Daily Dose

Toddler Tricks

I have to laugh out loud sometimes....as I find myself asking my little patient’s parents about developmental milestones and wondering what their toddler is thinking. I envision the child thinking,  “do they really think I will perform these tricks on cue?”, I am not a circus act!

By the time your child reaches 15 months your doctor will start asking you questions related to your child’s receptive language development, as well as expressive language.  Simple things like, “does she wave bye bye”, “does he point to his nose, eyes, ears when asked?’, “does she babble mama, dada?”, the list goes on and on.  

Other questions as a child gets a few months older are, “what sound does a dog make?”, “what does the kitty cat do?”, “what does a cow say?”.  The parent becomes the ringmaster of the circus with the cute toddler in the center ring performing the “high wire” act!! Or as one of my parents said, “we call these his party tricks”.  Just wait till later in life when those tricks become a bit “trickier”......will save that for another discussion.

But, with all of that aside, these are important milestones in child development that show how well your child’s brain is working!!! As a pediatrician I am also interested in watching how the child is responding to their parent during the “circus tricks” demonstration. Do they make good eye contact with their mother? Do they listen, process the command and then “perform?”. Do they babble with inflection while we are blurting out our commands.   All of these are very important signs that cognitive development is on track.  

Don’t worry if your child doesn’t always “perform” on command! Many times the 18 month old child just “doesn’t want to point to their body parts, or the picture in the book” right when I want them to.  It is not unusual for the parent to tell me, “they always make animals sounds at home”, I don’t know why they won’t now?  I am often still smiling as I leave the exam room and suddenly the child starts to wave, bark and meow!! Those toddlers....they do perform “party tricks”, but not always when the doctor wants them to.  A toddler does have their own agenda.  

Daily Dose

Kids Are Tech Savvy At Young Age!

1.00 to read

I keep a sheet of paper with me at all times while I am working in the office in order that I can write down interesting topics to blog about.  On some occasions, I jot a note to remind me of all of the cute and clever things my patients say.  Wish I had done this when my own children were growing up....you parents make sure you do, some things are priceless.

We have a rack of pamphlets in our office that hang in each exam room. When parents and kids are waiting, they will look at different pamphlets about a wide variety of topics. Parents even give them to their toddlers to amuse them and they may happily read, “going thru puberty”, or “do you have seasonal allergies?’’ at the age of 2.  Most children are happy just looking at the pictures. (yes, we also have tons of books for them to read, but for some reason these pamphlets are always a hit).

So, I walked into the exam room the other day to see this precocious 8 year old boy. He had been perusing the pamphlet on ADHD.  He immediately started chatting away when he said, “Dr. Hubbard, why does this little boy on the front of the pamphlet have a string wrapped around his finger?”  At first I didn’t understand what he was referring to, then I looked at the brochure and indeed there was a boy with a caption.....”does your child forget everything?” and the boy had strings wrapped around many of his fingers.  

I started explaining to him that some children who have problems with attention and focus forget things, so their parents would wrap a string around their child’s fingers to remind them to bring home their back pack, or their homework.  Clever way to help them remember things, right?

This little boy thought for a minute and had a puzzled look in his eye.  After a few seconds he looked right at me and said, “does he not have a device to remind him?”  Out of the mouth of babes!

Time for new brochures.....that are current for the “tech-ag"e!

Daily Dose

Sick Kids Home from School

1:30 to read

This "sick" season is a tough one. I'm seeing so many kids who are home from school with fevers, coughs and a variety of illnesses. Although it is never fun to be home with a sick child, especially as we enter the holiday season, parents and children can both try to make “lemonade out of lemons”. 

When a child is sick they often just don’t feel like eating (we are the same way right?), but they may like some “comfort” foods.  I remember being a little girl and being sick and my mother always made us stewed chicken and noodles. We also got to eat tapioca pudding and jello.  But half of the fun was making the pudding and jello. 

So, while I was talking to a mother with 3 year old twins who were both sick,  and I suggested jello and popsicles to help her feverish children. I asked her if she had ever made jello with the twins, and she loved the idea of going to buy a box of jello and then having the twins get to watch the liquid turn into a gel.  Jello is still somewhat of an early science experiment.  The pre-made jello cups are convenient, but cooking with a child is a great way to spend some “sick” time.  I am sure jello still has the jiggler recipe as well, and it is always fun for your preschool or early elementary school aged child to make cut out jello shapes. 

Popsicles are also soothing for a child’s sore and scratchy throat, and what about making homemade popsicles.  They sell the molds everywhere and you can make all sorts of crazy flavors as well.  Again, a bit of fun before a much needed nap and then popsicles are ready for “sick dinner”. No rules for meals when you are sick! 

