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Daily Dose

A Better Night's Sleep

1:15 to read

What is it about sleep and parenting? Babies never sleep enough and teenagers sleep too much!! Why can’t “we” get this right? While sleep patterns definitely do change with the age of the child, good sleep habits can begin in infancy and continue throughout adolescence.

Even from the beginning,  you should try to teach your child to fall asleep on their own and to self-console by either sucking on their fingers or a pacifier. But remember, this sleep thing is new and babies really do have to learn how to do this.  Think of it as if you were teaching your child to read, it doesn’t happen overnight, but evolves with practice, patience and repetition. Sleep is the same way.

After the early years of teaching your child to fall asleep on their own, the toddler, preschool, and elementary years are usually fairly easy to establish good sleep patterns if you follow a routine, with a set bedtime, reading to your child before bed and hugs and kisses and lights out. This is the age for occasional nightmares, or fears, but also for regular nights of uninterrupted sleep.

With the tweens and teens and hormone changes of adolescence comes a new sleep clock that is set to stay up too late and not wake up in the morning. Even teens need a good nights rest, so a bedtime should be encouraged and enforced unless there is a test of special event. There is not a reason I can think of for teens to be up past 11 pm on a school night, homework should be finished, and all of the accessories such as cell phone, computer and all other electronic gear put up before bed. The older you get the more you understand a good night’s sleep , but someone has to teach the basics along the way and before you know it the whole house will be on that schedule too. That's your daily dose for today.  We'll chat again tomorrow. Send your question to Dr. Sue now!

Daily Dose

When To Worry About Stuttering

1.15 to read

I received an e-mail today from a mother who is concerned about her 2 1/2 year old daughter who has started stuttering in the last week. She asked ”is this something to be worried about or just watch it and see?”

This is a common question from parents with preschool aged children, and is typically most frequent between 18 months and five years of age. Stuttering at this age is called disfluency or pseudo stuttering and is quite common as children learn to speak and develop more complex speech patterns.

In many cases the stuttering occurs out of the blue, and may last for several weeks, and resolve, but may return off and on during the preschool years as a child is learning more and more language. In a preschooler who is stuttering the parents usually note that the child repeats an initial sound such as l-li-like or s-st-star or may have frequent pauses with “um” and “er”. It is not uncommon to see this happen when a child is excited, or anxious or tired.

They may stumble or words or sounds and after a good night’s rest you may see an improvement. They often don’t seem to realize that they are even stuttering as their brains and mouth try to keep up with one another. Remember they have a lot to say!

The best medicine for stuttering is for a parent to reassure their child that it is okay to slow down as sometimes it is hard to make the words correctly. A hug from Mom or Dad while they are reassuring their child is also helpful. Practice slow and relaxed speech when you are talking to your child and try not to rush them when they are talking, even if the stuttering is bothering you. When your child asks you a question, pause before answering to also model behaviors with speaking. Reading aloud with your child in a slow and normal manner is also beneficial (I remember nights of trying to rush through those early books to try and get everyone in bed!).

The best person to emulate is Mr. Rogers, think of how relaxed he always was when speaking. He never seemed as if he was hurrying for anything! In most cases a child’s stuttering will not last more than weeks to several months and will resolve on its own.

If you think the problem is increasing in severity or is causing stress and anxiety for your child it may be time for a discussion with your pediatrician.

Do you have any tips?  Feel free to share them with us!

Daily Dose

Selfies Cause Lice?

Daily Dose, infections, teens

Are teenagers spreading lice when they put their heads together to take a perfect selfie?  This is a hot topic trending lately.  I have had emails and texts from parents who are fighting head lice in their homes and are wondering if this is possible.  I was skeptical that this is how lice is being transmitted among the teen crowd but it is possible.  Laying on the same pillow or sharing hair brushes and headbands are more likely the culprit.

But what can you do if your teen has lice? Try an over-the-counter product which contains permethrin or pyrethrin and follow directions.

Using a hair conditioner before the use of the OTC product can diminish effectiveness, and many products recommend not washing the hair for several days after finishing the application. Re-apply carefully in order to treat hatching lice and lice not killed by the first application. In other words, you must read the package insert! 

