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.   

Daily Dose

Migraines in Children

1:30 to read

I received an email via our iPhone App inquiring about migraines in children. Headaches are a common complaint throughout childhood, but pediatricians have recognized that children have many different types of headaches which include migraine headaches. 

Migraine headaches are best diagnosed by obtaining a detailed history and then a thorough neurological exam. There are several characteristics of childhood migraines that are quite different than adult migraines. While adult females have a higher incidence of migraine headaches, males predominate in the childhood population. 

Childhood migraines often are shorter in duration than an adult migraine and are less often unilateral (one sided) than in adults. Only 25-60% of children will describe a unilateral headache while 75-90% of adults have unilateral pain.  Children do not typically have visual auras like adults, but may have a behavioral change with irritability, pallor, malaise or loss of appetite proceeding the headache.  About 18% of children describe migraine with an aura and another 13% may have migraines with and without auras at different times. When taking a history it is also important to ask about family history of migraines as migraine headaches seem to “run in families”. 

Children who develop migraines were also often noted to be “fussy” infants, and they also have an increased incidence of sleep disorders including night terrors and nightmares. Many parents and children also report a history of motion sickness. When children discuss their headaches they will often complain of feeling dizzy (but actually sounds more like being light headed than vertigo on further questioning). 

They may also complain of associated blurred vision, abdominal pain, nausea and vomiting, chills, sweating or even feeling feverish. A child with a migraine appears ill, uncomfortable and pale and will often have dark circles around their eyes. It seems that migraine headaches in childhood may be precipitated by hunger, lack of sleep as wells as stress. But stress for a child may be positive like being excited as well as typical negative stressors. 

Children will also tell you that their headaches are aggravated by physical activity (including going up and down stairs, carrying their backpack, or even just bending over). They also complain of photophobia (light sensitivity) and phonophobia (sensitive to noises) and typically a parent will report that their child goes to bed in a dark room or goes to sleep when experiencing these symptoms. 

Children with migraines do not watch TV or play video games during their headaches. They are quiet, and may not want to eat, and may just want to rest.  Nothing active typically “sounds” like fun. To meet the diagnostic criteria for childhood migraine, a child needs to have at least 5 of these “attacks” and a headache log is helpful as these headaches may occur randomly and it is difficult to remember what the headache was like or how long it lasted, without keeping a log. 

There are many new drugs that are available for treating child hood migraines and we will discuss that in another daily dose.  Stay tuned! 

Daily Dose

K2: New Legal "Drug" For Teens?

1.30 to read

I was seeing patients the other day when I saw a teenage boy that I have taken care of since he was born (one of the perks of being a pediatrician).  He came in over lunch with his mother, as she had called me earlier that morning, and she wanted him to have a drug screen. She had found a “pipe” in some pants of his and she was concerned that he was smoking marijuana.  I am often asked to perform drug screens on kids, and I really think it is important to sit down with the child and parents to discuss their concern, rather than ruin the trust of the teen, and blindside them with the results of a drug screen obtained under false pretenses. So…the point of this is that the adolescent told me that he had been smoking K2.  He told me that it was a “legal” substance that you could buy over the internet or in smoke shops. K2 is a mixture of herbal and spice products that are then sprayed with a psychotropic drug.  When asked why he would smoke it, he told me that it had similar effects as marijuana with an overall feeling of feeling good, sleepy, and relaxed.   Seeing that I did not know anything about this new substance, I got my computer, brought it into the exam room and “googled” K2, only to see many different articles. The most interesting was an article in LiveScience written earlier this year, that explained how K2 had been developed by a research scientist who was studying cannabinoid receptors in the brain.  He had published articles about this substance (which when first discovered went by his initials, JWH-018),  and had found that that K2 binds to the same receptors in the brain as marijuana, and that it is actually much more potent than marijuana. K2 may be 10 times more active than THC (marijuana) and while it may have many of the same effects as the high with marijuana, it  has also been found to cause hallucinations, and seizures. Upon further investigation, I found that it is becoming a problem in many states with plenty of information on the internet. K2 has already been declared illegal in the state of Kansas.  There are concerns that this drug has caused adverse effects and ER visits due to hallucinations, vomiting, elevated blood pressure and heart rate, which are not typical symptoms seen with marijuana.  K2 does not show up on routine drug screens.  There is a researcher in St. Louis who is studying K2 and is seeking urine samples obtained from teens who have used the substance.  I called several private labs in my area and they did not have the capability of testing for it. The good news in my patient’s case is that he told me about K2, had not smoked it in the last several weeks, and his urine drug screen was negative for marijuana and other drugs. Oh the things we must learn to keep up with adolescents! How someone discovered the article written in scientific journals in the late 1990’s and extrapolated that this compound, which binds to the same receptors in the brain as marijuana, could be used “legally” for a high similar to “weed”  is beyond me.  But kids are really “smart and clever” and will do almost anything for a “high” especially in this case with a product that is easily obtained and is legal.  After a lengthy discussion with this boy and his mother I understand that K2 use is quite prevalent in his high school, even among the “non-drug” crowd. I am going to continue researching this topic and will keep you posted. But if you have an adolescent who you think exhibits odd behavior and may even require a visit to the ER for a suspected overdose, and the drug screen turns out to be negative, be aware of K2. Lastly, talk to your teens, they are probably already in the know. That's your daily dose.  We'll chat again tomorrow.

