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Daily Dose

Medicine Dosing Errors

1:30 to read

How do you give your baby/toddler/child their medications? In a recent article in Pediatrics it was found that up to 80 percent of parents have made a dosing error when administering liquid medicine to their children.  The study looked at children eight years old or younger. 

 

In the study both English and Spanish speaking parents were asked to measure different amounts of liquid medicines using different “tools”, including a dosing cup, and different sized syringes. They also were given different instructions with either text only or text with pictures. The different dosing tools were labeled with either milliliters/teaspoon or milliliters only.  Lots of variables! 

 

Not surprising to me, the parents who used the texts/picture combination instructions and who also used the milliliter only labeled dosing tools had the lowest incidence of dosing errors.  When parents had to use any math skills to calculate the correct dosage there were more dosing errors.  Most dosing errors were also overdosing rather than under-dosing the liquid medications.

 

This was an important article not only for parents to realize that it is not uncommon to make an error when giving their child medication, but also for doctors who write the prescriptions.  Before electronic medical records and “e-prescribing” I would typically write medication instructions in milliliters and teaspoons…in other words “take 5ml/1 tsp by mouth once daily”.  With electronic record you can only make one dosing choice which I now do in milliliters. But, with that being said, I still get phone calls from parents asking “how many teaspoons is 7.5 ml?”.

 

Previous studies have also shown numerous dosing errors when parents use kitchen teaspoons and tablespoons to try and measure their child’s medication. 

 

Some over the counter drug makers have tried to cut down on dosing errors with their liquid medications by making all of their products, whether for infants or children, the same strength. The only difference is the dosing tool that accompanies the medicine (syringe vs cup).  Interestingly, these medications may have a price difference when they are actually the same thing.  

 

This study may help to find strategies for comprehensive labeling/dosing for pediatric liquid medications, which will ultimately reduce errors.  Stay tuned for more!

 

 

 

 

 

Daily Dose

National ASK Day!

1:30 to read

Today is all about guns!!!  Unfortunately we seem to  awaken nearly every day to news of gun violence and death in our country.  Firearm-related deaths are the third leading cause of death overall among U.S. children ages 1-17 years, and the second cause of injury-related death, only behind car crashes.  Those are grim statistics.  

 

June 21st, the first day of summer is alway designated as National ASK day…which stands for “Asking Saves Kids”.  This a day to remind me and all pediatricians to ask my patients if they:

 

#1 have a gun in the home?

#2 Is it locked and away from children?

 #3 Is the ammunition stored separately?  

 

A new study being published in the July issue of Pediatrics showed nearly 1,300 children die and 5,790 are treated for gunshot wounds each year. Of those children who die, 53% were due to homicide, 38% were suicide and 6% were unintentional firearm deaths, while 3% were due to “other intent”.   Not surprisingly to me, 82% of all child firearm deaths were in boys. Firearm suicides among children are going up and have increased by 60% since 2007.Sadly, I had a patient who is one of those statistics. 

 

While the politics about gun control continue ….this is not about politics but rather about guns in the home being a threat to children and how to protect our children.  

 

Parents routinely ask other parents about safety before dropping their child off to play or spend the night …”is your pool fenced?”  “do you have a dog and is it friendly?”, “do you let your 8 year old child watch PG-13 movies?”, “how do you handle electronics in the home?”, “do you know my child has food allergies?”, “are you going to be home with the children?”…..the list is long. I think in these times…especially with more and more people buying firearms for their home…it is time to routinely ask about guns in the home!!! 

 

Just one question might save a child’s life!!

 

Daily Dose

Toddler Constipation

1:30 to read

I get so many questions about toddlers and constipation.  Constipation relates to stool frequency and consistency.  It is important to understand that everyone has different bowel habits and not all children will have a stool every day.  While some children will have several stools a day another may have a stool every 2 -3 days. Both of these scenarios may be normal and not an indicator of problem.  At the same time, stool consistency is important. If your child has  hard, dry, pebble like stools ( rocks rather than softer snakes or blobs ) this may be an indicator of constipation. Everyone will occasionally have a hard stool, but this should not occur consistently. Lastly, it should not be painful to pass the stool. While toddlers may grunt or push, or even start to “hide” to poop, it should not cause real pain.

