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Daily Dose

New Sleep Recommendations

1:30 to read

SLEEP! Who can get enough of it?  More and more studies point to the need for a good night’s sleep. But, as a new parent, you are sleep deprived, and then when your children get older they may sleep through the night,  but they want to wake up at the crack of dawn.  Once your children are adolescents their days and nights are totally up side down,  they often want to stay up too late and sleep half the day away.

Sleep is an important way to rest our brains and reset our bodies for another day.  Circadian rhythm helps to regulate sleep/wake cycles.  But trying to make sure that your children get enough sleep seems to be a never ending battle (at least in many houses). It is also one of the most frequent concerns of many of my patient’s parents.  

A recent study which was undertaken by the National Sleep Foundation reviewed over 300 articles published in peer reviewed journals between 2004-2014. Based upon their review here are the updated sleep recommendations:

Newborns (0- 3 months) 14 - 17 hours

Infants (4 -11 months) 12 - 15 hour

Toddlers (1- 2- years) 11 - 14 hours

Preschoolers (3 - 5) 10 - 13 hours

School aged children ( 6 - 13) 9 - 11 hours

Teens (14- 17)  8 - 10 hours

Young adults (18 - 25) 7 - 9 hours

So, how do your children stack up with their sleep?  Parents with newborns complain that their children may sleep 15 hours/ day, but not in the increments that they would like, while parents with children over the age of 13 rarely report that their children are getting  8 - 10 hours of sleep.

One mother recently was exasperated as her daughter age 7 would go to bed at 7:30 pm but woke up everyday at 6 am. I explained to her that her daughter was getting enough sleep, and that unfortunately her biological clock was set and that short of making her stay in her room until 6:45 when she wanted her to get up, there was not much to do.  The problem is that many parents cannot go to bed when their children do, (dishes, laundry, work emails, etc to get done while the children sleep.) So while their children may be getting enough sleep the parents are often sleep deprived!

While a good night’s sleep is important for mood and focus there is a lot of data suggesting that children who get enough sleep are less obese, are less likely to get into trouble and are certainly more pleasant to be around.

So, have a good nighttime routine beginning with a regular bedtime for your children. Commit to no electronics in their bedrooms and turn off any electronics at least an hour before bed.  We parents need to do the same!

Daily Dose

Picky Eaters

1:15 to read

There is an interesting article in Pediatrics which looks at children who were identified by their parents as picky eaters. It seems that being a picky eater (now also called selective eating), may not just be a phase for some children. Selective eating and a child’s  food preferences may be an indicator of other psychological problems.

Picky eating affects about 20% of children. In this study from Duke University, 917 children ages 2-6 who were identified as picky eaters by their parents were followed over 3 years.  The author found that those children with “moderate picky eating habits” were more likely to have symptoms of anxiety, depression and ADHD.  Children who had severe selective eating ( those children who had intense aversions that made it difficult to eat outside of their home) were even more likely to have social anxiety and depression.

I found this study to be fascinating as it does not show that picky eating causes psychological issues or even vice versa…..but it does show that there is a correlation between the two. I think this only substantiates what I have seen in my own practice and I often ask parents is this a “nature or nurture issue”, or both?

While many children go through phases when they only want peanut butter and jelly for lunch or could live on chicken nuggets and pizza, some children seem to develop more intense feelings related to food choices.  Many parents that I see say , “we just try to ignore it” and their child seems to “move on”. But over the years other parents have said that “their child would starve to death if they did not capitulate to their picky eating”, and that the struggles it caused were “just not worth the anxiety”.  Even before this study, it seemed that some children “are just wired” differently.

These children also seemed to have heightened issues with textures and tastes, that you sometimes even notice in a child as they begin to eat soft table foods between 9-12 months of age. Are these the children that go on to become extremely picky eaters? Could it be that these children are just born with heightened sensitivity to taste, texture and smell?