Daily Dose

Curfews When Home For The Holidays

1:30 to read

I have learned that one of the hardest adjustments for both parent and child is that first winter vacation home from college. I woke up this week and realized that it's my youngest son's birthday. At this very hectic time of year I often ask myself, "why did I have a baby during the holidays?" I think the answer would be "we just wanted another baby", not thinking that I would have an almost Christmas baby. But, the point of this is not about trying to have birthday parties for your child when you have a million other things to do. Or about always thinking we would celebrate half birthdays in the summer, which never happened.  Or trying to shop for both birthday and Christmas gifts, and swearing never to "cheat" him, but still taking things from closet to tree each year trying to figure out which gift should be for which occasion. The real discussion is about curfews.

It is such an exciting time for parents. Welcoming your child back home after that first long semester away! I am always longing for family dinners, games by the fire and "adult" conversation about their favorite professor or class. Discussions about new friends, roommates, second semester and what they think they will major in. Instead, most of the conversations are about plans they have to visit friends or hang out or do something away from the house and parents. This is always followed by the parental, "what time will you be home?" (to play the fireside family game). The reply seems to be universal, "I am in college now, I don't have a curfew in college."

Several years ago a parent of a patient and I were discussing this issue and they agreed with the theory that curfews were no longer appropriate. One of the great things about my job is that parenting advice goes both ways, and over the years I have learned so much from both patients and their parents. But this time the experiment, which lasted for one night, only reinforced my belief that college kids should have curfews while home. This is especially important if you have younger kids at home who are in school, parents with jobs or anything that requires getting up in the morning and getting a good night's sleep. The "young adult" college student usually has a different clock, and my idea of reasonable time and theirs is not always in sync. I could be getting up when they think it is time to come home. I still subscribe to the "nothing good happens after midnight" theory.

So.... If you have a college freshman arriving home this week after finals, have the discussion about curfews. They always argue, "you don't know when I come home when I am at school." That does ring true, but when they are "home", parents just get a better night's sleep once their "baby" is also tucked into bed.

That's your daily dose, we'll chat again soon.

Daily Dose

Parenting is Not a Competitve Sport!

1:30 to read

When did parenting become the latest competitive sport?  I have heard all sorts of new parents, even on their baby’s first day of life... start off by saying that their baby is “not....insert what their friend’s baby is already doing.” Does that mean not breathing as fast, or having a lower heart rate...I mean what is there to be competitive about in the first 24-48 hours?

It has always been hard to be a parent, and self doubt is one of the biggest issues a parent faces....but to start off feeling like you are already “failing’ is totally crazy.  There are so many feelings that a new parent experiences, without having competition even enter their minds.

Babies sleeping longer, crawling earlier, talking more...that only seems to be the beginning. Soon it is about who’s reading first, is on the more competitive soccer team at the age of 6, or even has the biggest birthday party. Unfortunately, all of this is shared on social media....which means that you are feeling “competitive” or inadequate with not only your closest group of friends but with hundreds if not thousands of people, and many of whom you don’t even know. It is just too much!

At the same time you are also getting comments about your parenting....which I think only compounds all of the emotions and worries and questions parents experience. Instead, why not rely on your own circle of friends, family and maybe a book or two on raising children.  

So....I would resist the urge to share every moment of your baby’s life and milestones with the social media world, or to compare your baby with total strangers....there will always be someone who does something earlier and faster....and that does not always mean better. 

Parenting is definitely a marathon...but not a competitive one. 

Daily Dose

Head Flattening on the Rise!

1:30 to read

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

Amber Beads for Teething?

1:30 to read

What is the deal with these amber teething beads?? Suddenly so many of “my” babies are wearing these little necklaces, which are “supposed” to help with teething. I worry they are a choking hazard and I have no clue why they would help a baby get their teeth?

I have previously written about teething and the many thoughts and/or “myths” surrounding babies and tooth eruption. A baby typically gets their first tooth around 6 months of age, and they are usually the lower 2 central incisors.  But, some babies will get teeth a bit earlier and some babies will not get a tooth until 15-18 months of age. The latest age that I have seen for a first tooth to come in was 22 months, and yes that child is totally normal and has all of their teeth!

Teething gets a bad rap for causing any fussiness in an infant once the baby reaches 4 months of age.  Whether the baby is fussy day or night, it is often attributed to teeth ( prior to this age it is “gas”). But, while many babies are drooling and putting their hands in their mouth and chewing on toys, it is probably actually due to development of hand to mouth coordination rather than tooth eruption.  A baby becomes really fixated orally around this age...and this stage last until they are about 24 months...you will see, everything goes straight to their mouth!

I am sure I remember my first child’s “teething” but I am also sure I could not begin to tell you when the 3rd son got his first tooth.  My middle son was the “crankiest baby/toddler” on the planet (he is a gem now) and he did not get a tooth until he was about 15 months old, and promptly knocked out his upper middle tooth around 2!   Don’t remember pain with teeth coming in or out?!?

