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Daily Dose

Language Development

1.30 to read

When talking to parents about language development there are two things that need to be considered: expressive and receptive language. 

While many parents worry that their children “need” to have 10-20 words by the time they reach 15 months, I am just as interested in a toddler’s receptive language. In other words, does their 15-18 month old child understand what they are saying to them (when they want to?). 

It is very important for this age child to understand simple statements and to be able to follow a one step direction.  Examples being, “where is your nose?”, “go get me the ball”, “point to the picture of the moon in the book”.  As a parent you are doing this all day long, probably without even realizing how much they are understanding (when they want to). Observing your child develop  receptive language shows you that your child’s brain is working away at developing language and comprehension. 

Some children will have later expressive language than others. There are 1 year olds that have 8-10 words and there are 15 month olds that are just acquiring that many words. But, just like you will someday help teach your child to read, you are teaching your toddler language by talking to them, reading to them and then suddenly your realize that they are saying a few words. You can’t “make” them say bye-bye, or thank-you but you can say these things over and over and know that they may comprehend before they actually talk. Most children have jargon or chatter as well as words and that too is a good sign of language development. 

Language acquisition is fascinating, and there is a wide range of normal.  It is true that boys are often later talkers than girls. I also think 2nd, 3rd, 4th children may also have later expressive language, but earlier receptive language...it seems the older sibling gives them commands that the younger child follows, but the older child also “talks” for the younger sibling. Those first children just can’t stand not to be the boss (birth order, another fascinating topic). 

So, remember just to keep reading to your child, talking to them about everyday life and magically language evolves.  Remember too, receptive language is an important milestone in your child’s development so give them some “things to do” and see what happens....you may be amazed at all of the things they do know how to do and how much they comprehend as well.

Daily Dose

Head Flattening

2.00 to read

I have received a number of messages via twitter and facebook about sleep positioning. Several of the responses related to back sleeping and the relationship to head flattening.

While there has been an increased incidence of plagiocephaly (flattening of the skull in either the front or rear of the head) since the recommendation that infants sleep on their backs, the reduction in SIDS has impressive. Several readers stated that their children had slept on their tummies and “they were fine”.

My own children were tummy sleepers (as that was the recommendation prior to 1992), but I personally knew 3 friends whose children succumbed from SIDS. That does not include the babies within our practice whose deaths were also attributed to SIDS, and there were several every year.

Since 1992 we have had 2 babies within our practice that died from presumed SIDS, one of whom was sleeping on their tummy.  I know that this is anecdotal data but nevertheless, a wonderful and impressive difference. While an article in the August issue of Archives of Pediatric and Adolescent Medicine confirms that there has been more than a nine fold increase in the incidence of plagiocephaly between 1999-2007, this finding should “in no way dissuade parents from protecting their babies from SIDS by placing them to sleep on their backs”. But there are ways to try and prevent head flattening while still adhering to “back to sleep”.

Tummy time can begin right from the start and an infant may be placed on their tummy off and on throughout the day (unless they fall asleep, when they MUST be turned over). Patients always ask, “how long” but it differs depending on the mood of the baby. Some babies love tummy time while others resist it.  But, just like many parenting issues, a baby has to have some tummy time and with time most babies will become less resistant.  

Those babies that “detest” tummy time often seem to be early rollers and flip from tummy to back just to get off their tummies!! At the same time, once a baby is rolling from back to front, you can’t be a”professional" tummy flipper” and be up and down all night or try to rig a contraption to keep your baby on their back. They will roll over in their sleep just like we all do and once they can roll on their own they may become a tummy sleeper.

The Bumbo chair is a huge help in preventing head flattening, as well as the exersaucer and the jumper-roos (or whatever they are called now).  These products all help support a baby’s back while keeping their heads upright which prevents flattening.  I encourage all of my patients to begin using these gizzzmos around 3 months of age, and especially for any baby that is already showing some flattening or tummy avoidance on their early newborn exams.