With all of that being said, it is not uncommon for toddlers to become constipated as they often are also becoming picky eaters. Due to this “phase”,  some young children will drink too much milk in place of eating meals and this may lead to constipation. Your toddler should be drinking somewhere between 12 -18 ounces of milk per day.  Many children also load up on other dairy products like cheese, yogurt and cottage cheese, which while healthy, may also lead to too much dairy intake and contribute to constipation.

Water intake is also important to help prevent constipation. If your child is drinking too much milk, substitute some water as well.  It is a balancing act to make sure your child is getting both milk and water. If necessary I will also put the smallest amount of apple or prune juice in the water. By the age of 1 year, your child should no longer have a bottle as their main source of nutrition is no longer in the liquid form!

Fiber is also important so offer plenty of whole grains and limit the “white foods” that toddlers love (yes, the bread, cereal, pasta). If you always buy whole wheat pasta and whole grain breads your children will never know the difference. Stay away from processed white foods whenever possible.  It is also easy to throw flax seed or bran into muffins or smoothies (disguising fiber). I also sometimes use Metamucil cookies (they are pre made) and may even resort to dot of icing smeared on it and offer it as a cookie for snack, along with a big glass of water.

Fruits and veggies are a must…even if you think your child won’t eat them! Your toddler needs 2 servings of fruits and veggies every day and rotate what you offer them.  You will be surprised at how one day they may refuse something and they next they will eat it. Don’t give up on fruits and veggies,  it may literally take years for your child to eat peas…but if they aren’t offered a food repetitively they will probably never it eat. I know a lot may get thrown to the floor but just clean it up and persevere.  Not only will this help their stools but their long term healthy eating habits as well.

Movement is also important to help keep the bowels healthy and “moving”.  Making sure that your toddler is moving seems crazy, as they are on the go all of the time.  But with an older child make sure they are getting plenty of time for play and exercise outside or in…and not just sitting in front of a screen.

Lastly, for short term issues with constipation it is also okay to try using milk of magnesia (MOM) or even Miralax….but ask your doctor about dosing in toddlers.   

Your Teen

Most Parents Don’t Know Their Teen’s Vaccination Status

1:45

Most parents believe that they are on top of their kids’ immunizations, but that may not be true, especially where their teen is concerned.

Data from the Centers for Disease Control and Prevention (CDC) shows that adolescents are not getting all their recommended vaccinations, however, more than 90% of parents believe that their teenager had received all vaccinations necessary for their age, according to a C.S. Mott Children’s Hospital National Poll.

“In the United States, vaccines have long been recommended for babies and at kindergarten entry; more recently, several vaccines have been recommended for the adolescent age group,” Sarah J. Clark, MPHa research scientist from the Institute for Healthcare Policy & Innovation at the University of Michigan, and colleagues wrote. “However, data from the CDC indicate that national vaccination rates are well below public health targets, particularly those that require more than one dose, such as meningitis, human papillomavirus and annual influenza shots.”

The poll focused on vaccination for teenagers between 13 and 17 and included a national sample of parents.

Most parents had reported that their adolescent child had definitely (79%) or probably (14%) had all vaccinations recommended for their age, despite 36% of parents not knowing when their child is due for their next vaccine. The rest believed their child was due for their next vaccine within the next year (19%) or in more than a year (26%). One in five parents believed their teenager needed no more vaccines (19%).

The majority of parents polled relied on information about their child’s upcoming immunizations from their doctor’s office either through an office visit, scheduled appointment or a reminder that was sent. Rarely, would a notice be sent from the school, health plan or the public health department. A large number were not aware of how to be notified about upcoming vaccinations. 

"Parents rely on child health providers to guide them on vaccines in childhood and during the teen years,” Clark said in a press release. “Given the general lack of awareness about adolescent vaccines shown in this poll, there is a clear need for providers to be more proactive for their teen patients.”

Parents can be more proactive in finding out about their teens and younger children’s immunization requirements by checking their child’s school website or calling the school. The CDC also has a website with vaccination recommendations for children of all ages, including college students at https://www.cdc.gov/vaccines/schedules/index.html

The 2017-2018 school year will be here before you know it. Many schools will start up again in mid to late August. Do yourself and your child a huge favor by getting their immunizations up-to-date before the last minute rush!

