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Daily Dose

Flu Season Isn't Over Yet

Just when you least expect it, those nasty viruses can rear their angry heads and guess what, they seem to be back.This has certainly been a weird end of winter and early spring in our office. I have always been very protective of my newborns and try to keep them "isolated" from all of those terrible winter viruses and germs for the first six to eight weeks of the infant's life. Especially for those newborns born during the winter months. Because we are fortunate to live in a temperate climate, we have lots of sunny days in the winter which allows for parents and babies to get out for walks in their neighborhood and even strolls in the park.

Even so, many of the parents (and they say their babies too) are getting a little cabin fever and are ready to head out to the mall, church and restaurants (the list seems endless). All of these venues are all full of crowds, so it is a given that germs are lurking there. By this time it had seemed that flu was long gone in our area and we had not seen RSV for months. Just when you least expect it, those nasty viruses can rear their angry heads and guess what, they seem to be back? I saw several cases of Influenza B last week, and yes they were documented! I was so skeptical that I had the lab techs pull out the boxes of flu tests to just check for checking sake and what do you know?! At the same time I saw several cases of RSV and even had to hospitalize one infant due to respiratory distress, the first child I had hospitalized all winter! Even the hospital was out of the rapid screening kits that had not been used recently, so it took us a day to document RSV. I am happy to report that both the your-baby with RSV and the adolescent with the flu are now doing well. I guess the moral of the story is, we cannot always predict the "official" end of the winter viral season. So keeping infants isolated seems like a good practice for at least several more weeks, until it is hard to find a coughing, sneezing, feverish, person among us. By June it will be a memory until winter of 2009 - 2010 and unfortunately the cycle begins again. That's your daily dose, we'll chat again tomorrow.

Daily Dose

Update on Autism

1:30 to read

Every parent watches for their baby’s first smile.  After the smiles are giggles and laughs and before you know it your baby is saying "dada" and "mama" and their vocabulary begins to explode. Suddenly you realize that your child is putting words together and may even start telling you what they want!  These developmental milestones all typically occur in the first 2 years of life.

Developmental screening is an important part of your visits to your pediatrician...especially for the first 2-3 years of life.  In many practices a parent fills out some sort of developmental screening questionnaire prior to their “well-baby” visit asking age appropriate questions....such as “does your child babble?”, “does your child point at objects?” “does your child play patty cake?”  “does your child put 2 words together?”.  During the check up your pediatrician is also watching how your child is interacting with their parents as well as with the doctor. I sometimes find that parents are “hard graders” and do not give their child credit for some milestones that I think they are actually doing when I am examining them.  Remember, there is a wide range of normal in the first several years of life. Not every baby does every thing at the same time!

Socialization and interaction is a very important part of early childhood development, but for some babies making eye contact and developing language skills is delayed. In fact,  for some children socialization and language seems to develop later and seems to be “different” than that of other children. These so called “red flags” in a baby’s development may be early signs of autism.  

The diagnosis of autism is typically not made until a child is between 18 months- 3 or 4 years of age.  The diagnosis of autism is based upon observation of a child’s communication and social interaction and for older children on their activities and interests. There is NOT a single test to diagnose autism.  In other words, your doctor cannot do a blood test to definitively diagnose autism spectrum disease (ASD). The diagnosis of ASD relies upon characteristic behaviors seen in a child, not on one milestone.

If you have concerns about your child’s development make sure you bring them up with your child’s pediatrician.  While it is hard for a parent to “wait and see” what happens over several months some babies will achieve their language and social skills later than others. Just like learning to read...some children do it earlier than others.

The most important thing is that you interact with your baby in those early years!! Talk, sing, read aloud and engage them in early play....as we know that every child needs that same stimulation.  

Daily Dose

Internet Gaming

1:15 to read

I know a lot of kids received electronics for Christmas so they may now play all sorts of games.  But, with the electronics comes the issue of how long may they play, what games are age appropriate and when is it “too much”? Do you ever feel as if your child vanishes for hours on end in their room and suddenly you realize that they have been “gaming” all day.  

 

I recently read an article on gaming addiction and I had not realized how problematic this issue has become.  It seems that an increasing number of of children and adolescents are becoming pre-occupied with internet gaming and they demonstrate compulsivity and exclude other interests, including family time, school and outside activities. 

This is a new type of addiction and is even included in latest version of the Diagnostic and Statistical Manual of Mental Disorders as “Internet Gaming Disorder”. Some of the criteria include:

*Pre-occupation or obsession with Internet gaming

*Withdrawal symptoms when not able to play, including irritability or sadness

*Loss of interest in other previously pleasurable activities

*Lying about internet gaming time

I did not realize that the problem with Internet gaming addiction is such a problem in South Korea. In 2006 it was reported that 50% of South Korea youth were dealing with addiction!! In the U.S. it has been estimated to affect somewhere between 2-7 % of the population. There have even been outpatient treatment programs that have recently opened in the U.S. to deal with this issue.

