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Daily Dose

Timeout!

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

The Morning Clothes Battle!

Tired of arguing with your kids about what to wear to school? Dr. Sue has a few tips to end the morning clothes battle!"I don't want to wear that! I can dress myself!" Ah, the morning clothes battle.  Demmeke sent me an email via our  iPhone App and she said she is not ready to surrender in the "what to wear to school" war with her kids.  She has girls!

Actually, the struggle over choosing clothes may be a struggle for either gender and interestingly may start at young ages.  The best time to begin good habits and decrease “the morning clothes struggle” is when your children are young. One of the first things I learned as a  parent was that it was easier to lay out the clothes the night before.  If you let each child help decide the night before and have the “rule” that once chosen that is what will be worn in the morning, everyone knows what to expect. I do remember one of our children always wanting to wear one of 2 favorite Nike sweat suits. He had a blue and a red one. We did go through some struggles about his choice of school clothes until I decided that a “slightly worn” nylon sweat suit was not the worst thing in the world and he managed to wear them for 5 days and only required 1 washing.  Some times you just have to choose your battles and that was one that I finally decided was not worth fighting. After about a year of blue and red “suits” as he liked to call them, I think he moved on to other choices. I also think that school uniforms make everyone’s life easier.  Once our children were required to wear a school uniform (in both public and private schools) I realized that it would be pure genius to have all school children in uniforms. I know that some feel that making all children wear a uniform” stifles their creativity” or something along those lines, I disagree. Uniforms are a great equalizer and put everyone on the same playing field. It is analogous as to why we don’t serve soft drinks in school. If you want to let your son or daughter wear t-shirts with weird messages on the front or inappropriate shorts or tank tops after school while drinking soft drinks, that is a parental decision. But to make teachers and principals spend time “policing” clothes choices seems to be a huge waste of teaching time, especially when our schools are in dire need of academic improvements. There have been numerous studies to show that children actually behave better in school and also have improvement in grades when uniforms are worn.  I thought my own children were creative enough choosing either a white or blue shirt and life seemed easy. I also think it is far cheaper to buy uniforms than to try to stay up with the latest trend in often expensive items. Lastly, I do recall some parents telling me that by sending your child to school in pajamas when they don’t want to get ready in the morning often “fixes” the clothes battle.  Fortunately that is one parenting experience I never had to do, but let me know if that works for you! That's your daily dose for today. We'll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Happy Thanksgiving

Wishing each of you a healthy and happy holiday with your family. I am thankful for the many blessings of friends and family. A special prayer and thank you for those men and women who are not with their families today as they are overseas protecting our values and freedom. Happy Thanksgiving from Dr. Sue and everyone at The Kid's Doctor!

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Daily Dose

Babies & Bow-Legs

1.15 to read

Fact or fiction: if a young baby puts any weight on their legs they'll become bow legged? Dr. Sue weighs in.I’m sure you have noticed, babies like to stand up! With that being said, I still hear parents coming into my office who say, “I am scared to let my baby stand up as my mother (grandmother, father, uncle) tells me that letting a baby put weight on their legs will cause bow-legs!  How is it possible that this myth is still being passed on to the next generation?

If you look at a baby’s legs it is easy to see how they were “folded” so that they fit inside the uterus. Those little legs don’t get “unfolded” until after delivery. A newborn baby’s legs continue to stay bent for awhile and you can easily “re-fold” those legs to see how your baby was positioned in utero. Almost like doing origami. So, how do those little bent legs get straight?  From bearing weight. If you hold a 3-5 month old baby upright they will instinctively put their feet down and bear weight.  A 4 month old likes nothing more than to jump up and down while being held. They will play the “jumping game” until you become exhausted. That little exercise is the beginning of remolding the bones of the leg, while straightening the bones. If you look at most toddlers many do appear bow-legged as the bones have not had long enough to straighten. Over the next several years you will notice that most children no longer appear bow legged. For most children the bow legs have resolved by the age of 5 years. I child’s final gait and shape of their legs is really determined by about the age of 7 years. Next time you hear the adage about bow legs, you can politely correct the myth. Standing up is going to make that baby have straight legs! That’s your daily dose for today.  We’ll chat again tomorrow.