Story source: https://www.healio.com/pediatrics/vaccine-preventable-diseases/news/online/%7Be6c9d80d-86d4-48a7-9090-b1e489e6db56%7D/majority-of-parents-unaware-of-teens-incomplete-vaccination-status

Daily Dose

What New Babies Need

1:30 to read

I have many friends whose own children are now having babies and they always ask, “what all do we need to have/buy for a new baby these days?”  While many things have changed since I had my own children, many have not,  and I still think “less is more” is a good adage to follow, especially for a newborn.  We all have a tendency to buy too much, or the “latest and greatest” only to find out that it is not necessary.

Carseat - a rear facing car seat is a must for your newborn!!!  Look at all of the reviews on line and pick which seat works best for you.  Do you want one with a base that you can also clip on to a stroller?  Remember your baby will sit in a rear facing car seat until 2 years. This is one item I would spend my money on!!

The baby needs a place to sleep so buy a crib and a good mattress.  If you are going to have more than one baby I would buy something that will last through several children. I like having a crib (rather than a toddler bed), as your baby will be in the crib for several years and then can move to a regular bed…no need for an “in between”.  Do not use an “old” crib that has drop sides, due to safety concerns. So that means the one that I had kept in the garage (from my kids) was a throw away! I usually move the first child to a bed when I need the crib for the next baby…no specific age. Bumpers are no longer recommended, so that saves money too!

Changing table or dresser for the millions of diaper changes.  It is so helpful to not have to bend over each time. I would also buy a diaper cream (Dr. Smiths, Destin or Butt paste) to have on hand….your baby will probably get a diaper rash at some time during their time in a diaper.

Baby bath tub: while you can bathe your baby in the sink, the newer bathtubs do make it easier for a newborn and you can use it in the tub as well until your baby can sit up alone. Remember, you will NEVER leave your child in the tub alone…even with all of the seats, rings and things  that they sell to support your baby!!  For bathing I like gentle bath wash like Cetaphil, Cerave, and Eucerin products….good for all skin types.  Pick one!

Swaddle blankets: WOW there are a million on the market and they all “claim” to help your baby to sleep better. I don’t think any of the products say “it will also takes weeks to months for your baby to sleep through the night” , no matter what you use.  I do like the thin swaddle blankets as they are useful for a number of things besides swaddling. Once you have your baby have the nurses show you how to swaddle (quick and easy).  The Miracle Blanket, Woombie and Halo also make it easy to swaddle as well. Pick one (or two) and stick with that.  Remember, your baby is going to be put in their crib on their back whether swaddled or not!! NO TUMMY SLEEPING.  

Diaper Bag: again their are a million out there in all shapes, sizes and price points. In the beginning you need to have a pad for changing (you will end up changing that baby all sorts of weird places), diapers, burp clothes, wipes…as your baby gets bigger you will have bottles, cups, toys all shoved in there too. All of my patients seem to have a travel size Purell strapped to the side of the bag as well. I would get a bag that you can wipe out as there will be spills of all sorts of stuff in that bag I assure you!  Somehow, over time you go back to “less is more” and the diapers end up in your purse!!  

So…that is a start. Will do another post on some other products in the future. 

 

 

Your Child

Kids & Lawn Mower Injuries

2:00

It’s lawn-mowing season again and a recent study urges parents to make sure that their children are not part of the seasonal ritual.

The Center for Injury Research and Policy at Nationwide Children’s Hospital found that 4800 children a year go the emergency room to be treated for a lawn mower related injury. On an average, that turns out to be about 13 kids a day.

The good news is that many parents and grandparents are getting the message about lawn mower safety. There has been a decrease in lawn mower injuries suffered by children in the last two decades.  However, this cause for serious injuries is still a concern.

The way children are injured by lawn mowers varies by age. Children younger than five years are more likely than older children to be injured from touching a hot surface, from a “back-over” injury, or as a bystander or passenger. Children age 5-17 years were more likely than younger children to be struck by or cut by the lawn mower or a projectile.

The researchers suggest that to help prevent back-over injuries, which are often the most devastating lawn mower injuries to young children, every ride-on mower should be equipped with a no-mow-in-reverse mechanism with the over-ride switch for this feature located behind the operator’s seat, which forces the person operating the ride-on mower to look behind them before backing up with the blades engaged.