Interestingly, when gaming there is stimulation of areas of the brain that have been associated with addiction.  Some studies have been done looking at images of the brain while gaming and this addiction is similar in neuro-circuitry to substance related addictions.  Scary stuff.

So parents, be aware and educate your kids on responsible Internet use and gaming.Remind kids that addiction issues tend to run in families…you can’t change your genetics. Make sure you know the warning signs of addiction such as decreasing school performance, cravings to play or withdrawal symptoms when games are taken away.

The best treatment and intervention seems to be cognitive behavioral therapy (CBT) and specific therapy has recently been developed. However, this treatment is in early phases and interventions will continued to need to be studied. 

 

Daily Dose

Plate Size & Childhood Obesity

1.15 to read

While I have been trying to change up my eating habits a bit and talking to patients about trying some new foods, I came upon an interesting study in the journal Pediatrics.  

The hypothesis for the study, which was done among school children in Philadelphia, was “can smaller plates promote age-appropriate portion sizes in children?”.

There have been previous studies in the adult literature that have shown that dish ware size influences self-serve portion sizes and caloric intake. Whether the same conclusions with children were true had yet to be examined, but it does make sense that it might.

So, the hypothesis was correct and when children were given larger bowls, plates and cups, they served themselves larger portions and in turn more calories. In the study, 80% of the children served themselves more calories at lunch when using adult-size plates and bowls.

This is really great news, in that by changing the size of the plate we might be able to affect a child’s portion size without them even really being aware!

I remember that our kids all had children’s bowls, plates and cups that they loved to use and eventually they either broke, got lost, or we just decided to have everyone eat off of the same plates. But, maybe it would make more sense to continue to have our children use child sized plates until they reach puberty?  Certainly seems that it wouldn’t hurt and if schools did the same thing we might be able to impact some of the obesity problem by just changing one behavior.  It is definitely worth trying!

Daily Dose

Jessica Simpson's Weight Gain

1.30 to read

Jessica Simpson has been getting a lot of press and TV time related to the amount of weight she gained during her recent pregnancy and the difficulty she is having “shedding” the pounds.  I just thought I needed to “WEIGH IN” on this subject as I don’t think the real issue is being discussed.  

As a pediatrician, I am not as concerned about when or how she loses the excessive weight that she packed on during her pregnancy.  I am more worried about the message that she is sending to other pregnant women.  Excessive weight gain during pregnancy may cause complications that could jeopardize an unborn baby’s health. It is not safe to gain all of that weight during a pregnancy. 

Jessica Simpson is quoted saying that she is a “southern girl” and enjoys fried foods, macaroni and cheese and cream gravy. Most obstetricians recommend that a woman of average weight gain between 25-35 lbs during a pregnancy. If a woman is overweight prior to becoming pregnant she may only need to gain 15-20 lbs during the 9 months. Being pregnant does not mean that you can forget all about nutrition, eat excessively and gain 100 lbs. (educated guess on my part). 

A woman who gains excessive weight during a pregnancy may have complications and is more likely to develop high blood pressure as well as gestational diabetes.  Gestational diabetes is typically controlled with dietary changes alone, but in some cases a pregnant woman may even require insulin. Gestational diabetes puts the baby at risk for having blood sugar problems at birth. At the same time, blood pressure problems may be dangerous for the mother and put the baby at risk for premature birth and all of the problems that are related to prematurity. 

At the same time, excessive weight gain during pregnancy typically causes the newborn to be what is termed, “large for gestational age”.   These big babies are often delivered by C-section either electively or emergently and again there are more complications seen after a C-section than a vaginal delivery. 

So.....I wish that the media would not put the focus on how Jessica Simpson is going to lose the weight or how much she is going to be paid to lose all of those pounds, but rather on the fact that she jeopardized the health of her newborn. She was fortunate that she had a beautiful and healthy newborn daughter. 

We all have had cravings while pregnant, but healthy eating and regular exercise are still recommended to ensure the health of the unborn baby.  Jessica Simpson’s weight gain and diet is not the role model we pediatricians want for pregnant moms to follow! 

Daily Dose

No Oreos in Lunch?

1:15 to read

I have been interested in the recent news article about a mother who had packed Oreo cookies in her child’s lunchbox. It seems that although she had also packed other lunch items, the school her child attended deemed the lunch “unhealthy” and not only did not allow her to eat the cookies, they  sent her mother a note encouraging her to “pack a nutritious lunch”.

WHAT?  Are schools and daycare centers now deciding what a parent may put in a child’s lunchbox?  I understand the need for nutritious lunches for our children. I talk about this everyday in my practice. But are there not bigger issues facing our schools than policing every child’s lunch. This mother did not “just” pack Oreos, her child had a sandwich and string cheese as well. Her mother stated that, “she was out of fruits and vegetables that day”, so added some cookies.  

Schools are in the throes of changing menus in an effort to help our children make good choices at lunch. But, even without serving fried foods or soft drinks, they do still offer dessert during school lunch.  They have ice cream, frozen yogurt, pies, cookies....and unfortunately many children probably eat more than one.  

