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Daily Dose

A Baby's Neck Issue

1:30 to read

Torticollis is becoming more and more common and it may be related to several different things. Torticollis is defined as a “twisted neck”, or as my grandmother used to say, a “wry neck”.  Most of us have experienced a tight neck after a bad night’s sleep, and you can hardly turn your head to back out of the garage it is so painful, but be reassured your baby does not have any discomfort, but will just hold their head somewhat “tilted”.

A baby’s 40 weeks spent in utero may cause some positional deformities of the head and neck.  Due to the intrauterine positioning a baby may “favor” turning their head to one side rather than another. At the same time back sleeping which is recommended for all babies, may also contribute to torticollis.  

In order to help the baby resolve the tightness in the neck which is actually due to the sternocleidomastoid muscle being tight, your doctor may have you do several things early on to help stretch the neck muscle.  

If your baby prefers to look to the right they have left sided torticollis. In this case turn your baby in the crib so they have to turn to the left to look out (they don’t want to face a boring wall). When you are feeding them have the bottle on your right arm. When changing diapers, place the baby so that they have to tur left to see you.  Hold the baby on your left hip as well and burp them on your right shoulder. All of these strategies will help to stretch the muscle.  On top of this the baby needs to have tummy time, when awake, and work of having them turn to the left during this time too. Lastly, do gentle neck stretches 3-4 times a day and massage the tight muscle.  

If your baby prefers to look to the left also called right sided torticollis, reverse the above.

Your baby should continue to work on stretching so that their head will also not get flattened on one side or another, which is called plagiocephaly.  By continuing to have tummy time and neck stretches, most cases of torticollis will resolve. In severe cases or when you don’t feel that the baby is improving,  ask you doctor about the possibility of physical therapy.

Daily Dose

When Is The Best Time To Potty Train?

1:30 to read

Every parent wants to know, when is my child ready to potty train? A study that was recently published  in an issue of the Journal of Pediatric Urology is one of the first to show that timing of potty training children seems to be more important than the technique.

I found this quite interesting as the lead author, Dr. Joseph Barone stated, this is the first study “that gives parents an idea of when it’s a good time to toilet-train”.  The best time to potty train has typically been thought to be somewhere between the second and third birthday, but that is a wide range. This study suggests that age 27-32 months is the appropriate time to move a child out of diapers. In the study, children who were toilet trained after 32 months  were more likely to have urge incontinence, and problems with daytime wetting and bedwetting when they were between the ages of 4 and 12 years. This data was gathered from a retrospective study of children who were being seen by pediatric urologists for problems with urge incontinence (daytime wetting episodes) and their answers to a questionnaire on when they started potty training and what method they used, was compared with children who did not have urge incontinence.  The results showed that the mean age for  children with the wetting problems to have been trained was 31.7 months while those children who did not have problems were toilet trained at 28.7 months. 

Potty training continues to be at the top of the question list for parents with toddlers. I still believe and this study tends to support that children who are potty trained younger seem to have “less issues” than those that are older. That is not meant to say that your child will be potty trained by 28.7 months, but in most cases if you begin discussing the potty and following a child’s cues and follow through with reinforcement and consistency that the majority of toddlers may be potty trained by age 2 ½  (which would be 30 months). In my experience as both a mother and pediatrician, those toddlers who are put in pull ups and never asked about going to the potty or are not taken to the potty seem to be the ones that I see at 3 year old check ups still wearing their pull-ups. By this time if you ask them if they want to go potty they all say, “NO”.  I believe this is termed “the child directed approach” which seems analogous to me as saying “what time do you want to go to bed?”

In most cases, if a toddler is introduced to the toilet, goes with their parent to “sit or practice or watch Mommy and Daddy potty” during the early 2’s, and given some incentive to perform, whether that be a sticker or M & M or both,  they will become interested in the potty and then they will become ready to potty train. I guess this is a combination of both the parent directed and child directed approach. Once you see your child is interested you have to “go for it” and put them in good ‘ole cotton training pants and go to the bathroom frequently. You can’t ask if they want to go, again it is a statement, “time to go potty” and most will be trained by the “magical” 27-32 months of age. To me potty training is somewhat like a space shuttle launch. “The window is not that wide” and you have to potty train during that magical window or the launch window may not come around again for a long time!

