Monday, December 5, 2016

Things you always knew that are not quite true

There are several tidbits of wisdom that have been handed down from grandmothers and grandfathers alike that are not backed up by science. 

Read Dr. Smitty's blog post to see if you have been guilty of saying any of them:
Winter Old Wives' Tales

Sunday, October 30, 2016

New Screen Time Guidelines have been released

In the ever changing world of electronics, it is hard for research to keep up and thus hard for groups that make recommendations to keep up.  However the American Academy of Pediatrics is doing their best and have updated their recommendations. 

Doc Smitty from Cook Children's has summarized them into 11 useful facts to guide us.

11 facts about screen time rules

Sunday, October 16, 2016

Time to get rid of your anti-bacterial soaps!

There has been an underlying focus on eliminating unnecessary antibiotics from our environment to prevent the development of "superbugs".  Most of the attention has been towards careful prescribing of antibiotics only when needed.  However, recently the FDA has taken steps towards eliminating antibiotics in household ingredients including soap. 

what to know about antibacterial soap

Thursday, September 8, 2016

Today's vaccines are safer then then the ones you got as a child parents!

The American Academy of Pediatrics (the professional society for pediatricians) has been emphasizing vaccines and what pediatricians can do to reassure parents about them. 

I have had families in our practice request a modified shot schedule due to concerns that their children will get too many shots too soon.  While I would rather do a modified schedule than not give the vaccines at all, the safest and most tested shot schedule is the official CDC one. 

I was lead to a great blog post discussing how vaccines today are so much simpler and safer than the ones we had when we were growing up.  Take a read.  Maybe it will reassure you that it is not only ok but best to follow the recommended shot schedule.

vaccines 101 too much too soon

Thursday, September 1, 2016

Saturday, August 20, 2016

Breastfeeding schedules

I will admit that breastfeeding is something that I do not know as much about as I wish I did.  Thankfully, I have some great help from the lactation consultants at our local hospital when my moms need it.  This week, I'd like to share a blog post about a common breast feeding myth: The essential 3 hour feeding interval.

Infant feeding intervals

Tuesday, August 9, 2016

Essential Oils in Pediatrics

  • A fellow Pediatrician I greatly respect compiled his meta-analysis of essential oils in the pediatric population:
http://www.checkupnewsroom.com/essential-oils-and-their-use-on-children
http://www.checkupnewsroom.com/essential-oils-and-children---more-questions-answered/
http://www.checkupnewsroom.com/how-safe-are-essential-oils/

  • Here is a chart of essential oils to avoid in children that I borrowed from our Pediatric pharmacy newsletter.  
< 2 yrs
Basil
Benzoin
Black Seed
Cassia
Clove
Garlic
Ginger Lily
Hyssop
Lemon Leaf
Lemongrass
Massoia
May Chang
Melissa/
Lemon Balm
Myrtle honey
Myrtle (lemon)/Sweet- Verbana
Oakmoss
Opopanax
Oregano
Peru Balsam
Saffron
Sage (Wild- Mountain)
Savory
Styrax
Tea Leaf
Tea Tree
Treemoss
Tuberose
Turpentine
Verbena
Ylang-Ylang
< 5 yrs
Anise/Aniseed
Fennel
Myrtel aniseed

< 6 yrs
Cajuput
Cardamon
Cornmint
Galangal
Ho Leaf/Ravintsara
Laurel Leaf/Bay- Laurel
Marjoram
Myrtle red
Niaouli
Peppermint
Rambiazana
Rosemary
Sage (Greek)
Sage (White)
Sanna
Saro
< 10 yrs
Eucalyptus



All Children
Birch
Chaste Tree
Wintergreen


  • In addition to these, the endocrinologists at Cooks recommend avoiding Lavender due to concerns for prepubertal gynecomastia in boys. (breast growth)
  • FYI: Thieves blend contains eucalyptus and so should not be used in children <10.   
Edris AE.  Pharmaceutical and therapeutic potentials of essential oils and their individual volatile constituents: a review.  Phytother Res. 2007;21 (4): 308-323.
 Tisserand R, Young R. Essential Oil Safety: A guide for Health Care Professionals. 2nd ed. London, England: Churchill Livingstone; 2014'

No water for babies

Summer heat is not over yet and it is important that everyone drinks plenty of water. Everyone but babies that is! See below for why.
http://www.checkupnewsroom.com/the-deadly–reason-you-should-never-give-your-baby-extra-water/

Can there be too many vaccines?