So, back to the amber beads...I think they are a bit like essential oils...not sure what they really do. I also worry that a baby might get tangles up in the necklace and get asphyxiated...even though they are supposed to break apart. I would NOT take the risk. 

Lastly, you don’t see 5-6 year olds wearing amber beads as they lose their teeth and get their first permanent teeth. You also don’t hear a parent make excuses for a cranky/tired elementary school aged child....”she is just behaving like this because she is teething”, sounds a bit crazy right?

We parents like to have reasons for everything...and I don’t care if you blame teeth for making a baby fussy...I am just not sure there really is a correlation and certainly not for month after month...as a child gets 20 teeth in the first 2-3 years of life.   

Daily Dose

Lactose Intolerance

How do you know if your child is lactose intolerant?A parent emailed me via our iPhone App and asked if her child’s constipation, which started as he was transitioning from formula to whole milk, could be a sign of lactose intolerance. She is concerned because her son is now having very hard stools.

Actually, lactose intolerance does not typically cause constipation, but conversely causes abdominal pain and often loose stools or diarrhea.  In the case of this 1 year old child who suddenly is having hard stools, it may seem to be “caused” by the switch from formula to whole milk, but is probably coincidental. It is routinely recommended that parents stop giving a child a bottle and formula at 1 year, which often results in a toddler drinking less milk (recommended amount is about 16 ounces /day) and therefore they are getting less fluid which may result in harder stools. This is also the age that children’s diets are changing as they are self feeding and often eat a lot of carbohydrates (breads, noodles, rice etc) and fewer fruits and vegetables, even when offered as they become “pickier” eaters. All told this often leads to bouts of constipation that can be managed with the addition of more fluids as well as clever ideas such as apple prune juice, bite sized prunes (often can be “sold” as raisins to a young child) and even with milk of magnesia if necessary. (see older posts on constipation) Lactose intolerance is defined as the inability to digest lactose which is a sugar found in milk and milk products.  It is due to a deficiency in the enzyme lactase, which is produced by cells lining the small intestine.  Lactose intolerance is uncommon in young children and is typically not seen before the age of 2 -3 years.  It is more common in older children and teens who may complain of abdominal pain, cramping, gas, bloating and diarrhea after ingesting dairy products. In most cases lactose intolerance is diagnosed on clinical history alone, and if suspected is managed by eliminating dairy products to see if the symptoms improve.  In many cases even children with a lactase deficiency may tolerate some lactose in their diet such as a scoop of ice cream, or milk on their cereal, but only experience symptoms when they have “too much milk”. Fortunately, there are products, such as lactose free milk, which will provide a child with the necessary vitamin D and calcium which is so important during childhood. Dietary supplements should also be used in children who do not drink milk in order that they meet their daily calcium and vitamin D requirements. Lastly, lactose intolerance is different than a milk allergy which is fairly uncommon and is due to an allergy to the proteins in milk, not the lactose.  True milk allergy usually presents in early infancy. That's your daily dose.  We'll chat again tomorrow! Send your question to Dr. Sue!

Daily Dose

Hand, Foot & Mouth Disease is Back

1.45 to read

I have been seeing a lot of cases of "hand, foot and mouth disease" (HFM) in the office. This illness is usually caused by a Coxsackie virus A-16, a member of the enteroviral family. These viruses are typically seen in the summer and early fall. Don't worry, this illness is not related to "hoof and mouth" disease seen in animals.

Hand, foot and mouth disease is most common in younger children and often is seen in the toddler crowd. You can see "hand, foot and mouth" in older children, but most children have had it at younger ages and are immune as they get older. It is not unusual to have outbreaks of HFM in child-care centers or pre-schools. How is Coxsachie virus transmitted?  Person-to person contact as well as from contact with contaminated surfaces. The incubation period from time of exposure is about three to seven days. The typical child with HFM will present with fever, which is often fairly high. If seen early in the illness they may not have any other physical findings but over several days they will develop a sore throat with painful sores on the tongue and throat. Several days later they may develop the classic small, red, blister like lesions on their palms, soles of feet and often in the diaper area. When they have all of the symptoms it is an easy diagnosis, but not everyone who gets Coxsackie virus will have every symptom. Sometimes you see a child with the classic rash on palms and soles, but they have never had fever or even felt badly, lucky for them! One of the most common complaints may be drooling and irritability in a child with fever as the mouth and throat are sore, even before the classic lesions appear. Because this is yet ANOTHER viral infection, there is no specific treatment and antibiotics won't help. Keeping your child comfortable with Tylenol or Motrin/Advil will help with both fever and pain. This is a good time to try things that would help soothe a sore throat, things like ice cream, popsicles, pudding, Jell-O and even a Slurpee, especially in a child who is refusing fluids. The main concern is keeping your child hydrated during the illness. Once your child is fever free for 24 hours and feeling better they may return to child-care or school. The small lesions on the palms and soles will clear over the next five to seven days. The best way to prevent others from getting sick is with good old hand washing. That's your daily dose, we'll chat again soon.


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