Daily Dose

Chubby Toddlers & Weight Gain

1:30 to read

So, what goes on behind closed doors? During a child’s check up, I spend time showing parents (as well as older children) their child’s growth curve. This curve looks at a child’s weight and height, and for children 2 and older, their body mass index (BMI). This visual look at how their child is growing is always eagerly anticipated by parents as they can compare their own child to norms by age, otherwise called a cohort. 

I often then use the growth curve as a segue into the discussion about weight trends and a healthy weight for their child. I really like to start this conversation after the 1 year check up when a child has  stopped bottle feeding and now getting regular meals adn enjying table food. 

This discussion becomes especially important during the toddler years as there is growing data that rapid weight gain trends, in even this age group, may be associated with future obesity and morbidity. Discussions about improving eating habits and making dietary and activity recommendations needs to begin sooner rather than later. 

I found an article in this month’s journal of Archives of Pediatrics especially interesting as it relates to this subject.  A study out of the University of Maryland looked at the parental perception of a toddler’s (12-32 months) weight. The authors report that 87% of mothers of overweight toddlers were less likely to be accurate in their weight perceptions that were mothers of healthy weight toddlers. 

They also reported that 82% of the mothers of overweight toddlers were satisfied with their toddler’s body weight. Interestingly this same article pointed out that 4% of mothers of overweight children and 21% of mothers of healthy weight children wished that their children were larger. 

Part of this misconception may be related to the fact that being overweight is becoming normal.  That seems like a sad statement about our society in general. 

Further research has revealed that more than 75% of parents of overweight children report that “they had never heard that their children were overweight” and the rates are even higher for younger children. If this is the case, we as pediatricians need to be doing a better job.  

We need to begin counseling parents (and their children when age appropriate) about diet and activity even for toddlers. By doing this across all cultures we may be able to change perceptions of healthy weight in our youngest children in hopes that the pendulum of increasing obesity in this country may swing the other way. 

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

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. 

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

Vomiting And Diarrhea

What can you do if your child is vomiting and had diarrhea?I received an iPhone App email, this one from Holly.  She writes “my son is on his 5th day of diarrhea. What can I do? Is this going around? Will my other kids get this? HELP!!!"