I also notice that more of my 2nd and 3rd babies seem to have some flattening because they spend a great deal of time in their car seats as they are “carted” around town with an older sibling. In these cases I encourage the parent to pick the child up once out of the car and carry the baby rather than keeping them in their carrier.  This is good for bonding, head control and keeps the baby off of their back as well. So with all of this being said, if a head is severely affected there are “molding helmets” that can be utilized to prevent the cosmetic consequences of head flattening.  This should be a separate discussion with your doctor, but my philosophy is to try and discuss the issue of positional head flattening at every visit to try and avoid the problem all together.

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

Daily Dose

All About Puberty

1.30 to read

It happens to everyone:  PUBERTY.  Although puberty starts anywhere from age 9-16, every teen will eventually experience the hormonal changes and subsequent body changes as well. With that being said, the subject of puberty is still “awkward” for some parents and most of the time it is a subject that a child/tween isn’t really interested in discussing either. 

But, the discussion of puberty is not only necessary for everyone, both parent and child, it is also one of the most important talks a parent will have with their child. So many of my patients, around 9 -11 years old, tell me “they don’t want to talk about growing up or body changes”. In a few cases their bodies are already changing and it must be confusing if they haven’t even talked about puberty, right?  I know they may hear things from their friends, and many schools have puberty “talks” somewhere around 5th or even 6th grade, but that is often too late. 

The biggest concern I have is misinformation. If a parent does not sit down and have the basic “ birds and bees” discussion, their child may hear all sorts of crazy information. With all of the internet availability as well I worry that a child might search on their own and go to websites with “too much information” for the first discussions about puberty. 

The facts of life and the male and female anatomy have not changed!!  I think it is every parents responsibility ( I jokingly tell the kids that when they were born we parents were given a contract that says we HAVE TO HAVE THE TALK)  to find the appropriate time to sit down with their child and begin the discussion of puberty. This is often more of an anatomy lesson and the biology of the human body. If a child has never asked about the difference between males and females (most have prior to this) then that is a good starting place. Many times questions will arise that leads to further discussion including sexuality. 

Every parent knows their own child and may approach the “facts of life” discussion in their own way. There are a lot of good books to help facilitate the discussion and I went to the bookstore to check out books that I wanted my children to have as a resource as well. I remember my own mother using a World Book encyclopedia with the human body pages of transparencies when she talked to me. I also remember being horrified. 

Puberty should not be mysterious, every child needs to be comfortable with their changing body (and mind) and parents are key to providing this information.  

Lastly, it usually takes more than one discussion to cover all of the topics and different topics are more appropriate at different ages. Don’t stop the conversation, make sure you let your child know that nothing is off limits, so if they have questions or concerns, ask.

Daily Dose

Concussions: A Life Lesson

A life lesson from a professional football player who knows first hand there's more to life than playing football.As you know, I have written many times and done numerous radio segments on the topic of concussions.  In the past several years there has been more attention paid to the risks of long term brain injury secondary to concussions and the medical literature continues to update guidelines for screening and treatment of concussions.