That's your daily dose. We'll chat again soon.

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. 

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

Rice Cereal & Childhood Obesity

Does white rice cereal cause childhood obesity? One pediatrician thinks so.I recently saw Dr. Alan Greene on TV discussing infant feeding practices and how that may relate to the problem of childhood obesity. Dr. Greene, like most pediatricians, has long been a proponent of healthy eating. He recently launched his “White Out” campaign to change how babies are introduced to solid foods.

His argument is that an infant’s first food has long been rice cereal.   Rice cereal is typically introduced to a baby between 5 – 6 months of age when they are just beginning to sit up in a high chair, and may be fed with a spoon. Rice cereal  typically comes in a box and breast milk or formula is added to the dried flakes in order to make it the consistency where the  baby may be  offered a few bites from a spoon. Although rice is a “white grain” there are also other infant cereal products available, and there are no “directives” that say that a brown rice or mixed grain cereal may not  be used. As I understand it, the whole idea is really just to get the baby used to spoon feeding and then I begin introducing my infant patients to vegetables and fruits. So, the idea that the baby rice cereal is somehow linked to the entire problem of childhood obesity seems somewhat shortsighted to me. An infant is only fed rice cereal one or two times a day while still receiving either breast milk or a formula. Remember that breast milk and formulas contain carbohydrates too. Infant cereal whether it be brown or white rice should not be the only food a baby is introduced too, nor should they eat cereal all day long. While Dr. Greene is concerned that babies will “get hooked on the taste of highly processed foods”, I'm more concerned that parents will quickly forgo rice and whole grain cereals, fruits, veggies and meats and begin feeding their children frosted or honey nut cheerios (a favorite early finger food),  as wells as goldfish and puffs, pasta and other white foods.  These are the foods I  am most likely to see in my office, not a bowl fruits and vegetables. Babies really get the  majority of their calories from breast milk or formula until about 9 – 12 months of age. Parents should be encouraged to feed their babies a wide array of healthy foods including cereals, vegetables, fruits and meats.  Dr. Greene is right,  a baby doesn’t tell you he won’t eat brown rice, or oatmeal or spinach or prunes. For the most part an infant happily opens their mouths and will take what is fed to them. The problem occurs a little later as babies start to show a preference for foods , whether that is by making a face, or pushing food away, they definitely show preferences. This is when the idea of getting “hooked on foods” really begins. It is not uncommon for me to hear a parent of a one year old say, “my baby doesn’t like…… squash, or cereal, or peaches.”  Soon thereafter you hear, “my toddler will only eat…..fill in the blank”. Those are the words that send shivers down my spine. Trying to get those parents to buy into the fix the meal and they will eat it if they are hungry is quite a difficult concept at times. The issue is not only beginning a baby on rice cereal, the problem is more complex. It is getting parents to understand that our children will always have food preferences, that does not mean that we need to acknowledge them or submit to them. It means that we need to make good healthy meals for our families, white rice or brown rice is only the beginning of the story. That's your daily dose for today. What do you think? Leave your comments below!

Daily Dose

Anemia

1:30 to read

Adolescent females are at greater risk for anemia than adolescent boys. This may due to several reasons including the fact that adolescent girls lose blood each month during their menstrual cycles and many teenage girls eat less red meat than adolescent boys.  

 

While some adolescents with anemia (low hemoglobin and hematocrit) complain of headaches, irritability or fatigue (which are very common teenage complaints), others are completely asymptomatic.  It is recommended that teens have a screening complete blood count around the age of 13 and then every 5 years or so thereafter. At the same time, the AAP recommends more frequent blood counts in those with risk factors for anemia, including diets low in iron rich foods (meat, eggs, fortified cereals) teens who have significant physical activity (especially female adolescent athletes) those with vegetarian or vegan diets and for any adolescent girl with excessive menstrual bleeding. Obese teens also have a higher incidence of anemia and should be screened. This list includes many of my patients.