Here is a nice series of blog posts about vaccines:

Vaccine additives: vaccines-dissected-part-1

How can our little ones handle so many vaccines at once:  vaccines-dissected-part-2

What about vaccine side effects: vaccines-dissected-part-3

Carseat Tips

Carseat Tips

For such a basic piece of safety equipment, car seats can be complicated to install and use correctly.  Check out this link for a list of common mistakes parents make.

10 Common Carseat Mistakes

What apps are your teens using?

What apps are your teens using?

http://www.checkupnewsroom.com/7-dangerous-apps-that-parents-need-to-know-about/
Parents take a look at this list of apps. Even if you don’t know about them, your kids likely do!

For the parents of extreme picky eaters

This post is for those of you saying,  "Your last post was great and all, but if you knew my kid, you would know that those tricks won't work!" 

Checkout this podcast (transcript below):
http://www.medscape.com/viewarticle/848035
and then remember
  1. Establish good mealtime hygiene so that your kids come to the table hungry.
    1. (you are not supposed to be mobile vending machines)
  2. Trying something new at least 8-15 times will lead to acceptance of a new food.
  3. It is just fine to reward your child to eat or punish them for not eating
  4. This is a years-long project
Hang in there!

Sort of an ARFID-y Kid

I am Dr Katherine Dahlsgaard. I am lead psychologist of the Anxiety Behaviors Clinic in the Department of Child and Adolescent Psychiatry and Behavioral Sciences at the Children's Hospital of Philadelphia. I am here today to talk to you about the scourge of our age—extremely picky eating—those patients of yours who eat a total of four foods and have driven their parents crazy. These are not the toddlers who are going through the "ew" phase, but those 8- to 12-year-olds who are so picky that it is causing true functional impairment.
I often refer to this as "selective eating disorder." The technical term is avoidant/restrictive food intake disorder (ARFID). ARFID came of age with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In the DSM-IV, if a child had extreme picky eating or selective eating disorder such that it was causing functional impairment, you had to diagnose the child with "eating disorder not otherwise specified"—not that they had anorexia or bulimia, but that they had disordered eating. Now we have a word for it, and the adjective is "ARFID-y," as in "He is sort of an AFRID-y kid."

Blame the Food Culture

Why should we care about ARFID? The first reason is because of the prevalence. I called it the "scourge of our age." ARFID is increasing in rate and prevalence in every single Western country that is keeping data. We don't know why, but it has something to do with our food culture—our national eating disorder. We are a culture that has never known as much plenty in terms of food and yet the rates of food sensitivities, dietary restrictions, interest in food, and funny rules about food seem to be increasing among adults, so it shouldn't surprise us that we are seeing more ARFID among children.
The second reason why we should care about ARFID is that it is medically compromising. These children typically eat only four foods, and usually it is carbohydrates: foods such as chicken nuggets, buttered noodles, plain bagels, and macaroni and cheese. These children eat foods that are like a bride's dress, in shades of ivory, white, or beige. The problem is that they might be getting enough calories to be of normal or even above average weight, although many of the children that I work with are quite thin and underweight. They are often medically compromised. Eating only carbohydrates and sugars is a good way to be malnourished.

Picky Eating: Myths and Misery

These children don't have sensory sensitivities. Many parents and healthcare professionals think that the reason they are selective is because of sensory sensitivities: They just can't tolerate the chewiness of meat; they just can't tolerate the crispness of vegetables. However, these kids will typically eat any kind of simple carbohydrate or junk food. They tolerate the crispness of potato chips and Doritos® and the chewiness of candy, so it really isn't sensory sensitivity.
Another reason to care about ARFID is that many children don't outgrow it. People think that if they just leave it alone, these kids will grow out of it. The research says that a significant minority do not outgrow it and become that man or woman who goes to dinner at someone's house and annoys everyone.The final reason that we should care about ARFID is the misery that it causes the family. I treat many extremely anxious kids who are incredibly compromised by their anxiety, and it has taken over the whole family. It pales in comparison to the misery caused by selective eating disorder. Every meal is a battle. Parents feel like terrible parents. Vacations are messed up because they can't find a McDonald's in Italy. When they finally find one, it is 90 minutes away and the McNuggets don't taste the same as they do in the United States, and the child is falling over with hunger. It is very tough on families and kids.