Many  professional sports organizations like the NFL, as well as college and undergraduate athletic organizations have also become aware of the risks of recurrent concussions and are adhering to guidelines to prevent players from returning to play without medical clearance. As a UT Longhorn fan/alumni, it was with concern and admiration that I read the story of  Tre Newton’s decision to retire from the UT team due to his history of repetitive concussions. The media reports out of Austin stated that, “Tre along with his parents and physicians” had decided that it was time to give up football to prevent further head injuries.  What a difficult and heartfelt decision that must have been!!!  His father, Nate Newton, had played for the Dallas Cowboys and Tre was a starting running back for UT. It is obvious that this is a “football family”. But, having watched as Tre suffered another concussion during a recent UT loss, and then reading the stories about his past history of concussions in the previous football season as well as during his high school days, it seems as if this young man took a good long look at the newest data on recurrent concussions and long term complications and knew it was time to end his football career. He is obviously not only an athlete, but also a scholar. I think that Tre Newton will be a role model to other talented young athletes who too may have had the unfortunate luck to have suffered concussions.  Sustaining a concussion whether in football, hockey, cheerleading, or any other sport is a risk that comes with contact sports. Some athletes seemed to be luckier than others. Despite the best efforts at developing new helmets, and mouth guards, the incidence of concussions is on the rise.  Children, teen and young adult athletes continue to report symptoms seen with a concussion, and we pediatricians are seeing this in our own offices.  I recently saw an 8 year old whose mother brought him in to be examined as she thought he might have a concussion. As you know, a concussion is not a structural injury, but rather a chemical and functional injury to the brain. It is somewhat analogous to a “bruise or sprain”, but involves the brain rather than a bone. Therefore the x-ray or scan of the head and brain will appear normal, but the neurological exam or the cognitive exam will be abnormal. This little boy did not remember the hit or being brought to the sideline, he was nauseated for a bit afterward. But…after my exam my recommendations, his mother did not want to “bench him” for the next week as he had a playoff football game and lacrosse try-outs. My question is “WHY”?  Why would you worry that your child might have a concussion, take him to the doctor, and then not follow the established guidelines for return to play. This just doesn’t make sense to me.  She also pointed out that her husband was the coach and had not heard of any information regarding concussions and rest, with gradual return to play. Hmmm. But, Tre Newton’s decision to retire from football makes a tremendous amount of sense. It also shows a great deal of maturity and intelligence. Tough decision, supported by loving parents who also knew “what was best for their son”.  I commend each of them and wish Tre good luck in whatever field he “plays” on post graduation. That’s your daily dose for today. We’ll chat again tomorrow. Send your question or comment to Dr. Sue!

Daily Dose

Summer Series: Best Ways To Use Bug Spray

The right ways to use bug sprayNow that you know all about the options for bugs sprays this summer, let’s discuss the guidelines for using these products.

The American Academy of Pediatrics (AAP) and the Environmental Protection Agency (EPA) have issued recommendations for the application of insect repellents in children. These include the following: -Do not apply bug spray to children under 2 months of age -Use up to 30% DEET in children, depending on duration of outdoor activities. Avoid the use of higher concentrations in children. -Apply insect repellent only to exposed areas of skin and/or clothing. Do not use repellents under a child’s clothing.  Certain repellents may damage synthetics, leather or plastics. -Do not apply insect repellent to eyes or mouth, and apply sparingly around the ears. Do not spray directly on the face, spray on your hands first and then apply to the child’s face -Do not apply bug spray over cuts, eczema or breaks in the skin. -Have a parent or caregiver apply the bug spray as a child may inadvertently ingest the spray.  Do not allow children to handle the repellents without supervision. -Wash repellents off with soap and water at the end of the day. This is especially important when repellents are used repeatedly in a day or on consecutive days. Also wash treated clothing before wearing again. -Combination products containing DEET and sunscreen are not recommended, as sunscreen should be reapplied frequently (every 2 hours) and in contrast bug repellents should be applies as infrequently as possible.  It is also thought that DEET may decrease the effectiveness of sunscreen. -Do not use spray in enclosed areas or near food. Avoid breathing the repellent spray. -There are other ways to beat the bugs too.  Try to avoid go outside when the bugs are most active, dawn and dusk. - When your child does go out cover as much of the skin as you possibly can. Use lightweight, long sleeved clothing and pants.   Do not dress your child in bright colors or flowery clothing.  For young children use mosquito netting over their strollers etc. -The use of citronella candles or bug zappers have not been shown to help . -Eliminating standing water in yards and areas around the house and yard will help eliminate mosquito breeding. Fans do seem to help as mosquitoes have trouble maneuvering in the wind, so buying a fan to use around the picnic table may be useful. There are many ways to try and avoid the dreaded insect bites, the “battle” is just beginning. So, gather information and your favorite repellents and enjoy the outdoors. That's your daily dose for today.  We'll chat again tomorrow! Send your question to Dr. Sue right now! Check the UV Index in your neighborhood here

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Daily Dose

The Need to Stay Calm During Swine Flu Season

I have found myself sounding like a broken record for the past week, and feel certain that the record is going to continue to “skip” as the confusion over the use of antiviral for H1N1 (swine flu) continues.