I once headed a committee at our sons’ school to change the school cafeteria’s policy to have a “soda fountain”.   I realized that even if I talked to my children about nutrition and health, and did not have soft drinks in our home , if they were offered a choice between soft drinks and milk I knew  that they would sometimes choose a soft drink (with free refills I might add). 

After about a year of discussions and some very unhappy parents and students our school did stop serving soft drinks. As I pointed out even then, this was for children who were buying school lunch and drinks....we were not telling parents what they could and could not send or have in their own homes.

At the minimum I think this poor 4 year old should not have been put in the middle of this discussion. Would it not have been more appropriate to send the mother a note asking her not to send cookies for lunch again?  Was there a notice of acceptable lunch items that had been posted at the beginning of school?  Is there a “zero tolerance” for cookies rule?

I guess schools will be sending sandwiches home that have white bread or bologna, or who knows what else. While I am a huge advocate for healthy eating habits and making changes in all of our homes...let’s not take it out on a 4 year old.

Daily Dose

Too Much Pressure to Play Sports?

1:30 to read

Does your child play a sport “after school”?  It seems children as young as 3-4 years of age are now involved in soccer and even football.  Some children are barely walking before they are signed up for a team.  Parents tell me various reasons for this including, “if they don’t start young they will be at a disadvantage athletically”, “if we don’t get on a team now, there will not be room for our child once they start kindergarten or first grade”,  and “our child wants to play and wear a uniform”. I just see lots of issues with burn out.

It seems awfully early to start “team sports” to me. I am a huge advocate of families and children playing together and learning all sorts of games and sporting skills. Kicking a soccer ball in the yard, or hitting the wiffle ball off of the tee, or having Dad throw a pass with the football all seems pretty “normal” to me. But organized sports with a 3 year old who is still in diapers….really?  Maybe one of the “guidelines” should be you have to be potty trained.  Yes, this is true, I see children in diapers who “will not pee or poop in the potty” according to their parents, but they go to soccer practice?  What is wrong with this picture?

So, while some of these well intentioned parents have told me that they are having fun being the coach, or attending games with other friends, their pre-school children “don’t have time to be potty trained”. They are too busy going to school, followed by organized activities that “it is just easier to let them stay in diapers”. I was even with a 4 year old at a football game and she was still in diapers?

At some point these children and parents will need to skip a practice or two and stay home long enough to get potty trained.  I am noticing that children are getting older and older before they are potty trained. I know there are books written on this topic with the philosophy that “the child will ultimately train themselves”, or “ how to potty train in 3 days, with a child who shows no interest”…or something along those lines.  But really, in my experience, if you watch your child’s cues, spend the time to “talk bathroom habits” and have the “time” to be home to potty train most children are potty trained between 24-36 months of age.  Yes, there are occasional children (none of my own) that just show interest earlier and say things like “I go potty now” and really do it on their own. There are also some who are more difficult to get interested and may be harder to potty train…but again, which is probably a more important life time skill…..getting out of a diaper or trying to figure out how to line up for a soccer game? I’m just saying.

Daily Dose

Teething and Fevers

1:15 to read

Does teething cause a fever?  Ask many parents and they will say yes… but a recent study in the journal Pediatrics says no.  Researchers looked at signs and symptoms associated with primary tooth eruption in 3500 healthy children ages 35 months and under.  For most children the first tooth appears around 6 months, but don’t be overly concerned if your child does not cut their first tooth until later, there is still a lot of variability.

In this study 71% of children had some signs or symptoms related to teething including gum irritation, drooling and irritability.   Although about 25% of those studied reported “fever”, the rise in temperature was actually less than the level of 100.4 degrees, which is the definition of fever. About 20% of those studied also reported diarrhea.

The study also showed that the peak of signs and symptoms during teething were reported when the incisors (front teeth) erupted and that symptoms seemed to decrease with age. ( interesting as well, as I wonder if parents were just less focused on teething as their child gets older?).

While many parents will bring their child in to my office complaining that they are teething and have a temperature of 102 degrees, the two issues are not related. I had always been taught that teething does not cause a fever…so this study only serves as further confirmation.  Babies and toddlers are getting many viral infections during the same time that they are “teething” and their illness is the reason for the fever. This means that a child with a fever over 100.4 cannot go to daycare or school, despite the fact that parents want to send them with a note stating, “they are just teething”. 

I continue to tell many parents that their “irritable” toddler is probably just in a bad mood and “being a toddler” rather than attributing their temperament to cutting a tooth.  Once your child is older you begin to realize that teeth come ( and go) and many times you don’t even know it until your child drops to the floor throwing a tantrum and you see those molars have broken through the gums.  The same about sleep issues, as your child will cut teeth when they are 5, 7, 10 years of age and don’t complain that they can’t sleep or have hourly sleep awakenings.  A toddler that has sleep awakenings is more likely to be dreaming than teething, and is not “in pain”.

So when your child wakes up with a fever, don’t be attributing the fever to teething - something else is going on and that is usually yet another viral illness. 

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. 

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