bilirubin. Bilirubin excretion is also facilitated by the liver, and just like everything else in a new baby....it isn’t in full working mode quite yet. It takes a few days for everything to kick start. At the same time a breast fed baby may be more likely to  get jaundiced  due to the fact that they often don’t pee and poop as much a formula fed baby....that all corrects itself once the mother’s milk is “in”. Lots of recent articles about this...be reassured.

If your baby does have a problem with higher bilirubin levels, which typically occur somewhere between days 2 -7, then your doctor may recommend phototherapy with special lights that help to breakdown the bilirubin in the skin. This may be done in the hospital or even at home under a contraption called a “bili -blanket”.  Once the bilirubin levels drop the lights are turned off!

But, what did our mother’s say long ago, “don’t ask for trouble”. Ask your doctor before you start to worry and remember a little yellow is to be expected.  

Here is a picture of one of my newborns in their bili -blanket at home! Looks pretty comfy to me.

Daily Dose

Picky Eating: Magic Words Offer Food for Thought

1:15 to read

I am trying to clean up my desk and I have been looking through stacks of pediatric articles that I felt were really interesting. An article by Dr. Barbara Howard entitled “Three Magic Words Offer Food for Thought” made a wonderful point regarding family meals and eating habits.

She states that one of the best questions to ask a child during a “well-child” visit only requires three words, but offers so much insight into a family’s interactions. What are the magic words? “How are your meals?” I know you know how much I believe in, and promote, families eating together.

There has been a lot of data substantiating the many positive side effects that stem from family meals.  Not only does eating together as a family help improve food choices which may help prevent obesity, it also leads to children who have improved vocabulary and language skills, social skills and manners. Family meals have also been shown to lessen the chance of risk taking behaviors in adolescents. There has also been an association with fewer eating disorders among adolescents who have regular family meals. So, when I ask children about their meals, I also get parental feedback. The biggest complaint is that their children are “picky eaters”. Many children and parents will say that they don’t eat together as a family as everyone eats something different. I don’t think being a “short order cook” is a job requirement of any parent.

Social worker Ally Slater, delineates parent’s responsibilities with regard to food as “what, when and where” while leaving children, “how much and whether”. I love that!! Parents control the grocery cart, meal and snack choices and food offerings on the plate. It is nice to always offer at least one food that most family members like. Once that food is offered and we are gathered together to eat, parents need to back off. Is that easier said than done? Maybe in the beginning, but over time it actually simplifies family life. I think it is really fairly easy if you “buy into” the idea of family meals and know that children will make better and wider food choices if given that opportunity. It may take up to 100 times, and many months for your child to try different foods, but eventually you will be pleased that you have a child who is a healthy eater, and who also enjoys a wide variety of foods. Trust me, your children when raised this way, really turn out to be great eaters as adolescents and young adults.  I think my boys are less “picky” than I am! (No sushi for me).

Make family meal time a priority. Your children will respect the rules, learn table manners, and enjoy dinnertime conversation, while eventually developing a more mature palate. It just takes time. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Get the Most fromYour Child's Well Check

2.00 to read

When was the last time you saw your pediatrician for a “well child check up”?  Can you remember how much time you spent with your doctor?  According to an article in the October issue of the journal Pediatrics, 33% of parents surveyed spent less than 10 minutes with their child’s doctor.  Another 47% stated that they spent between 11-22 minutes with the doctor and 20% stated that they spent 20 minutes or longer.

This study really only reinforced what I already know…it takes longer than 10 minutes to do a comprehensive well child exam and have enough time to discuss all of the topics that need to be addressed, even if you are talking fast!

It doesn’t matter what aged child I am seeing, there are just so many issues to be covered.  High on the list is anticipatory guidance. It is a look ahead at how your child will be changing and developing.

For a first time parent this may mean a discussion about their child beginning to crawl and the need to childproof the house. For a parent of an older child, it may be a discussion about a new driver and driving contracts, or a college bound student and the risks of binge drinking. The list of topics is enormous and the topics to be discussed continue to grow!