In the last week I have not only been to the office, but also to a school board meeting and several social engagements after work, all which were opportunities to discuss the continued H1N1 outbreaks and anxiety associated with “swine flu”. I guess the good thing is that no one is discussing the economy; it is all chatter about flu. It is important to reiterate that H1N1 is another flu, really no different than seasonal flu which we experience every year in the U.S. The difference is that this is a new or novel flu virus and it has managed to spread, quite effectively, throughout the spring and summer months, and into the early fall, with a clear predilection for school aged children. With that being said, now that schools are back in session and our children are all together in close quarters, we are seeing an increase in H1N1 activity throughout the country. Because of the previous concerns about swine flu last spring and the uncertainty of how the population as a whole would handle this virus, there has been a great deal of anxiety associated with this particular virus. Fortunately, over the last five months, the data is showing that H1N1 has not caused more pediatric deaths than we see each year with seasonal influenza (which is still yet to come this winter). The MAJORITY of children with this virus are doing well, and are recovering within two to seven days, even without the routine use of antivirals like Tamiflu and Relenza. The CDC has reiterated that routine testing for influenza and use of antivirals is not necessary for the school aged child, without underlying chronic illness, who is not seriously ill. That is most of our children. Younger children, under the age of five, and especially under the age of two, needs to be evaluated and may or may not need antiviral treatment. That is a decision for their pediatrician to make. Despite these ongoing recommendations parents are frantically calling the office requesting that antivirals, like Tamiflu, be prescribed for their family, “in case” they are exposed to flu, get sick, feel like they might get sick, or as one mother actually said, “I’ll feel better if my son is just on Tamiflu all winter.” This is not going to help anyone. The exposures are going to continue throughout the winter. Not just at schools, but also at the grocery store, cleaners, church, after school events and the list is endless. We need to try and keep a level head and not horde a medication that others may truly need, or spend unnecessary valuable health care dollars on medicine that will be thrown out in a year, or have people start and stop Tamiflu and Relenza as they feel better. Just like antibiotics, overuse and indiscriminate use of antiviral medication will lead to resistant influenza strains. When we really need these drugs, we all want them to work, for our children, for ourselves and for all of those that may get seriously ill throughout this flu season. This “swine flu frenzy” is reminiscent of the hording of Cipro during the anthrax scare. I wonder how much Cipro was hidden away, “just in case you opened your mail and found a white powder.” As I recall, there were shortages of Cipro for months, and the same might happen with antiviral medications. It is easy to write prescriptions, but it is much harder to do the right thing and try and teach patients and families why doctors are not routinely prescribing antiviral medications. If things change and recommendations change doctors will let you know, but in the meantime, keep sick children home until they are fever free, read the information about those who might need to take an antiviral medication and keep washing hands. That’s your daily dose, we’ll chat again soon.

Daily Dose

More Reasons to Get a Flu Shot

Just released in the October issue of Pediatrics is news related to children and the need for flu shots.Just released in the October issue of Pediatrics is news related to children and the need for flu shots. There has been previous data to support the need for giving flu vaccine to infants (six months and older) and young children, as they have higher rates of complications and hospitalizations. There have also been more deaths in infants who had influenza.

Recent information from the last several flu seasons has shown an increased risk of complications and death in children five and older who get the flu and also contract a staph infection. Many of the reported deaths in the 2006-2007 flu season were in otherwise healthy children who had no known risk factors for complications secondary to influenza. In the study only six percent of the children who died had been fully vaccinated against the flu. So with this year's recommendations for flu vaccine including all children from six months through 18 years, any parent with a child should be heading out to get their child vaccinated. If your child is under the age of nine years, and has never had a flu vaccine, they will require two doses separated by at least four weeks. This is important news, as 73 children died from flu in 2006-2007. That may seem like a small number, unless it is your child. That's your daily dose, we'll chat tomorrow.

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Daily Dose

Plan B in College Vending Machine

1.30 to read

With college students heading to school, I was reminded about a story at Shippensburg University in Pennsylvania, which is providing their students with the emergency contraceptive, Plan B, via a vending machine. Although at first this seemed like a “different” idea, the more I researched the more sense it made to me. 