All in all this is an interesting study which actually raises more questions about how to handle a picky eater. Is there one right answer….like most things the answer is NO. But having family meal time is still important and I always start with the statement, “a parents job is to provide their children with a healthy well balanced meal, and their child will decide if they want to eat it” . Sounds easy enough…..but for some it may not be.

So, if you find that your child is getting more selective, food choices are more intense and this is causing anxiety for both parent and child, make sure you discuss this with your pediatrician.  

Daily Dose

Staying Heart Healthy

1:30 to read

With it being heart month it seems like an appropriate time to discuss sudden cardiac death (SCD) in children. Thankfully, sudden cardiac death is rare in children with estimates somewhere between 0.6-6.2 deaths /100,000 in children in the U.S.  

SCD is defined as “a death that is abrupt, unexpected, and due to a cardiovascular cause”. It is also defined as a death that occurs within 1 hour from the onset of cardiovascular symptoms, and in the pediatric population death typically occurs within a few minutes of symptoms.  The majority of these tragic sudden deaths occur during sports (20-25%), and in many cases there have been no previous warning signs.

While congenital heart disease is the most common cause of SCD, there continues to be a great deal of research into this subject.  It is now known that there are genetic risk factors involved for many of the disorders that lead to heart disease, arrhythmias and SCD.  Hypertrophic cardiomyopathy ( enlargement of the heart) is the most common cause of SCD in children and adolescents and is due to a genetic abnormality as is prolonged QT syndrome.

Since sport participation has been associated with an increased risk of SCD in children, it is now recommended that athletes are pre-screened for risk factors associated with SCD. A good history is always important, with questions directed towards the heart - including chest pain with exertion, recurrent syncope (fainting) or syncope with exertion.  While many children may not be symptomatic a detailed family history of sudden early unexplained death may be a clue to provoke a further work . The physical exam is equally important including blood pressure readings with the patient both supine, sitting and standing. A good cardiac exam is necessary to listen for murmurs as well as any physical findings suggestive of Marfan’s syndrome. 

Routine ECG (electrocardiogram) screening for all athletes is currently not recommended, although this is the recommendation in several other countries ( Italy has a lot of data on this topic). Unfortunately, an ECG alone does not diagnose all abnormalities and there are frequent false positive results as well, which may lead to unnecessary testing.  An echocardiogram is also necessary to diagnose some abnormalities, and again is not routinely recommended and requires a pediatric cardiologist to read it. 

The most important treatment for SCD is early cardiopulmonary resuscitation (CPR) and to have an AED (automatic external defibrillator) available.  It is estimated that early CPR/AED use could prevent about 25% of pediatric sudden deaths.  If we increase the number of people ( including older children)  who have been instructed in CPR and feel comfortable knowing the correct way to use an AED the statistics for survival may even become more favorable.  There have been anecdotal reports of children performing CPR successfully simply due to the fact that they had seen CPR performed on TV shows or the internet.  Taking CPR/AED training into middle and high schools may be one way to insure this. For children that have been found to have a genetic abnormality which puts them at risk for SCD, or for those who have survived a sudden cardiac event, there are treatments available including medications and in some cases implantation of an internal cardioverter and defibrillator ( almost like your own AED).  Evaluation and treatment by a pediatric cardiologist with expertise in this area is preferred.  

So…with it being heart month a good family activity might be CPR training…who knows when you just might save a life!

Daily Dose

Being a Dad

1:30 to read

Seeing that this is the week of Father’s Day (have you made your card or shopped yet?), I thought this was a good time to discuss some recent data that might be of interest to men….especially those who may be planning a family in the near future. 

For years research has shown that maternal age may contribute to birth defects and chromosomal abnormalities, including Down’s syndrome.. It has also been known that a pregnant woman’s health and habits may also affect their unborn baby’s health, therefore  woman are instructed to stop smoking and drinking alcohol while trying to get pregnant as well as throughout their pregnancy.

