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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. 

Daily Dose

Baby's First Foods

1:30 to read

Have you heard of “baby led weaning” (BLW)? Many of my patients who have infants that are ready to start “solid foods”, also called complementary foods, have questions about this method. Most babies begin eating foods along with breast milk or formula somewhere around 5 - 6 months of age.  So BLW is not really “weaning”,  as your infant will continue to have breast milk or formula in conjunction with foods…so this really should more aptly be named “baby self feeding”. 

In this method you never offer your baby “mush” or pureed foods, but rather offer them foods from the table.   While I am a huge advocate of self feeding (old term is finger feeding), I also think that early on offering a baby “mushy” food on a spoon is an important milestone. In fact, for most babies at 5 -6 months, it is difficult to pick up a small piece of food to self feed as the pincer grasp has not developed. So, a baby is trying to get food to their mouths by cupping it or hoping it sticks to their hand while pushing pieces around their tray. Some parents will put the food into their baby’s hand.  But, by 8-ish months most babies have developed their pincer grasp and the finger feeding should be preferred.  

Parents are also concerned about starting solid foods and the possibility of choking.  I am always discussing how to make sure that your child avoids choking hazards with foods. In other words, no whole grapes, or hot dogs, or popcorn or chunks of meat.   Other hazards are raw carrots, apples, celery and any “hard” food that your baby might be able to bite a chunk of and then choke. But, if you cook the carrots and then cut them in small bites they are easily handled by a baby who is self feeding.  It is really all about the consistency of the food as once your baby has lower teeth they can easily bite/pry off a big “chunk” of food that could lead to a choking hazard.

Interestingly, there was a recent study that looked at the incidence of choking in children who started with self feeding vs those fed traditionally with pureed foods from a spoon. In this study of about 200 children between 6 - 8 months of age the incidence of choking was similar, while there were more gagging events in the BLW group.  Fortunately, “the choking events resolved on their own”. Gagging is quite different than choking. Some children will gag on pureed foods just due to texture issues. 

I am an advocate of what I am going to call parent led feeding followed by early self feeding of appropriate foods. By the time a child is 9 months of age they should be able to finger feeding the majority of their meals. But there are some foods that are just not conducive to finger feeding at all….yogurt, apple sauce, puddings…and they will be spoon fed until your child is capable of using a spoon which is anywhere from 12 -18 months.   But as a reminder, whenever you offer your child a finger food you should remember two things, #1 is the piece small enough that my child cannot choke and #2 is the food cooked well enough to not pose a choking hazard.  

Several years ago there was a 1 year old in our practice who was given a piece of an apple to chew on… she bit off a chunk of the apple, aspirated and died. It was a terrible accident.  I will never forget that….and re-iterate to all of my patients…a pork chop, or chicken leg or any number of foods can become a choking hazard if your child bites off a chunk. Children really don’t chew until they are around 2 years, they just bite and try to swallow so I pay a great deal of attention to what foods they are offered.

Old school and new school…the combo seems to make sense to me. 

Your Teen

Overweight Girls Start Periods At Earlier Age

1.45 to read

Early-onset menstruation is linked to later health problems such as breast cancer, said Sarah Keim, a researcher at The Ohio State University College of Medicine in Columbus, who wasn't involved in the new study. Girls who get their period early in life are also more likely to have sex sooner than their peers, Keim added, which increases the risk of teen pregnancy and sexually transmitted diseases.It's nothing new that girls are getting younger and younger when they have their first period, but experts worry that the current obesity epidemic could be fueling that trend.