Plan B is a single pill that contains a higher dose of a progestin (hormone) than a regular birth control pill. If this hormone pill is taken within 72 hours of unprotected sex it can reduce the chance of an unintended pregnancy by up to 89%. 

Plan B is available at pharmacies as well as many college health centers, and does not require a prescription, although the product is “behind the counter”. It is available to women over the age of 17 who show proof of their age. 

The vending machine in question is not sitting in the middle of the student union!! It is also not in a dormitory, or in the gym. It is in the student health center!! The machine is also “behind the counter” as students must sign in and then be granted access to the treatment area. After going “behind the counter” a student may purchase Plan B (which costs $25) as well as condoms, pregnancy tests, cold remedies, throat lozenges etc.  

This is no different to me than having a student walking across campus to their nearest CVS, or Walgreens to obtain the medication or condoms etc. Plan B is readily accessible if a woman is of age and can “get to the pharmacy”  The university is providing this service to their students only, all of whom are over the age of 17 and have shown ID and are admitted to the clinic treatment area.  

The vending machine was put into place after a student vote that showed that over 85% of students approved of this idea. The students also felt as if this would help students obtain the medication or condoms while maintaining their privacy. The administration is not out on the street or on the main mall of the campus passing out medication. 

The fact that college students are having sex is not new. If a vending machine allows a student to buy a condom before having sex bravo! At the same time if the vending machine allows a woman access to Plan B, which is “technically OTC” (although not out on drugstore aisles), why does it matter whether she walks/drives to the pharmacy or to the health center on her campus?  I hope that while purchasing Plan B they maybe she will also buy a condom for future use by her partner as I am equally worried about STD’s (not just pregnancy). 

I don’t think the vending machine is promoting sex, but hopefully providing access and affordability of products that are also available at many other locations.  Maybe they can put a brochure about the risk of STD’s as well as pregnancy in the same vending slot as the products that are being sold?  I would plaster those around the campus as well! 

This is a hot topic right now. What are your thoughts?

Daily Dose

Summertime Can Mean Snakebites

1:15 to read

Due to wet weather, snakes are being oushed out into the open. What does it mean? There is a higher risk of being bitten by a snake. News reports have families on alert: snakes are being pushed out into the open.  More snakes mean the potential for more snakebites.  I have never treated a patient with a snakebite and thought they were quite uncommon. Unfortunately, a rattlesnake bit a friend of mine (they are out of the hospital and doing well) so upon review I have learned a lot more about venomous snakebites.

There are actually over 45,000 snakebites reported in the U.S. each year. The majority of these are due to non-poisonous snakes and often requires little or no treatment. The days of the old Cowboy movies showing rope tourniquets being applied to the area of the bite and the cutting and “sucking” of the venom are over! Don’t start practicing “movie medicine” if you find yourself dealing with a snakebite. There are about 8,000 venomous snakebites reported each year. Fortunately, with these large numbers and the advent of anti-venom, only six to eight people die each year secondary to a venomous snakebite. Unfortunately, due to their smaller size, children do not handle snakebites as well as adults, and the fatality rate is higher in children.

In the U.S. 99% of poisonous snakebites are by the subfamily pit viper, which includes rattlesnakes, copperheads and cottonmouths (YUCK). The other species of poisonous snake found in the U.S. is the coral snake. I am not going to detail the specific treatment for each type of bite, but if a snake bites your child the first thing to do is to determine if it was a poisonous snake. Non-poisonous snakebites cause minimal pain, no swelling and really only require local wound care with irrigation and antibacterial soap. If the bite is thought to be from a poisonous snake the child should be transported to the nearest hospital. Do not put a tourniquet around the bite, apply ice or suction the area of the bite as these are all thought to cause more tissue damage than benefit.

Pit viper bites typically cause symptoms of swelling, bruising and progression within minutes of the bite. Children typically have more severe symptoms with nausea, vomiting, sweating, muscle weakness and clotting abnormalities, all of which are a medical emergency. Anti-venom should be delivered within four hours of the bite and will be given until improvement in systemic symptoms is achieved. All of this is done in the ICU setting. That’s your daily dose, we’ll chat again tomorrow.

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