Dr. Joanna Kitlinska a researcher from Georgetown University has been studying how men’s age as well as their habits might also impact a child.  Her findings have shown a link between men who are over 40 years- “advanced paternal age”  and the incidence of autism as compared to fathers under 30 years of age.  Studies have also found that older fathers are more  likely to have children who develop schizophrenia.  Researchers wonder if this link may be due to changes in a father’s genes as they age….but to date this is unclear. “Biological clocks” and a woman’s decision to delay a pregnancy until their career is established (or for a myriad of reasons) may now be a decision that men will face as well.  Could both aging eggs and sperm play a role in genetic abnormalities? 

Smoking seems to be another habit that may somehow affect a man’s sperm and could potentially lead to genetic abnormalities in a child. 

While fetal alcohol spectrum disorders are known to be found in women who have consumed alcohol throughout their pregnancy,  researchers have also noted that 3 out of 4 children diagnosed with FAS also have alcoholic fathers.   Could their father’s excessive use of alcohol have also played a role in their developing brain?  This association has been found even if the mother did not drink alcohol during her pregnancy. Again, did the alcohol affect a father’s sperm and genes which was passed on to their child?

So…bottom line, it is important that “fathers to be” are equally invested in a healthy lifestyle when they are planning on having children.  It goes without saying that smoking, drinking, and even obesity and stress are not good choices for anyone …..but the fact that these choices may affect a future child are good reasons for both fathers, and mothers to be aware of this research when they are planning a family. 

 

Daily Dose

Breastfed Babies & Diaper Rash

1:30 to read

I was shopping at Target just the other day and happened to be in the “baby aisle” looking for one of those snack cups with the lids to let little fingers get in and not let the puffs fall out.  I needed it as part of a baby gift basket.  Useful for sure!!

So…while I am browsing, I see a young mother and her mother looking at diaper creams and obviously trying to decide which one to buy. I could’t resist offering help (always worry about being intrusive). When I asked what they were trying to treat the mother said, “ my new baby has this raw and red diaper rash right around his bottom”.  “He is just 12 days old and I change his diaper all of the time….how could he possibly get a diaper rash? What am I doing wrong?”

As we say in Texas, “bless her heart”!!! I asked if she was breast feeding,  and she was,  then I immediately knew what she meant. A breast fed infant will poop ALL OF THE TIME.  Many times you change a new diaper and as soon as the next diaper is put on the baby stools again. There are many times when your infant may poop a bit of stool during sleep and when you get them up they have a dirty diaper…all normal. No new mother guilt!!

The good news is that a newborn who is stooling a lot is probably getting plenty of breast milk as well…and that means they are gaining weight too!  The flip side is that it is not uncommon for a newborn to get that raw red bottom during the first month or so of breast feeding.  After that time, the stools do slow down a bit and diaper rash is less common.

The best remedy I have found for treating that tender new bottom is a combination of a diaper cream that contains zinc (Destin, Dr. Smith’s, or Boudreaux’s Butt Paste) and a bit of a liquid antacid (Mylanta, Maalox, Gaviscon). I put  a blob of diaper cream in my palm and then pour a bit of the antacid into it and mix….you can’t use too much of the liquid or it will run off.  Then I take that combo and coat the baby’s bottom. You can’t over do it. Use it with each diaper change.   It seems to do the trick and is easy. Several years ago I told a mother about the concoction (she had 4 children and was very sleep deprived) and I  just said use some antacid if you have some. She called later in the day and said she had tried to crush up the tablets and mix it with diaper cream and it wasn’t working.  I have since learned to be a bit more specific about a LIQUID antacid.  