Overweight or obese girls get their first period months earlier than their normal-weight peers, according to a Danish study. Early-onset menstruation is linked to later health problems such as breast cancer, said Sarah Keim, a researcher at The Ohio State University College of Medicine in Columbus, who wasn't involved in the new study. Girls who get their period early in life are also more likely to have sex sooner than their peers, Keim added, which increases the risk of teen pregnancy and sexually transmitted diseases. About 17 percent of American kids and teens are obese, according to the Centers for Disease Control and Prevention. For the study, researchers used information on body mass index (BMI) -- a measure of weight in relation to height -- and age at first period from about 3,200 Danish girls born between 1984 and 1987. The girls started their period just after they had turned 13, on average, which is about half a year later than in the U.S. Keim said part of the reason for this difference may be that African-Americans tend to start their periods before white girls. On average, a girl got her period about 25 days earlier for every point her BMI increased. For a female of about average height and weight, a one-point change in BMI is equivalent to about six pounds. Overweight and obese girls, for example, got their period three to five months before normal-weight girls, said Anshu Shrestha, a graduate student at UCLA School of Public Health, who worked on the study. There has been past research showing a link between BMI and when girls start menstruating. However, since this study was done more recently, it shows that the link is holding up in today's generation, Keim said. The researchers also found that a girl's mother's weight was related to when her daughter started menstruating, but less so than earlier work had hinted. For every point her mother's BMI when pregnant went up, the girl's period came about a week earlier, according to the new study, which was published in the journal Fertility and Sterility. Keim said the Danish findings reinforce the importance of keeping a healthy weight. "It's important for your entire life, starting from very early on," she told Reuters Health. "And it can even affect your children's health." Talking to your daughter about Menstruation. Most girls begin to menstruate when they're about 12, but periods are possible as early as age 8. That's why explaining menstruation early is so important. But menstruation is an awkward subject to talk about, especially with preteen girls, who are often embarrassed by this discussion. So what's the best way to approach this ticklish topic? If your daughter asks questions about menstruation, answer them openly and honestly. Provide as many details as you think she needs at the time. It's OK to let your daughter set the pace, but don't let her avoid the topic entirely. If she's not asking questions as she approaches the preteen years, it's up to you to start talking about menstruation. Don't plan a single tell-all discussion. Instead, talk about the various issues - from basic hygiene to fear of the unknown - in a series of short conversations. Consider it part of a continuing conversation on how the human body works. Remember, your daughter needs good information about the menstrual cycle and all the other changes that puberty brings. If her friends are her only source of information, she may hear some nonsense and take it for fact. To introduce the subject of menstruation, you might ask your daughter what she knows about puberty. Clarify any misinformation and ask what questions she might have. It may be helpful to time your conversations with the health lessons and sex education your daughter is receiving in school, or you could broach the subject before a routine doctor's appointment. You can tell your daughter that the doctor may ask her whether she's gotten her period yet. Then ask if she has any questions or concerns about menstruation. Girls might prefer to learn about menstruation from a female family member, but sometimes that's not possible. If you're a single father and you're not comfortable talking about menstruation, you might delegate these conversations to a female relative or friend. The key is to make sure the information is relayed somehow. The biology of menstruation is important, but most girls are more interested in practical information about periods. Your daughter may want to know when it's going to happen, what it's going to feel like and what she'll need to do when the time comes. - What is menstruation? Menstruation means a girl's body is physically capable of becoming pregnant. Each month, one of the ovaries releases an egg. This is called ovulation. At the same time, hormonal changes prepare the uterus for pregnancy. If ovulation takes place and the egg isn't fertilized, the lining of the uterus sheds through the vagina. This is a period. - Does it hurt? Many girls have cramps, typically in the lower abdomen, when their periods begin. Cramps can be dull and achy or sharp and intense. Exercise, a heating pad or an over-the-counter pain reliever may help ease any discomfort. - When will it happen? No one can tell exactly when a girl will get her first period. Typically, however, girls begin menstruating about two years after their breasts begin to develop. Many girls experience a thin, white vaginal discharge about one year before menstruation begins. - What should I do? Explain how to use sanitary pads or tampons. Many girls are more comfortable starting with pads, but it's OK to use tampons right away. Remind your daughter that it may take some practice to get used to inserting tampons. Stock the bathroom with various types of sanitary products ahead of time. Encourage your daughter to experiment until she finds the product that works best for her. - What if I'm at school? Encourage your daughter to carry a few pads or tampons in her backpack or purse, just in case. Many school bathrooms have coin-operated dispensers for these products. The school nurse also may have supplies. - Will everyone know that I have my period? Assure your daughter that pads and tampons aren't visible through clothing. No one needs to know that she has her period. - What if blood leaks onto my pants? Offer your daughter practical suggestions for covering up stains until she's able to change clothes, such as tying a sweatshirt around her waist. You might also encourage your daughter to wear dark pants or shorts when she has her period, just in case. Your daughter may worry that she's not normal if she starts having periods before, or after, friends her age do, or if her periods aren't like those of her friends. But menstruation varies with the individual. Some girls have periods that last two days, while others have periods that last more than a week. It can even vary this drastically from month to month in the same girl. The amount of blood lost each month can vary, too, usually from 4 to 12 teaspoons (about 20 to 60 milliliters). It's also common for girls to have irregular periods for the first year or two. Some months might even go by without a period. Once your daughter's cycle settles down, teach her how to track her periods on a calendar. Eventually she may be able to predict when her periods will begin. Schedule a medical checkup for your daughter if: - Her periods last more than seven days - She has menstrual cramps that aren't relieved by over-the-counter medications - She's soaking more pads or tampons than usual - She's missing school or other activities because of painful or heavy periods - She goes three months without a period or suspects she may be pregnant - She hasn't started menstruating by age 15 The changes associated with puberty can be a little scary. Reassure your daughter that it's normal to feel apprehensive about menstruating, but it's nothing to be too worried about and you're there to answer any questions she may have.