I try to cover the “list” of topics that I want to cover in each well child visit and then leave time for parents/children to ask questions or address any specific issues that they might have.  In most cases it is not possible to accomplish this in the scope of a 10 minute exam.

As a child gets older, and many of the issues become more complex than “what is the first food I should feed my baby”, the time crunch is even more evident. I only wish that I could spend 45 minutes to an hour with each teen that I exam as there are just so many topics to cover, and most teens will talk if you just give them the time. Therein lays the rub; not enough time!

Unfortunately for both the patient and the pediatrician, medicine is becoming more and more about the insurance company, time and billing. Many insurance companies do not cover the time spent for preventative care and the numerous screening services that are recommended.

There is nothing more important than preventative care, especially in the pediatric population. The time (and therefore money) spent now may be the solution to more costly heath care issues at a later date. How can you discuss obesity, food choices and type 2 diabetes with an overweight 13 year old, whose parents are also overweight, yet they continue to buy fast foods.  

The visit should also include discussing the child’s learning issues at school, throw in rules surrounding social media, sleep needs for teens, and round it out with gun safety in a 10 minute time span? Oh yes, you need to do a thorough physical exam too.  I find these conversations hard to do with my own children during a dinner conversation, yet alone during 10 minutes with the doctor.

Next time you go in for your child’s check up, make sure your questions are all answered and see how long your average visit takes. I wonder why I am always “behind”; I just can’t do it in the 10 -15 minutes allotted. I want to answer all of my patient’s questions and concerns and if it takes a bit longer, so be it! 

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

Daily Dose

Treating Dry Skin

The best way to counter the effects of the winter weather is by using moisturizers on the skin, and lubricants in the nasal passages.I am reminded once again of the cold weather and the problems that ensue with dry skin, dry mucous membranes and frequent upper respiratory infections. The best way to counter the effects of the winter weather is by using moisturizers on the skin, and lubricants in the nasal passages, and by good hand washing, which also leads to dry skin. It seems to be a vicious cycle. The only solace is that we are well into winter weather and its effects.

The air is cold, the heat is running and your skin gets dehydrated. Bathing and showering with your usual soaps may not work at this time of year. You might try using a more gentle soap such as Vanicream, Cetaphil, Purpose, or Basis. Try bathing a little less frequently, with shorter periods in the bath. Every other day would be fine during the winter. The hotter the water the more drying it may be, so turn it down a notch to where it is warm and comfortable. If the kids are bathing, let them play awhile before lathering them up, and once soapy, rinse and get them out of the bath water. Pat dry lightly and while they are still a bit, damp rub in a moisturizer, and creams are better than lotion. Vanicream, Cetaphil cream or Eucerin creams. A little Vaseline up the nostrils before bedtime will keep the nasal passages moisturized too. Keep it up until spring. That's yours daily dose, we'll chat again tomorrow.

Daily Dose

Allergy Season!

1:30 to read

There are a lot of kids (and their parents) who are dealing with “red eyes” right now.  The spring winds are really blowing that pollen around and the oak, mulberry, maple, hackberry....all trees that are the major contributors to this problem.  

I have received lots of pictures of children with puffy eyelids as well as the area beneath their eyes, (so called allergic shiners).  They also have inflamed eyes where the whites are streaked with red and many have a watery or gunky discharge.  They are all rubbing their eyes like crazy as well..and how do you really explain to a child under the age of 5-6 years to stop rubbing their eyes!

Allergic conjunctivitis is uncomfortable and also causes a lot of children to be sent home from school due to having “pink eye”. But this type of pink eye is not contagious, rather it is due to an allergic reaction causing eye inflammation.  It is often seen several hours after children have been outside for play time and recess.  

Seasonal allergic eye symptoms are some of the most aggravating.  Fortunately, just like the over the counter nasal steroid sprays to help allergic nasal symptoms, there are also over the counter eye drops to combat the misery of allergic conjunctivitis.  While these eye drops were previously only available by prescription you can now get them at any drug store.

There are two brands, Zaditor and Patanol that combine both an antihistamine/decongestant with a mast cell stabilizer, which in combination help to prevent allergic conjunctivitis. Like a nasal steroid, you should start using the eye drops before the the pollen count increases as it takes several days for the drops to become effective. They also need to be used on a regular basis...better compliance means less symptoms.