Even with parents following the directions to a “T”, there are cases where the lice continue to thrive. This may be due to the fact that the lice have become resistant to the OTC products, and different geographic areas do seem to have different rates of resistant head lice. 

There are now four prescription products that have been approved by the FDA for use when OTC products have not worked. These products are Sklice, Natroba, Ovide and Ulesfia. Each of these products contains a different product that has proven to work against the human louse. These prescription products do differ by application time, FDA labeled age guidelines, precautions for use and cost. There is not one product that is the best one to use.

There has been a study that looked at oral Ivermectin as a therapy for head lice in children over the age of 2. The drug is not FDA labeled for this use. There are guidelines for its use when both OTC and prescription topical agents have failed to eradicate lice.  

There is no need to try all of the crazy stuff like applying mayonnaise on your teen’s head, or blow drying concentrated moisturizers into the hair shaft.  There are several areas of the country where there are businesses that will “nit pick” your child’s heads, but one of my patients spent $500 dollars on this (really), but continued to have problems with lice.

So, if the lice won’t go away, call your doctor before resorting to alternative, unproven therapies. And don't forget to smile in your next selfie.

Daily Dose

Heart Murmurs

What can you do if your child has an "innocent" heart murmur?I received an email from Brinley who was worried that her 1 year old had recently been found to have an “innocent heart murmur” and she wondered what this meant. Did she need to see a specialist? A heart murmur is simply an extra sound the doctor hears when listening to your child’s heart with their stethoscope. A murmur is caused by the flow of blood through the heart or the major blood vessels around the heart. In the case of an “innocent” heart murmur the flow is through a completely normal heart and is solely due to turbulence but there is nothing else wrong with a child’s heart therefore, the term ”innocent murmur”. These murmurs may also be called functional, benign, or a Still’s murmur. Innocent murmurs are very common and may be heard at different times in a child’s life. Some cardiologist’s quote that somewhere between 50 - 90% of children will have an “innocent murmur” at some time during their childhood. None of these children have any underlying cardiac pathology. It is quite common to hear an “innocent murmur” in a child due to the fact that their heart is close to their chest wall, especially in thin children. It is also not uncommon for the doctor to hear the murmur on one exam and maybe not on the next, as it depends on the position the child is in when they are examined as well as other factors. Fever is one of the most common reasons that a child is found to have an innocent murmur as their heart rate is typically higher and the blood flow is more dynamic. The quality of the murmur is what lets the doctor know that it is an “innocent murmur”. Murmurs are graded on intensity from a grade 1 to grade 6 (the loudest). Most benign murmurs are a grade 1 or grade 2, and they have a musical or vibratory quality. If you have concerns about an innocent murmur a pediatric cardiologist may be consulted. In most cases they will not only listen to your child’s heart, but also do an EKG and an echocardiogram to ensure that your child’s heart is structurally normal. Don’t worry. These murmurs usually go away as your child reaches adolescence. That's your daily dose for today. We'll chat again tomorrow.

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

Summer Skin Infections

1:30 to read

I have been seeing a lot of skin infections and many of these are due to community acquired methicillin resistant staph areus (caMRSA). The typical patient may be a teen involved in sports, but I also see this infection in young children in day care, or summer camp. The typical history is “I think I have a spider bite” and that makes your ears perk up because that is one of the most common complaints with a staph infection, which is typically not due to a bite at all.

The poor spider keeps getting blamed, and how many spiders have you seen lurking around your house waiting to pounce? The caMRSA bacteria is ubiquitous and penetrates small micro abrasions in the skin without any of us every knowing it. The typical caMRSA infection presents with a boil or pustule that grows rapidly and is very tender, red and warm to the touch. The patient will often say that they “thought it was a bite” but the lesion gets angry and red and tender very quickly and typically has a pustular center.