 

 

 

 

 

Daily Dose

National Poison Prevention Week

1:30 to read

It is National Poison Prevention Week and it seem appropriate since I just received a call last week from an anxious mother whose toddler had gotten into some medication at their house. The child was fine but I reminded her that more than 2 million people each year, about half under the age of 6, ingest or come into contact with a poisonous substance.  The majority of these incidents occur when parents or babysitters are present but are not paying attention at the time. As I remind parents, it is IMPOSSIBLE to watch your child, even with just one child, all of the time. So…it is necessary to take steps to try to prevent accidental poisonings.

 

The most dangerous potential poisons are medicines, cleaning products, liquid nicotine, pesticides, gasoline and kerosene. I am always surprised to hear that a child will drink gasoline (YUCK right?) but toddlers do crazy things and put EVERYTHING in their mouths.

 

When “child-proofing” the house against so many dangers, try to keep as many poisonous products outs of a child’s reach and view as possible.  Install safety latches on all cabinets that may contain any hazardous products …including laundry products and cleaning products. I would advise against using any detergent “pods” with children under the age of 6 and use powder or liquid instead.  A safer product is worth a little bit of hassle!

 

Make sure that ALL medications, even vitamins are in containers with child safety caps (adults can’t open them but kids seem to?), but you must also keep them out of reach of children and I would recommend a cabinet that you can lock.  There have been several occasions when a parent has left a pill out on a counter for another child to take and then suddenly the toddler has chewed it up…this has been most common with stimulant medications.  Grandparents who are visiting also forget and leave their medications out and kids seem to find these as well.

 

Another common potential poison comes in the form of a button cell battery. These are common in remote controls, key fobs, greeting cards and even musical children’s books and not only pose a choking hazard but may cause tissue damage. If your child ingests a battery it is imperative that you seek immediate treatment at an emergency room.

 

If you are ever in doubt about the potential for poisoning call Poison Help at 1-800-222-1222. They are experts in walking you through potential side effects, treatments and need for an ER visit!  One of my patients just asked me if there is a limit to how many times you can call Poison Control…she seems to be a frequent flyer.

 

 

 

 

 

 

 

 

Daily Dose

Toddlers & Tantrums

1.15 to read

I see toddlers for check ups nearly every day and for both the 15 month and 18 month visit, there are many challenges for parents and the pediatrician (and of course the child). Toddlers are not at what I would call an EASY age.

As you know if you have a toddler, they are quite moody (just wait for teenagers) and they can “stop, drop and roll” into a tantrum in the blink of an eye.  So while I was examining an 18 month old this week ( she is one of three adorable girls), she suddenly became infuriated (her mother and I were really clueless as to what triggered this) and she jumped off of her mother’s lap and fell to the floor kicking and screaming. 

Now, for a first time parent this might be alarming behavior, but for a seasoned mother of three it was really no big deal. Appropriately, we all just ignored her as she laid on the floor and screamed (no, the mother was not worried about germs on the floor either) and we continued our conversation about her child’s less than stellar sleep habits.

After a few minutes her daughter calmed down, the older sisters got her a sticker and she left without a fuss. Her mother had already learned, like we all do, that the best way to stop tantrums is by ignoring them and letting your toddler have some time to “express her emotions” with age appropriate (although inappropriate for older children) behavior.  

Several days later, her mother sent me an email with another picture attached of the same child having yet another tantrum after she found her in her diaper with a sharpie pen happily marking all over herself (the photo above). Of course, the minute she took the marker away her daughter fell to the floor again to express her outrage! So funny that her mom thought to document it and send me another picture.

By the way, she also told me that she had taken practical advice and was working on having her daughter cry herself to sleep and it was working well!  Both the tantrums and sleep were improving by just ignoring her behavior. Back to those laws of natural consequences.  

Daily Dose

Timeout!

1:30 to read

When I am seeing toddlers for their check ups, the topic of behavior is usually at the top of both the parent’s and my list for discussion.  Once a child is walking and beginning to talk, all sorts of new behaviors seem to occur! 