While most of the country is not currently experiencing flu (yet), we are seeing a large number of cases of vomiting and diarrhea.  Many people call this the “stomach flu” but in reality it is not related to influenza at all.  The medical term for the illness is gastroenteritis, and this illness is typically caused by a viral infection.  The problem with these viruses is just like colds, there are a lot of viruses that can cause vomiting and or diarrhea.  In other words, you may see your child get several of these viruses in a season, and often, because they are contagious, you the parent develop the dreaded illness too!   I have written about vomiting in an earlier blog, so we are going to cover diarrhea today. Rotavirus was previously one of the most prevalent fall and winter viral illnesses that caused vomiting and diarrhea in young children.  A vaccine against rotavirus was introduced more than 3 years ago,  and since that time there has been a greater than 50% reduction in childhood hospitalizations for dehydration secondary to rotavirus. This also means that fewer parents may be getting rotavirus from their children.  But other viruses like norovirus, adenovirus, or enteroviral infections can also lead to vomiting and diarrhea and dehydration. If your child has loose, frequent, watery stools (which often follows vomiting) the key is to make sure that you are giving them enough fluid to maintain hydration.   It is much easier to do this once the vomiting has stopped. (think about putting as much in as comes out the bottom).  Parents often want to “show me” the diarrheal stool, but honestly, unless there is blood in the stool,” diarrhea is diarrhea” and bringing in stool is usually not necessary. The best way to maintain hydration is by giving your infant frequent breast feedings or formula feedings and to make sure that they have tears when they cry and a moist mouth.  When you stick a finger in a baby’s mouth, the finger should never come out dry. A drooling infant is not dehydrated. It is difficult to tell if your child has urinated if they are in diapers, and are having diarrhea, as it is all watery together and the newer diapers “wick” the urine. Unless there is a large volume of urine you may not be able to tell that your child has urinated.  When in doubt, we actually either put a bag on a baby to see if they urinate or weigh the diaper, but this is not necessary at home. I see a lot of babies and toddlers whose parents are worried that they are dehydrated because “they have not urinated in 12 hours”. But while saying that,  the child is crawling or walking around the room drooling.  They just could not tell that they were wet as the diaper was not saturated. So much for advanced technology diapers, sometimes they are TOO good. For older infants and children, let them have frequent drinks of either Pedialyte or Gatorade and also let them eat solid foods.  When I was first in practice it was thought that the “gut” needed to rest and a BRAT diet was recommended. So, kids who had diarrhea were only given bananas, rice, applesauce and toast.  This was not only boring, but is was found to be too limiting and did not provide enough protein and nutrition to allow the gut to heal. It is now recommended to “feed a child through their diarrhea”, but to avoid fatty foods, and food high in simple sugars like apple juice.  Provide complex carbohydrates like cereal, potatoes and bread, along with lean meats, fruits and vegetables. In most cases of diarrhea a child can still tolerate dairy products, but if their diarrhea seems persistent or returns after your child drinks milk etc. you might limit their dairy for several days in order that the cells that produce lactase may regenerate. It is not uncommon for children to have 5 – 7 days of diarrhea with a viral gastroenteritis. There is some new data on using probiotics to shorten the course of diarrhea and in cases of prolonged diarrhea I have used some of these products (such as Florastor for kids) with success. This may help the gut by restoring good bacteria to promote intestinal health. We've all been there, haven't we?  We'll chat again tomorrow! Send your question to Dr. Sue!

Daily Dose

It's Allergy Season!

1:30 to read

WOW!  A busy week in the office and while I was on call in the evening,  the biggest problem right now seems to be allergies!  While some parts of the country may still be experiencing cold and a few snow flake, many states are warming up and the trees and grasses are starting to spread their pollens. In fact, my backyard is covered in yellow oak tree pollen, and some of it is so thick it looks like tumbleweeds. This cannot be good for anyone.

While I am finally seeing fewer and fewer children with the multitude of winter upper respiratory infections I see every year, the allergy season is looking “wicked” this year.  Seasonal allergies due to pollens from grasses and trees are typically not seen in children until they are over 24 months of age.  At times it is difficult to distinguish the last of the cold viruses from early allergy symptoms. But at this time of year, a good history is important (always) as well as a family history of allergies.

The good news is, there are a lot of medications available to help relieve the symptoms of itchy eyes, scratchy throat, cough, and drippy nose.  While the non-sedating antihistamines like Claritin, Zyrtec, and Allegra have been available over the counter for quite some time, intra-nasal steroids are now available as well. 

Intra-nasal steroids are one of the mainstays of allergy treatment, as they are a preventative medication. When used on a daily basis they help to prevent the “allergic cascade” that occurs when you inhale all of those pollens blowing in the wind.  They work best when used every day for the duration of allergy season which is really dependent on where you live. Allergy sufferers in the northeast will typically have symptoms later in the spring/summer than those in the “sunbelt”.

So you can now pick up Flonase and Nasacort over the counter and use them daily, even in children.  Make sure you try to aim the spray toward the outer side of the nostril and not toward the nasal septum (middle). This will allow the steroid spray more coverage as well as to try and help nosebleeds which may be a side effect of a nasal steroid spray. 

Lastly, with all of the kids playing outside in the “yellow mist” of pollen, make sure to bath/shower them and wash their hair when they come in.  This will help to reduce some of the itching and rubbing of their eyes and nose as well!

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