Last activity for those at home children, slice and bake cookies. Even a sick child can often be tempted to eat a warm sugar cookie or gooey chocolate chip cookie right out of the oven. Decorating cookies is another fun activity and doesn’t take much preparation either. Sprinkles go a long way to distract and entertain a child who is feeling under the weather.  

I wish I could twitch my nose and put an end to the sick season before it even started, but I must say, besides all of the illness it is my favorite time of year.  Cold nights, warm fires, changing leaves, sweaters and coats are all delightful.  The only problem is that viruses love this weather too. 

Daily Dose

Why Posture is Important

1.45 to read

Whenever I am doing a child’s physical exam I always spend some time looking at their backs. Why? It’s important to look at a child’s spine to assess any irregularities or disease that may be present like scoliosis.  I also check the skin around their neck and back (really everywhere) for moles that need to be noted and watched. This is all part of a child’s yearly physical.

But as children get older I often note that when I ask them to stand up to look at their backs, they are slouching or slumping! I can just hear my own mother’s voice, “Susan, stand up straight, put your shoulders back”.  I am suddenly, noticeably, sitting up straighter even while typing this!

Posture is so important and at times a parent will even ask me to discuss the importance of good posture with their child. It typically isn’t the 3-10 year old set, they really seem to stand up fairly straight, but the tween and teen group is often guilty of poor posture. It is interesting as most patients that age talk about wanting to be taller, but regardless they don’t even stand up straight.

Then there is the “tall” group who for many teenage reasons, feel as if they are “too tall” and try to hide their height by slumping. In either case, slouching and slumping not only looks bad, but it’s not good for the back.

Poor posture can lead to neck and shoulder pain, which is a common complaint of adolescents. Not only do they have poor posture while standing but have you watched them as they hunch over their computers?

Adolescents are often spending in excess of 8 hours a day online and are not paying any attention to how they are sitting. I see many a teen with neck pain that radiates down their back and scapula, often secondary to their posture while “computing” on their many electronic devices. This poor posture leads to lots of muscle spasms as well.

My advice? Have your child start practicing standing up straight. Have them try good old-fashioned time with their back and shoulders up against the wall and see if you they can step away from the wall and maintain that erect posture.What about the ‘ole book on the head trick as well?  A younger child will find balancing a book on their heads to be a fun exercise, but this exercise may not be as much fun for the older set.

Everything just works better with good posture don’t you think?  You can breath better, your tummy muscles get tighter as you stand up straight, and that takes pressure off of your back as well. You will have less neck and shoulder pain and lastly, you just look better! (boy would my mother be proud of me for agreeing with her.)

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

Daily Dose

Whooping Cough Epidemic!

1.30 to read

For the first time in many years, being a pediatrician in Dallas means that I am seeing children with pertussis (whooping cough). That is due to the fact that Dallas-Ft. Worth is in the midst of a whooping cough epidemic, the worst in over 20 years. But pertussis is not just a problem in the DFW area, the entire country continues to see rising pertussis cases.  

The CDC reported that in 2012 the U.S. had more whooping cough cases reported( >41,000) than since 1955. There are currently 16 states, including Texas reporting higher pertussis rates than last year. In 2012 there were 18 reported deaths in the U.S.  due to whooping cough.  Sadly, there have already been more than 2,000 cases of whooping cough reported in Texas this year,  and there have been 6 deaths in infants and children.    

Unfortunately, one reason for increasing pertussis cases seems to be that some parents are choosing to either not vaccinate their children, or to vaccinate them on an “alternative” vaccine schedule.  A study just published shows that unvaccinated or under-vaccinated children between the ages of 3 months and 36 months of age are at greatest risk for getting whooping cough. The study from The Institute for Health Research at Kaiser Permanente Colorado stated that “children who had not received the  recommended 3 or 4 doses of DTaP (diptheria, tetanus, pertussis vaccine) were about 18-28 times more likely to have had pertussis than children who were fully vaccinated”. 

These children are not only at risk for getting ill from pertussis themselves,  they also pose a public health risk for others as they spread the bacteria (bordetella pertussis) with their coughs. This is especially true for innocent infants under the age of 2 months who have not even started their DTaP vaccines. The recommended schedule for DTaP is 2,4,and 6 months of age with a 4th dose between 15-18 months of age.  

What we doctors do know is that vaccines are safe, effective and save lives. They are given on a schedule for a reason.  We also know that when too many children “opt out”, or rather their parents choose not to vaccinate them, we see increase in disease numbers. This is not only true in this country with pertussis, but with measles as well. Measles cases in the United States are also at their highest in years.