For most of us pediatricians, you can see a lesion and you know that it is staph. It is most common to see these lesions in athletes on exposed skin surfaces such as arms and legs, but lesions are also common on the buttocks of children who are in diapers in day care. The area is angry looking and tender and the teenage boy I saw the other day would not sit on the chair, but laid on the table on his side as he was so uncomfortable. If the lesion is pustular the doctor should obtain a culture to determine which bacteria is causing the infection, but in most cases in my office the culture of these lesions comes back as caMRSA or in the jargon Mersa. When I say Mersa, I often cause widespread panic among my patients, but in most cases to date these infections may still be treated with an oral antibiotic that covers caMRSA, such as clindamycin or trimethoprim-sulfa. Many of the lesions improve dramatically once the site is drained and cultured. I will reiterate that if possible you want your doctor to obtain a culture to identify the bacteria that is causing the infection.

To prevent caMRSA remind your student athlete not to share towels, clothing or other items. Make sure that common areas are disinfected and once again encourage good hand washing. The closure of schools or disinfecting an entire football field or area with turf is not recommended. Lastly, this is a good reminder that you only want to take an antibiotic for a bacterial infection and that overuse of antibiotics leads to resistance. That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

4th of July Celebrations!

1:30 to read

The 4th of July weekend is here, which means many families will celebrate with a long weekend with other families and friends. Let’s remember the importance of making it a safe holiday!   

Of course the celebration includes fireworks which are definitely fun to watch, but at the same time, when they are used by consumers (many of whom are children and teens) rather than by trained professionals, there are many associated risks.  Being on call in the ER as a new doctor was one of the scariest and longest nights in my life...and I can remember seeing children with burns...several which were disfiguring. Burns remain one of my biggest fears.

In 2013 there were an estimated 11,400 people treated in emergency rooms for fireworks related injuries, and the risk of fireworks injury was highest for children ages 0- years, followed by children 10-14 years. I know that having fireworks in your backyard or on the beach is fun, but also dangerous. Although I was used to my boys saying, “ Mom, you tell us that everything that is fun is too dangerous...which not only included fireworks, but trampolines, and motorcycles.”  I am sticking to that.

The majority of fireworks related injuries were to the extremities followed by those to the head (eyes, ears, face).  The greatest number of injuries were caused by small firecrackers, sparklers, and bottle rockets. Did you know that a sparkler burns as hot as 1200 degrees F, while water boils at 212 degrees F and wood burns at 575 degrees F!! Even a left over sparkler may cause a significant burn to little hands.

Fireworks are best left to the “hands” of the experts. Fireworks are dangerous and can be unpredictable, especially in the hands of amateurs (including parents).  Public firework displays are equally enjoyable and are carefully planned and executed. Especially with drought conditions and fires already raging in parts of the U.S. it is especially important to be aware of the risk of inadvertently setting a small fire from a misguided bottle rocket.  That small fire may lead to an even bigger fire which destroys acres of land as well as puts firefighters themselves at risk. No one wishes for that scenario but there were over 17,500 fires caused by fireworks in previous years. 

Start planning your holiday fireworks viewing now....from a safe venue! Happy 4th!

Daily Dose

Raising a Tech Savvy Child

1:30 to read

It seems that there is a new article published every week discussing the use of electronic devices by our children. There is a lot of interest on this topic for a very good reason…as we do know that children, many as young as 6-12 months are “using” their parents smart phones and iPads, as they learn to touch the screen to see pretty colors and sounds. Before you know it  they are even able to “double click” to get to their own pictures.

I have written about this very topic before, as I was seeing 12-15 month olds whose first words included Momma, Dadda, and “swipe” Then there were the toddlers asking their parents to “refresh” the screen and 3 year olds who could type in a password to buy an app. Many of these youngsters could point to the iPad picture of their favorite video or pictures and they could do it faster than their parents.

Another new study just published in Pediatrics points out that up to three-quarters of children from a lower socio-economic class are being given smartphones, tablets and I-pods of their own by the age of 4 years. Although the sample size of this study and survey were small…it is not hard to believe that what is happening in Philadelphia is also happening in Atlanta, LA, St. Louis, Detroit, Dallas, Miami… the city, big or small and across all socio-economic classes.