 

Interestingly, you can have low iron stores without yet being anemic.  I have now started looking at the serum ferritin levels in teens with risk factors for anemia, as I am finding that some of my athletic patients have low ferritin levels, with a normal blood count. Some recent studies have shown that low ferritin may impact athletic performance including fatiguability. While fatigue during exercise is a subjective symptom,  maintaining iron stores is important for overall health.

Lastly, iron deficiency may impact cognitive function in adolescents. There have been several studies showing that girls who had higher serum ferritin levels had statistically significant improvement on cognitive tests of verbal learning and memory…so it may be worth looking at levels in a teen who is suddenly having difficulty in school, without previous issues. One blood test!

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Daily Dose

Breath-holding & Fainting

2.00 to read

Have you ever fainted?  I bet you may have not realized how common fainting is in the pediatric age group?  I know this from my own children (yes, I had 2 “fainters” and boys no less) as well as from many of my patients.

The medical term for fainting is syncope, and it really is common among children. It starts during the toddler years with breath-holding spells.  Many in this age group (up to 50%) will hold their breath when they are hurt or angry.

When a child holds their breath while crying (you can just see it happening in front of you) they will often turn a bit blue and “pass out”. This is a type of fainting. This can be very scary for parents who have never seen their precious child have such an attitude and then hold their breath over not getting the cookie? Yes, this is a normal part of being a toddler! They are very emotional and labile at this age (foreshadowing for teen years?) and most toddlers don’t have a lot of language yet, so when they get mad or frustrated they just SCREAM! But, while screaming, the child forgets to take a breath, and then the brain and autonomic nervous system takes over and the breath holding leads to fainting.

The breath holding spell, as scary as it is, is just a form of fainting. It will not hurt your child, but it may take your breath away!

My advice? Try not to pay attention to your child if they begin having breath-holding spells. It may be hard to “ignore” the first two or three, but these “spells” usually last for months (maybe years) and you do not need to rush to your child when they hold their breath. By calling attention to the event you may inadvertently reinforce the behavior. As a child gets older, the breath holding will stop (but not the tantrums?) and there will be new behaviors to conquer. Do you have a breath-holder? How do you cope? Let us know!

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

Daily Dose

Breaking Bad Habits

1:15 to read

Do any of your children bite their nails or suck their thumbs? If so, are you always saying, “take your fingers out of your mouth, they are dirty”, or “if you keep biting your nails you will get sick due to all of those germs on your fingers”!  I was guilty of saying those very things to my own children, and I also remember being a nail biter and my mother saying the same thing to me.

Well, who would have thought that a study just released today in the journal Pediatrics might make us parents eat our own words (it wouldn’t be the first time).  The study, “Thumb-Sucking, Nail-Biting and Atopic Sensitization, Asthma and Hay Fever” suggests that “childhood exposure to microbial organisms reduces the risk of developing allergies”.  Who knew that there might be something so positive coming from a “bad habit”.  

This study was done in New Zealand and followed over 1,000 children born between 1972-1973 (dark ages) whose parents reported that they either bit their nails or sucked their thumbs at 5,7,9 and 11 years old. The participants were then checked at ages 13 and again at 32 years old to look for an allergic reaction ( by skin prick testing) against at least one common allergen.  And guess what…at 13 years of age the prevalence of an allergic reaction was lower among those children who HAD sucked their thumbs or bitten their nails.  Incredibly the the findings persisted almost 20 years later!  This study even looked at cofounding factors including sex, parental history of allergies, pet ownership, breast feeding and parental smoking… none of which played a role. 

So, while not advocating for children to suck their thumbs or bite their nails (which unfortunately I did until high school when I decided to have nails to polish) there may be a silver lining….a protective effect against allergies that persists into adulthood. 

Lemonade out of lemons!!!

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Potty training can be tricky.

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