Daily Dose

Autism Linked to Testosterone?

New research links autism to testosterone levels in children.I just read an interesting article by Dr. Baron–Cohen who is a professor of developmental psychology and the director of the Autism Research Centre at the University of Cambridge, England.  He is the principle architect of a theory which suggests that autism is linked to in utero exposure of the fetus to very high levels of testosterone.

This interesting hypothesis is that these very high levels of in utero testosterone can lead to extreme masculinization of the brain and the mind of the newborn. In Dr. Baron-Cohen’s words, “autism can be thought of as a case of extreme male brain”.  This seemed fascinating to me, so I continued to read on. According to Dr. Baron-Cohen, the hormone testosterone and the genes that regulate testosterone during fetal development may be part of the link to the cause of autism. Although it is known that autism is likely due to complex and multifactorial issues, Dr. Baron-Cohen has found that fetal testosterone levels are typically twice as high in males as in females, and testosterone levels may vary up to 20 times in male fetuses. Given that the prevalence of autism spectrum conditions is about 1% in the general population, and that classic autism has a male: female ratio of 4:1, and Asperger’s syndrome is 9:1, the increased testosterone levels may be significant. Dr. Baron-Cohen has been conducting an ongoing study looking at 235 developing children whose fetal testosterone levels were known from maternal amniocentesis.  He has followed them for 8 years and had parents rate their children for autistic traits.  He found that the number of autistic traits a child displayed correlated with their fetal testosterone level, regardless of their sex. He also reported that earlier studies done on these children at 12 months of age, showed that those babies with higher testosterone levels were less likely to make eye contact with the mothers, and at age 2 these children had  more limited vocabulary and language development than did those infants with lower fetal testosterone levels. So, many of the hallmarks of autistic spectrum disorders include social and communication difficulties, narrow interests, and extreme need for routine. Many would view these characteristics as being extreme “male” interests and behaviors. Does this in any way relate to those higher fetal testosterone levels?  Are these gender differences due to cultural and social influences?  These are very interesting questions and will need even more study. Dr. Baron–Cohen and other investigators will need to continue to research this very important, yet preliminary hypothesis, to see if they continue to find a correlation between fetal testosterone levels and autistic symptoms.   Any information that brings us closer to solving the puzzle of autism is very exciting.  I look forward to reading further data as it becomes available. That's your daily dose for today.  We'll chat again tomorrow. Send your question or comment to Dr. Sue!