While younger children may not be “fans” of eye drops (and these do sting a bit), I can usually get a 5 or 6 year old to begin using them as they can see how much better they feel if they do.  I continue using them for the duration of the allergy season. Watch the pollen counts for your area. The northern states will be dealing with this issue a bit later than those of us in the southern and middle of the U.S., where we are in full pollen bloom!

Daily Dose


1:30 to read

When I am seeing toddlers for their check ups, the topic of behavior is usually at the top of both the parent’s and my list for discussion.  Once a child is walking and beginning to talk, all sorts of new behaviors seem to occur! 

Parents ask, “how do I stop my child from hitting or biting?”  “What about misbehaving and not listening?”  The toddler years are challenging for behavior as a child is gaining independence, and testing as well.  Toddler and teens have some of the same attributes and it is important to begin behavior modification during the toddler years. 

Time out is the most commonly used behavior modification and not only will parents use this method at home, but preschool and day care teachers begin using this technique as well. This is the age that children begin to understand rules and consequences. 

So how do you “do” time out and when?  I usually start using time out when a child is between 15 -18 months of age. While I try to ignore and distract tantrums, I use time out for biting, hitting and those age appropriate yet inappropriate behaviors. 

I pick a chair in the house (we had a small set of table and chairs which seemed perfect) and every parent needs a kitchen timer to use for time out.   It is important to get at your child’s level when disciplining them as well. Tell them why they are going to time out and then have them sit in the chair for 1 minute per year of age.  (Trust me a minute sometimes feels like forever!)  

Here is the trick, if your child will not just sit in the chair (and many won’t), go behind them and hold them in the chair as if you were a human rope.  In most cases the child will be crying and trying to get up out of the chair, but you calmly hold them in the chair from behind. No eye contact!  Once the timer goes off, you let go of them, go back around so that you make eye contact again, get down to their level, and explain once again that they had to sit in the chair because they (fill in the blank).  

Time out takes time and patience.  If you are consistent about using time out for misbehaving, your child will learn to sit in the chair.  For some it may only take 1 time and others are more head-strong and it may take months of “human rope” before they decide to sit alone. 

Don’t give up!!!  This is a very important lesson for children to learn and you will use time out many times, not only in that little chair, but in other venues as your child gets older.    

Daily Dose

How to Treat A Vomiting Child

We are definitely in the throes of "sick season" in our office and with that comes a lot of kids with vomiting. I remember the first time that one of my own children vomited.