“While we are happy to see that the number of lawn mower-related injuries has declined over the years, it is important for families to realize that these injuries still occur frequently during warm weather months,” said Gary Smith, MD, DrPH, senior author of the study and director of the Center for Injury Research and Policy at Nationwide Children’s Hospital. “Improvements in lawn mower design during the last few decades are likely an important contributing factor in the decrease in injuries. We would like to see manufacturers continue to improve design and include additional needed safety features on all mowers.”

Injury prevention experts recommend these rules to help prevent mower-related injuries to children and adults:

  • Teach and supervise teens. Children should be at least 12 years old to operate a push mower and at least 16 years old before using a ride-on mower. An adult should supervise teens before they are allowed to operate a lawn mower on their own.
  • Kid-free zone. Children should never be passengers on ride-on mowers and children younger than 6 years of age should be kept indoors during mowing. Never let children play on or near a lawn mower, even when it is not in use.
  • Before you mow. Pick up any stones or other objects in the grass. Objects thrown by a lawn mower can cause severe eye and other injuries. Put on protective eyewear and make sure you are wearing sturdy shoes. 
  • While you mow. When using a walk-behind lawn mower, use a mower with a control that stops it from moving forward if the handle is released. Always mow going forward. If you absolutely have to mow in reverse, always look behind you before you start backing up.
  • Turn it off. Wait for the blades to stop completely before removing the grass catcher, unclogging the discharge chute, or crossing gravel roads. 

The study was published in the American Journal of Emergency Medicine.

Story source: http://www.nationwidechildrens.org/news-room-articles/lawn-mower-injuries-send-13-children-to-the-emergency-department-every-day?contentid=163616

Parenting

Bedwetting Causes and Coping Tips

2:00

Most children will go through a bedwetting stage and though some kids get through it rather quickly, others take longer before they have consistently dry nights.

Bedwetting can also be a symptom of an underlying disease, but not typically. In fact, an underlying condition is identified in only about 1% of children who routinely wet the bed.

Bedwetting is not only difficult for the child, but it can strain a parent’s patience as well. It’s important to remember that a child that wets the bed doesn’t do it intentionally. Children who wet are not lazy, willful, or disobedient. Bedwetting is most often a developmental issue.

Did you know that there are 2 types of bedwetting? They are called primary and secondary. A child with primary bedwetting has episodes of bedwetting on a consistent basis. Secondary bedwetting is bedwetting that starts up after the child has been dry at night for a significant period of time, at least 6 months.

So, what causes primary bedwetting? It’s usually a combination of factors:

  • The child cannot yet hold urine for the entire night.
  • The child does not waken when his or her bladder is full.
  • The child produces a large amount of urine during the evening and night hours.
  • The child habitually ignores the urge to urinate and put off urinating as long as they possibly can. Parents usually are familiar with the leg crossing, face straining, squirming, squatting, and groin holding that children use to hold back urine.

Secondary bedwetting may occur because of an underlying or known medical condition or emotional problems. The child with secondary bedwetting is much more likely to have other symptoms, such as daytime wetting.  Reasons for secondary bedwetting can include:

  • Urinary tract infection: The resulting bladder irritation can cause severe pain or irritation with urination, a stronger urge to urinate, and frequent urination. Urinary tract infections in children may indicate another problem, such as an anatomical abnormality.
  • Diabetes: People with diabetes have a high level of sugar in their blood. The body increases urine output to try to get rid of the sugar. Having to urinate frequently is a common symptom of diabetes.
  • Structural or anatomical abnormality: An abnormality in the organs, muscles, or nerves involved in urination can cause incontinence or other urinary problems that could show up as bedwetting.
  • Neurological problems: Abnormalities in the nervous system, or injury or disease of the nervous system, can upset the delicate neurological balance that controls urination.
  • Emotional problems: A stressful home life, as in a home where the parents are in conflict, sometimes causes children to wet the bed. Major changes, such as starting school, a new baby, or moving to a new home, are other stresses that can also cause bedwetting. Children who are being physically or sexually abused sometimes begin bedwetting.

If your child suddenly begins to wet the bed after months or years of dry nights, talk to your child about it and your pediatrician. Your doctor may want to do an examination and bloodwork to rule out any health conditions. 

Most children do not stay dry at night until about the age of three.  And it's usually not a concern for parents until around age 6.

Bedwetting can be embarrassing for children. Be supportive and reassure your child that they won’t always wet the bed. Bedwetting often runs in families. If you want to share your own personal story, your child may see that people do outgrow it.