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Daily Dose

Teaching Your Kids About Their Private Parts

Why do parents give their child's private parts nicknames instead of real names? If you have a child who is over the age of 15 months I know that you have played the game  "where’s your nose, where’s your eyes, where’s your ears?” It is a favorite for both parent and child as a toddler learns to point to various body parts. This game is also an important milestone in observing a child process language (receptive speech) and follow a command.  But, what happens after your child has learned the usual body parts?   In other words, what about the rest of their anatomy, specifically their “private parts”.

This topic came to mind the other day while I was seeing a little girl who was complaining of burning and itching with urination.  This is not an uncommon problem in the 3-6 year old little girl set, and part of the physical exam involves looking at the child’s “private parts”. As I begin talking to both the parent and child I always start off with the statement, “I am going to look at your vagina, and it will not hurt”. I also say “no one else should pull your underpants down and touch your vagina. The only people that can touch your vagina are you, your mother or father, and the doctor. These are your private parts, they are covered by your underwear and never let a stranger or even a friend pull down your underpants”. It is important that this age child understand who may or may not pull down their underpants. But, with that being said, it is always amazing to me how many parents say, “we don’t call it a vagina or penis”, and on this occasion the mother said, “Dr. Sue means your bunny hopper!!”  Okay, really? What in the world is a “bunny hopper?”  Why would a parent not name the body parts correctly and where do these names for vagina and penis find their derivation? Over the years I should have kept a list of “secret names” for vagina and penis as I have heard many. From the “princess patch” to “peanut” to “bo-hiney” you name it, there seem to be many parents who either are uncomfortable, or just cannot bring themselves to use the correct word for genitalia. Even Oprah has her word, “va-j-jay”. I submit that we go back to the correct anatomical name. It is so important to teach your children the appropriate words for penis and vagina. Just as they learn eyes, ear, nose, knee, foot, toe they need to know the names of their “private parts”. If you begin with the correct words it never seems awkward or uncomfortable and is no different than naming any other body part. You will be surprised at how easily your child accepts these words, but uses them appropriately too.  It is also important to name body parts correctly, especially if there is ever a question of inappropriate touching or abuse, in order that a child can correctly explain what happened. I still have to laugh when I hear all of the different names a child hears when a parent discusses genitalia, it must be confusing.  But regardless of what you name it, a penis and a vagina are private parts and need to be covered by our underpants, keep repeating that message to your child. What do you think? Would love to hear from you!

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

Babies Rolling Around in Their Crib

Many babies roll around in their crib, but should parents worry they will spend too much time on their tummy and not be able to roll on their back?I received an email from the parents of a 3½ month old daughter who has recently learned how to roll from her back to her tummy.  Their “conundrum”, as they put it, was twofold.  They were concerned about her sleeping on her tummy, as well as the fact that she would get upset after she rolled from her back to tummy and would then “scream loudly” So,what to do?