We were in Target, he was about two and he had said he "was sick". Now, seeing that he was not very specific and did not elaborate, I just went on shopping. Several minutes later, as he sat in the cart (with seat belt fastened), he just looked at me wide eyed and suddenly vomited. This is the moment as a parent that you understand the difference between babies that "spit up", and true, projectile vomiting! Now what do you do once your child has vomited (besides rush out of Target as fast as you can)? Once a child has vomited it is important not to give them anything else to eat or drink, for at least 30 to 45 minutes. That means even if they are "begging" for a drink, as you will probably see it come right back at you if you do. After waiting, you want to begin re-hydrating with clear liquids. Not a good idea to pull out the milk or food yet. In an infant you can use Pedialyte, which is an oral electrolyte solution, and instead of breast milk or formula you can try feeding your infant about an ounce of Pedialyte every 10 to 15 minutes and see if they can keep Pedialyte down. In toddlers and older children I use Gatorade, as it is not quite as "salty" and kids seem to take it better. Again, frequent small sips of Gatorade while you wait to see if the vomiting is persistent. Don't go too quickly on giving them larger volumes. The key is small amounts, frequently, which are easier to handle. As your child keeps down the Pedialyte or Gatorade you can increase the volume that they are taking and decrease the frequency. The main thing you are trying to do with a child of any age is to keep them from getting dehydrated and their vomiting is typically due to a viral illness affecting their GI tract. Because it is typically a virus that is the culprit for nasty vomiting, it just takes time to get through the illness. There is no "miracle" cure, and watching your child vomit, or cleaning up the vomit that invariably is usually not in the toilet, is one of the worst parenting jobs. That being said, there are very few children who will not experience vomiting at least once or twice during their childhood, so you need to keep "clear liquids" on hand in the pantry. Having powdered Gatorade around is a lifesaver at 2 a.m when your four-year-old wakes up and throws up. If you are giving the clear liquids, and your child tolerates larger volumes, but then vomits again later on, you just back up and start all over with smaller amounts more frequently. It is somewhat like a "balancing act" to give enough that they are hydrated, but at the same time to not give too much at one time that they vomit again. Slow and steady is the mantra. You should always be looking for your child to have tears, a wet and moist mouth (put your finger in there, it should come out with some saliva on it), and urine. It is often hard to tell if a child in diapers has had a wet diaper as they will not be "soaking" the diaper and smaller amounts of urine are "wicked" with the new super absorbent diapers. Children will also be pitiful after vomiting and may seem "lethargic" to you, but if they are an infant and can smile and make good eye contact or they are an older child who can tell you they feel terribly and don't want to drink Gatorade or play with their blocks they are probably not dehydrated. If in doubt, give your doctor a call to discuss what is going on. After using Pedialyte and Gatorade, and your child has not vomited for six to eight hours you can try adding some formula or breast milk, or other liquids such as chicken soup or a Popsicle. I still would not start solid food until the child has kept down other liquids. We parents all worry if our children don't "eat" but the fluids are the important part, and as we all know, a day without out chicken nuggets or peanut butter will be okay. Keep up the fluids!! If your child continues to vomit despite your best efforts with "slow and steady" fluids you need to call the doctor. We have plenty of patients that we see everyday to make sure they are hydrated, and to even watch them while they take fluids in our office. Occasionally, when all else fails we will have to hospitalize a child for IV hydration. Oh yes, remember to wash your hands frequently as these nasty viruses are contagious and parents will often find themselves getting sick after their children. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Toddler Behavior

1:30 to read

Toddlers....you gotta love them but they can also drive you a bit crazy! I have seen several parents lately who have said, “he/she turned from a cute loving baby to a toddler overnight, what happened?”  What happened is that this cute baby reached somewhere between 12-18 months of age, and went to bed one night and read, “how to become a toddler....in 3 easy steps”.

I think of a toddler as being somewhere between 1-3 years of age.  They are now exploring the world on two legs and walking turns to running in a matter of weeks. Most toddlers can run faster than their parents.  They are also just starting to learn language and soon after finding Momma, Dadda, and uh-oh, they learn the word NO.  Oh dear, it doesn’t matter how much you try not to use the word, a toddler quickly learns to shake their head, stomp their feet and fall to the floor when they don’t get their own way....you don’t even have to say NO.

Toddlers are notoriously egocentric and narcissistic, it is all about ME. ( just wait for those teenage years).  They want everything to go their way, and are incredibly frustrated when it doesn’t.  This means that throughout the day when the meal is just not quite to their liking, or the toy you offer them is not the I-phone that they wanted to play with, or you take them to bed at the end of a long day....their reaction is the same, “I don’t like this!” and this means crying, throwing the toy or arching their back and flopping to the floor as you try to get them into bed.  You, the parent, are being totally appropriate and are teaching your child limits and boundaries and rules...they just don’t like it!! ( and who does, right?)

Toddlers are just beginning to comprehend that they cannot always get their way. They often lash out when frustrated with biting, hitting, and screaming while laying on the floor and acting like they are having a seizure.  All of this is inappropriate, age appropriate behavior. Our job as parents is to continue to be consistent and calm while redirecting their behavior.  It sounds much easier than it it. How can a 25-40 year old lose to a two year old....easy!

But, you cannot lose...you just re-direct..   If they are throwing food you take the meal away, they hurl a toy at their sibling, you put the toy up,  and you hug and kiss them and put that limp or screaming body to bed when it is bedtime.  Rules need to start at this age...you are setting up behavior for the rest of your child’s life.  Toddlers do turn into loving and well behaved pre-schoolers but it takes a lot of patience on a parent’s part to get there.  Be strong and consistent.   


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