The other group of people who need to be immunized are teens and adults. Many adults incorrectly think that they “don’t get more shots”.  But, adults need “booster” shots as well as children. This is especially true with the TdaP (adult version of the pertussis vaccine). While this vaccine is safer than the older whooping cough vaccines, it doesn’t seem be as effective at providing long term immunity. This too may account for increased whooping cough rates in teens and adults.  Research is looking at giving the TdaP more often as well as the possibility of a more effective vaccine.

The bottom line? Everyone needs to be up to date with their vaccines. Don’t depend on others to get vaccinated to protect you either, not everyone “plays by the rules”.  Help protect those innocent babies under 2 months of age. In the meantime, try to limit your baby’s exposure to crowds until they have started their vaccines. 

Daily Dose

Finger Foods & Choking Hazards

1.15 to read

I get a lot of questions in my office and via email about when to start children on table foods.  In reality, as your 9 – 12 month old child begins to eat soft table foods there really are not foods that are off limits. With that being said the issue is not allergic reactions to some foods, but rather airway obstruction and choking. By that I mean that your child can eat almost any food that can be cooked, mashed, squished, slurped, or can dissolve in saliva. (Only rule is no unpasteurized honey until 1 year). 

I saw a mother last week who was so nervous about finger foods that she was cutting up cheerios! How can you even cut up a Cheerio?  I haven’t tried it, but it seems to me that the Cheerio would just disintegrate into little particles of dust. In actuality, if your child put a Cheerio into their mouth they might gag from a new texture, but the Cheerio itself would break up in the child’s saliva and would not obstruct the child’s airway as it was swallowed. The newer version of Cheerio’s is the Gerber Puff and also the Mum-Mum. Any of these work well as an early finger food.

Young children, under the age of 2 ½ to 3 years, don’t know how to chew. Even if they have a lot of teeth they instinctively put the chunk of food in their mouths and swallow (have you seen teenage boys eat?). If the chunk is large enough or cannot be broken down by the saliva in the mouth, the chunk of whatever might be aspirated and go down the wrong way and cause a child to choke. This is obviously true with not only foods, but with small objects.

So, a child can have peanut butter, but not a peanut. Almonds and cashews are a no-no too, but almond and cashew butters are fine.  No worrying about allergies anymore, those guidelines changed several years ago, but I still hear gasps when I tell parents to try peanut butter!  

A child can have a strawberry or melon that is really ripe and has been cut into very small pieces, but not a fancy melon ball. No need to worry about allergies to berries or exotic fruits, just watch for choking issues. 

What about fish? Flaky fish is a great finger food for a child and very healthy too, but avoid scallops or shrimp that are difficult to eat unless you can chew. (maybe you know of a way to prepare mushy shrimp?)

Questions continue about veggies, and they are all fine. Just cook  them well done, some might even say overcooked, and then cut them into little pieces and just hand your child several pieces at a time.

A brussel sprout may be a choking hazard if it is not taken apart, but green beans, peas, carrots, beets, spinach are all great for young children. Experiment with as many fruits and vegetables as you can. You may even find some new foods that you like.

A well balanced diet is the most important rule. Even if your child pushes some of their finger foods away, keep offering a wide variety of foods.  Children only learn to try new foods and textures with repetitive exposure. It may take 12 times for your child to smoosh the broccoli between their fingers before they even put it in their mouths. 

So… remember airway protection is what you are concerned about, and not reaction to foods. Although food allergies do exist they are much less common than previously thought to be.  Let your child try different foods all of the time and eventually you may be surprised at what a good eater your child becomes. It takes practice and time.  A little patience with the mess of finger feeding is important too, toddlers do not start out neat, they have too learn those manners along the way.  

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

Daily Dose

Is it Appendicitis?

1.15 to read

Last night, a patient called me and wondered if their daughter had appendicitis. I always thought it would be the easiest diagnosis, and that we would call the surgeon and whisk the patient off to the operating room for an appendectomy, just like Madeline (one of my favorite books as a child). Well, over the years have I been taught a few things. At times the diagnosis is easy. The patient has the classic symptoms of a "tummy ache" that starts around the belly button, they may vomit a few times and have a fever and the parent in all of us thinks, "yuk, another one of those tummy viruses". But over several hours the tummy aches worsens, and moves from around the belly button (peri-umbilical) to the right lower quadrant and the nausea and vomiting persist and your child just looks SICKER. At the same time you may notice that they have a funny walk, and won't stand up straight, as they try to get to the bathroom and when possible, they move very little at all, as any movement makes the pain worse. This is classic appendicitis. For a parent, that means a phone call to the pediatrician, day or night, as that child needs to be examined. On the other hand some children just forgot to read Nelson's text book of pediatrics. They don't vomit, they may not have a fever, they are a little nauseated, but when pressed could still eat, and it only hurts in their right lower quadrant, everything else is just okay. These are the difficult cases to diagnose. These children require a lot more history, repeat exams and lab tests and may even need a CAT scan to look at their appendix. But, you don't want to miss an appendicitis, as a perforated appendix is serious and requires a lengthy hospitalization. So as a parent and a doctor, if your child's tummy ache seems to be getting worse, it may be worth a trip to the doctor to feel that tummy, run a few tests and decide how to proceed. It is not always as easy as in a book or on TV. That's your daily dose, we'll chat tomorrow!