Most babies learn to roll around 4 months of age and like everything else there is variability in this milestone.  Many babies learn to roll tummy to back first, typically while they are having tummy time. Suddenly you realize that the baby has used their arms to push up and then over onto their back.  Watching them do this is fun, as they will often look up with big startled eyes almost as saying, “Wow, this is like an amusement park ride!”, while other babies will let out a shriek and start to cry as they were scared by the whole event.  Remember we are all different and some of us (me) like roller coasters that go upside down and backwards and others (one of my children) would still rather give up a week’s allowance than get on a ride like that. There are also babies, like the one in question, who learn to roll from their back to tummy first.  This often occurs at night and causes a lot of concern, as all parents hear from the beginning, put your baby “back to sleep”.  But, even when sleep positioners were being used (they are no longer recommended), many an infant would figure out how to roll from their back to get all cozy and sleep on their tummy. Once your baby has achieved this milestone on their own, you cannot keep them from becoming a tummy sleeper. It is important that you still put the baby to bed on their back, but after that your baby will begin to find their own sleep position which many times is at the opposite end of the crib and may be on their tummy. Trying to be a vigilant parent who turns the baby back over is an exercise in futility as they have a mind of their own and will just flip over again, which is not as cute at 3 am. . You do not  need a video monitor or check on your baby every 10 minutes to see if they have rolled during the night.  As an infant has learned to roll it is also assumed that they will turn their head to clear their nose and mouth and the risk of SIDS decreases. Now, in the case of the baby in the email, she loved to flip from back to tummy, but then it would make her upset and she would scream.  Every time the parents went in there and turned her over and settled her again on her back, she would flip over to her tummy again, and the screaming would re-start.  In this case, I think you have to let your baby fuss (scream loudly) for a few minutes to see if they will either roll back over or fall to sleep again. It is so hard to hear your baby so upset, but she got herself in this mess (first of many) and so it is the beginning of figuring out how to handle it. She will either cry or roll, and you can flip a coin to see which comes first. After she has cried for 5 – 10 minutes I would go back in the room, try to soothe her while she is on her tummy (remember she rolled there) and then see if she will calm down and go back to sleep.  This is going to take patience and time and some sleep deprivation (which you had hoped was past I am sure), as she learns to self-console again after rolling over.  The good news is that she has achieved an important developmental milestone with rolling over. Lastly, once your baby is rolling remember never to leave them unattended on the bed, changing table, couch etc.  I call this 4–6 month old a “floor baby” as it is best to leave them on the floor on a blanket while you run to get a diaper or answer the phone etc.  Many a baby, including my own, has rolled right off that bed to the floor, usually without sustaining any injury but causing a lot of parental worry and guilt.  That experience must be like a free fall ride at Six Flags! That's your daily dose for today. We'll chat again tomorrow. Send your question or comment to Dr. Sue!

Daily Dose

Head Flattening on the Rise!

1:30 to read

A recent study published in the online edition of Pediatrics confirms what I see in my practice. According to this study the  incidence of positional plagiocephaly (head flattening) has increased and is now estimated to occur in about 47% of babies between the ages of 7 and 12 weeks.  

The recommendation to have babies change from the tummy sleeping position to back sleeping was made in 1992. Since that time there has been a greater than a 50% decline in the incidence of SIDS. (see old posts).  But both doctors and parents have noticed that infants have sometimes developed flattened or misshapen heads from spending so much time being on their backs during those first few months of life.

This study was conducted in Canada among 440 healthy infants.  In 1999, Canada, like the U.S., began recommending  back sleeping for babies. Canadian doctors had also reported that they were seeing more plagiocephaly among infants.  

The authors found that 205 infants in the study had some form of plagiocephaly, with 78% being classsified as mild, 19% moderate and 3% severe.  Interestingly, there was a greater incidence (63%) of a baby having flattening on the right side of their heads.  

Flattening of the head, either on the back or sides is most often due to the fact that a baby is not getting enough “tummy time”.  Although ALL babies should sleep on their back, there are many opportunities throughout a day for a baby to be prone on a blanket while awake, or to spend time being snuggled upright over a parent’s shoulder or in their arms.  Limiting time spent in a car seat or a bouncy chair will also help prevent flattening.

Most importantly, I tell parents before discharging their baby from the hospital that tummy time needs to begin right away. It does seem that some babies have “in utero” positional preference for head turning and this needs to be addressed early on. Think of a baby being just like us, don’t you like to sleep on one side or another?  By rotating the direction the baby lies in the crib you can help promote head turning and prevent flattening.  

Lastly, most cases of plagiocephaly are reversible. Just put tummy time on your daily new parent  “to do list”.   

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