The study also found that one-third of parents of 3-4 year olds said “their children liked to use more than 1 device at a time”, and 70% of parents reported “allowing their children ages 6 months-4 years to play with mobile devices on their own, while the parent was otherwise occupied”. 

According to the parents involved in the study, “nearly half of their children younger than 1 year used a mobile device daily to play games, watch videos or use apps”, and most 2 year olds “used a tablet or smartphone daily”. I know that statement is true, just from watching children in my own exam rooms. The study did not look at length time the child was on the mobile device. 

The biggest issue is the lack of parental supervision and involvement.  While interactive apps may teach children, is it different when it is done in an isolated manner?  Is listening to a bedtime story alone the same as reading with a parent?  Is passive play in a room full of children on iPad any different than group play?  I have to believe that there are differences and those studies are ongoing and will be for quite some time. It may take a generation to really see the long term implications of young children and use of mobile devices.

While the AAP has re-looked at their recommendations regarding screen time for younger children, pediatricians are still recommending setting time limits for screen time and making “unplugged” play a priority in every family. I don’t think the “magic number is 2 hours for all”….but what is too much??  How do you disconnect from technology when even your kindergartner is given an iPad at school? 

So you will continue to see much written on this topic…but as Dr. Dimitri Christakis, a pediatrician at the University of Washington stated, “children need laps more than apps”.    

Daily Dose

Girls: The Teen Years

1:30 to read

It’s the time of year when I am seeing a lot of my adolescent patients who come in over the summer for their check ups.  An important part of an adolescent female’s yearly exam is a discussion about her periods.  

The average age of a first period (menarche) is 12.43 years and in my practice this has been the norm for the last 30 years. Yes, I do have a few patients who start their periods at 11 years (and typically their mother’s did as well), but I also have patients who don’t begin their menstrual cycles until they are 14 - 15 years old.  Remember, genetics plays a big role in determining the timing of puberty, and there is a wide range of “normal”. 

While we still talk about younger girls having “irregular” periods in the first 1-2 years after menarche, studies now show most adolescents have fairly regular cycle intervals (32 days) and bleeding patterns even at a young gynecologic age.  Studies also show that 88-94% of girls have menstrual bleeds that last 3-7 days, with less than 1% having bleeding episodes lasting more than 10 days.

It is important to ask specific questions about an adolescent’s periods and intervals between her periods (cycle length) as well as length of bleeding. With all of the smartphone apps available to record menstrual cycles, most young girls are pretty savvy and have the dates of their periods which makes this easier. Having a period 28 days apart and then the next being 32 days apart is not “abnormal” but many girls “worry” if they don’t have a cycle every 28 days and they need to be reassured that there may be a few days of variability every month.  

I also ask questions to see if an adolescent is having excessively heavy periods (but this is sometimes really difficult to judge early on as a girl doesn’t have a big frame of reference).  If a girl feels as if she is having very “heavy” periods I also look at past history for signs of excessive bleeding or bruising as well her family history for any bleeding abnormalities.  Having her pay attention to pad count for the next month is sometimes helpful.

Many young girls (and their mothers) also ask when they may were a tampon?  It is safe to wear a tampon whenever you begin your period, it really has nothing to do with “age appropriate”. I have a group of adolescents who wear a tampon from the “get go”, while I have others who swear “I will NEVER put in a tampon”.  It is totally about personal preference. I do let young girls know that if they are going to swim during their periods they will need to learn to wear a tampon.  Many of my patients learn to put in a tampon out of necessity!!  They are involved in cheerleading, sports or maybe they are going away to a water sports camp.  I tell all of them, whether your mother, best friend, camp counselor or the direction on the box teaches you to insert a tampon….once you have done it you realize it is certainly not as difficult as imagined.  (one of those check the box moments as a girl!!)

Lastly, I discuss menstrual cramps and how to treat them…which means don’t wait until you are doubled over in pain. It is important to begin an over the counter pain reliever like ibuprofen or naproxen when cramps begin…don’t wait too late. I encourage these girls to carry these products in their purse so that they may be more comfortable sooner rather than later. 



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