Daily Dose

Moms Drinking During Play Group?

1.15 to read

I was chatting with one of my daughter-in-law’s good friends from college who recently finishing her master’s in psychology with her thesis focused on drinking patterns among young adult women and how it affected their sexuality.  Really interesting!

While discussing her data, I brought up the topic of young mothers and alcohol.  I seem to see/hear about more alcohol consumption at play groups and toddler birthday parties. 

Maybe it is just that I am older, but I don’t remember my children’s play groups serving wine and margaritas.  But many of the young mother’s I see, routinely talk about “who is bringing the wine” to the after nap play group. They even told me that you can now by mini wine boxes that look like juice boxes.  They come in 6 packs and have straws! Some of their children refer to this as “mommy’s milk”. 

I don’t want to be a hypocrite as I often enjoy an evening glass of wine with a late dinner after work. I know that I drank in front of our children as they were growing up and tried to teach them responsible drinking. But, I don’t remember taking wine to the park or to the pool to drink while the children had play group.  

Back when my children were young the grocery stores did not carry alcohol, so it was not as easy to throw it in the basket along with the animal crackers and apple juice boxes that often accompanied us to play group. 

One of my concerns is with young mothers drinking in the afternoon before heading home to cook dinner or bathe young children. Many times this might involve driving children from one place to another.

There may be older children that need to be picked up after school or shuttled to early evening events. They are being driven by a parent who has had “several” glasses of wine with friends while the little ones were playing. There may also be more wine or a cocktail with their husband’s as they get home from work. 

The evening is tiring and hectic enough without adding a “buzzed” parent.  I just wonder if any of these children are suffering from a parent who begins drinking in the late afternoon?

I am also concerned about the child’s perception of drinking and alcohol as they are getting older and more aware of what “mommy’s milk” really is. 

Like I said, I might just be getting older, but some of the statistics about women’s drinking habits show that mothers are routinely drinking more and more. More research is being conducted tight now and I am anxious to see some of the newest data.  I might start a study in my own practice.

What are your thoughts? I would love your feedback!

Daily Dose

Medical Decisions at Age 18


It suddenly seems that I have been in a time warp and so many of my patients who “should still be little” are coming in for a visit while home frm college.  It was hard enough for me to realize that my own children had “grown-up”, but I am now realizing that my own patients are “growing up” as well. With many of them now being 18 years old, they are now also “in charge” of their own health care decisions. This became apparent the other day as I was seeing a long time patient for her 18 year old check up, and I was filling out her college health form as well. 

When I got to her immunizations I realized that she had not had the HPV vaccine series, and I then remembered that her parents had decided not to give her this vaccine. (I had discussed the importance of the HPV vaccine with her mother and father every year for the last 4-5 years). As I started to say, “Oh I forgot you did not get the HPV vaccine”, she chimed in with “now that I am 18 years old I want to get that vaccine.” 

I paused for a few seconds and then she said, “I always thought I should get that vaccine and I listened to you every year, but my Dad just didn’t think I was old enough to get it.”  “Now that I can make that decision, I think it is a good vaccine and something that I want to have.” “Can I get it today, and can I come back at the end of the summer and get the second one before heading off to school?” 

Now I am thrilled that she had been listening to our discussions about HPV and the need to vaccinate, but it also felt a bit weird that she suddenly could make her own decisions about vaccines.  In reality, she could make all sorts of decisions now, even though her parents were actually still the holders of her health insurance benefits and would be until at least she was out of college. 

I thought about asking her to call her parents one last time to see what they thought she should do, but then decided that she wanted the vaccine and at her age needed the vaccine, so she had the legal right to sign off on it herself---lets get the vaccine. 

This is really not about HPV, but rather it is about children becoming adults and getting to make decisions about their own health care.  It is also about having a long-standing relationship with patients and hoping that you can help them make good decisions about taking care of themselves and the need for preventative medicine. 

She got the shot, she signed, she was happy, I was glad she was going to be protected (once the series of 3 was completed).  It was a good day, I just wonder what her parents thought? 


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