To help your child make it through the night dry, make sure he or she isn’t drinking a lot of liquids before bedtime. Make using the bathroom just before they get in bed part of a bedtime routine. Also remind them that it's OK to get up during the night to use the bathroom. Nightlights can help your child find his or her own way when they need to go.

Some parents wonder if they should wake their child up during the night to go. That’s a personal choice, however, keep in mind that if you deprive your child of rest and sleep, you may increase his or her level of stress. Stress can be a bedwetting trigger. Some children may also have a difficult time getting back to sleep once woken.

If your child wets the bed, you might consider getting a plastic bed cover to help protect the mattress.

If accidents do happen, try these tips to remove the smell and stains from linens, clothes and the mattress.

  • Try adding a half-cup to a cup of white vinegar to your wash to remove the smell from their sheets and clothes.
  • If you need to clean urine from a mattress, first use towels to blot up as much as you can.
  • Once you've blotted up as much of the urine as you can, saturate the entire area of urine stain with hydrogen peroxide. Let it stand for 5 minutes, and then use towels again to blot the area dry.
  • Once the mattress is dry, sprinkle baking soda over the entire area and let it stand for 24 hours. The next day, vacuum the baking soda away. It should be clean and odor free.

Bedwetting is one of those stages that kids go through that some day will just be a memory. Until then, reassure your little one that this too shall pass. Praise your child when they make it through the night without wetting the bed and let them know that if an accident happens, it’s OK – we’ll try again tonight.

Story sources: http://www.webmd.com/sleep-disorders/guide/bedwetting-causes#2

http://www.webmd.com/parenting/ss/slideshow-bedwetting

 

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Potty Training

Potty Training

Daily Dose

Bug Bites

1:30 to read

It is the time of year for bugs and bites and I see a lot of kids with bites coming into my office.  Parents want to know “what kind of bite it is?” and in most of the kids I see, they are having a reaction to a mosquito bite. Parents are extremely concerned that the reaction may be abnormal and lead to breathing issues or that the bite it is infected. For some reason, baby and toddler skin just seems to swell more - that is not science but my observation…maybe because they are “yummier”?  At any rate, the best way to avoid “the mystery bite” is by using insect repellent.

 

The AAP recommends that children be protected from mosquitoes as they may not only cause discomfort and itching, but may cause several viral illnesses including West Nile, Zika and Chikungunya. Insect repellents will also prevent ticks, some of which may transmit Lyme Disease.  

 

Both the AAP and CDC recommend the use of DEET containing repellents for children 2 months of age and older. For young infants it is often easy to protect them from bites by using mosquito netting over their stroller or carseat when they are outdoors.  Once your child is older and hard to “contain” beneath mosquito netting you may use a DEET containing repellent and start with the lowest concentration - you will need to read the labels on each product.  The protection and effectiveness for DEET products of different concentrations is similar, but a higher concentration provides a longer duration of protection. Picardin has also been approved for use in concentrations of 5-10 %. The higher the concentration the longer the duration of protection as well.  So choose accordingly. I often have several products at our house and decide which to use based on the length of time we are enjoying the backyard, age of child or adult and method which I want to use to apply (spray, lotion, wipes).

 

You do not want to choose a product that contains both sunscreen and an insect repellent. Sunscreen should be applied about every 2 hours and bug spray should be applied far less frequently. I recommend applying the insect repellent with my hands rather than trying to spray a young child who is a moving target. I even put the bug spray on those precious bald baby heads (if over 2 months).  It is also important to wash the insect repellent off at the end of the day - bath time for all!

 

It is also important to dress appropriately if you are going outdoors. When possible dress your child in long sleeves, pants and even socks which will prevent bites. Avoid brightly colored and flowery clothes (may be boring), as these too attract insects.

 

It is also especially important to remove standing water around your house and yard. After a rain or watering check any standing water and empty any residual water from buckets, candles, bird baths or empty pots. Standing water is an easy breeding ground for mosquito larvae.  The type of mosquito that carries Zika also prefers to be close to houses…so it is really important drain standing water near your house. 

 

Enjoy the summer and don’t be afraid of bug sprays in children if you use them appropriately, as prevention is always preferable!

 

 

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DR SUE'S DAILY DOSE

How do you measure your child's medicine?

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