Parents ask, “how do I stop my child from hitting or biting?”  “What about misbehaving and not listening?”  The toddler years are challenging for behavior as a child is gaining independence, and testing as well.  Toddler and teens have some of the same attributes and it is important to begin behavior modification during the toddler years. 

Time out is the most commonly used behavior modification and not only will parents use this method at home, but preschool and day care teachers begin using this technique as well. This is the age that children begin to understand rules and consequences. 

So how do you “do” time out and when?  I usually start using time out when a child is between 15 -18 months of age. While I try to ignore and distract tantrums, I use time out for biting, hitting and those age appropriate yet inappropriate behaviors. 

I pick a chair in the house (we had a small set of table and chairs which seemed perfect) and every parent needs a kitchen timer to use for time out.   It is important to get at your child’s level when disciplining them as well. Tell them why they are going to time out and then have them sit in the chair for 1 minute per year of age.  (Trust me a minute sometimes feels like forever!)  

Here is the trick, if your child will not just sit in the chair (and many won’t), go behind them and hold them in the chair as if you were a human rope.  In most cases the child will be crying and trying to get up out of the chair, but you calmly hold them in the chair from behind. No eye contact!  Once the timer goes off, you let go of them, go back around so that you make eye contact again, get down to their level, and explain once again that they had to sit in the chair because they (fill in the blank).  

Time out takes time and patience.  If you are consistent about using time out for misbehaving, your child will learn to sit in the chair.  For some it may only take 1 time and others are more head-strong and it may take months of “human rope” before they decide to sit alone. 

Don’t give up!!!  This is a very important lesson for children to learn and you will use time out many times, not only in that little chair, but in other venues as your child gets older.    

Daily Dose

Don't Give In To Picky Eating

2.00 to read

I am trying to clean up my desk and I have been looking through stacks of pediatric articles that I felt were really interesting.

An article by Dr. Barbara Howard entitled “Three Magic Words Offer Food for Thought” made a wonderful point regarding family meals and eating habits. She states that one of the best questions to ask a child during a “well-child” visit only requires three words, but offers so much insight into a family’s interactions. What are the magic words? “How are your meals?” I know you know how much I believe in, and promote, families eating together. There has been a lot of data substantiating the many positive side effects that stem from family meals.

You can look at some of the studies by going to The Promoting Family Meals Project, http://www.cfs.purdue.edu/CFP/promotingfamilymeals. Not only does eating together as a family help improve food choices which may help prevent obesity, it also leads to children who have improved vocabulary and language skills, social skills and manners.

Family meals have also been shown to lessen the chance of risk taking behaviors in adolescents. There has also been an association with fewer eating disorders among adolescents who have regular family meals. So, when I ask children about their meals, I also get parental feedback. The biggest complaint is that their children are “picky eaters”. Many children and parents will say that they don’t eat together as a family as everyone eats something different. I don’t think being a “short order cook” is a job requirement of any parent.

Social worker Ally Slater, delineates parent’s responsibilities with regard to food as “what, when and where” while leaving children, “how much and whether”. I love that!! Parents control the grocery cart, meal and snack choices and food offerings on the plate. It is nice to always offer at least one food that most family members like. Once that food is offered and we are gathered together to eat, parents need to back off. Is that easier said than done? Maybe in the beginning, but over time it actually simplifies family life.

I think it is really fairly easy if you “buy into” the idea of family meals and know that children will make better and wider food choices if given that opportunity. It may take up to 100 times, and many months for your child to try different foods, but eventually you will be pleased that you have a child who is a healthy eater, and who also enjoys a wide variety of foods. Trust me, your children when raised this way, really turn out to be great eaters as adolescents and young adults. I think my boys are less “picky” than I am! (no sushi for me).

Make family meal time a priority. Your children will respect the rules, learn table manners, and enjoy dinnertime conversation, while eventually developing a more mature palate. It just takes time.

That’s your daily dose, we’ll chat again tomorrow. 

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New study reveals how much sleep kids really need.

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