What to Do: Mealtime Hygiene

What should you do about it as a physician? The first thing I suggest is that you don't "pooh-pooh" it. That is the number-one complaint I get from the families of picky eaters: They went to the pediatrician and she said, "Eh, he will grow out of it." Many of these children will grow out of it, but the parents could really use some quick advice from you.
I suggest the following advice. First, insist that parents have good mealtime hygiene. Children have become snackers and grazers and moms have become vending machines with their large purses. Even Home Depot sells candy in the checkout aisles. Children are snacking and grazing all day and they don't come to the table hungry. Parents also truly don't know that they are allowed to let their children be hungry until mealtimes and that children will eat much better if they are hungry. Let parents know that children should eat three square meals and maybe two or three snacks a day, and that there should be at least 2 hours between a snack and a meal or between meals. Many of the families of picky eaters forego snacks entirely so that their children sit down very hungry to eat. They send me emails, raving that cutting out snacks was the best thing they have ever done for their families.

Palate-Expanding Exposure

You should also suggest to parents that exposure works to help their children accept new foods. By exposure, I mean putting the food in front of the child and insisting that the child chew it and swallow it, not just having in on the plate or on the table, but actually chewing and swallowing the food. Parents are loath to insist on this for various reasons. They are afraid that their child will develop an eating disorder if there are rules about eating. I tell parents—and they find this extremely helpful—that we make children do things that they don't want to do all the time. It's called being a good parent. We make them go to bed and we make them wear their seatbelt because we know better than they do. Food is the same thing. We know better that if you keep trying something you will eventually like it.
The other thing you should tell parents about exposure is that it is okay to insist that the child chews and swallows a food even if he or she doesn't like it. The number of times that a food must be chewed, tasted, and swallowed before it will be accepted is eight to 15. The average parent puts the food in front of the child, and if the child rejects it three to five times, the parent tends to give up. Tell parents about the eight to 15 times minimum. Also let them know that their child does not have to like the food. The child just needs to be able to tolerate it. Eventually, with enough exposure, the child will come to like the food because that is the way our brains work. They need to keep exposing the child to food and expecting the child to eat it because the child's palate will expand. Even if the child doesn't grow to like the food, he or she will tolerate eating it without complaint.

Busting Bigger Myths: Reward and Punishment

You can also let parents know that they are well within their rights as parents to use contingency management procedures to encourage kids to eat these foods. In other words, parents are allowed to reward their children for trying, swallowing, chewing, and tasting new foods. Parents always say the following to me: "I had to bribe him to eat broccoli." The answer is that rewards are not bribes. A bribe is giving someone $10,000 to throw a fight. Bribes don't work. The bribed person already has what he or she wants. They have no reason to follow through with the behavior. A reward is when the child performs the wanted behavior and then gets the prize. A good example of a reward is a paycheck. Rewards are the way that the world works, and it is okay for parents to reward their kids with dessert for eating their broccoli. It is okay to withhold dessert if the child doesn't eat the broccoli. That is fine. Parents are not going to give their kids eating disorders by using rewards or punishments around food. There is no good evidence for that. Contingency management procedures are well established in the literature. It is very clear that many children will eat for rewards, and it is okay to do.
With my extremely picky eaters, I find that no reward will make them eat broccoli or deli meat or, heaven forbid, a different brand of pizza. I find that with these children, parents really do need to employ a response cost, which is saying that if you don't make this response, it will cost you this. In other words, you need to earn screen time after dinner by eating a couple of bites of this every night. The clinician can let parents know that all screen time should be earned. A great way to earn screen time after dinner is to try a new food, and this should be the new normal in this house. Every night, your child should be required to eat a bite of a new or nonpreferred food, and after a while it will become routine. It is just like brushing your teeth. It is the only way that their palates will expand.

Final Advice

To summarize, try not to pooh-pooh picky eating. Insist that the parents use good mealtime hygiene so that their children come to the table hungry. Give moms and dads permission to not be mobile vending machines. Let them know that there is no shame in rewarding their children for trying new things and that, in fact, repeated exposure (at least eight to 15 times) will help their children to expand their palates. Finally, be a cheerleader for parents. They are exhausted with the mealtime battles, and an optimistic "never give up" attitude is something that parents need to hear. This problem won't resolve overnight. It won't resolve in a couple of weeks or months. This is a years-long project, but let parents know that with a smile.

Meal battles

Meal battles

A common refrain I have been hearing from parents at well checks is complaints about their kid’s eating habits. “My kid will only eat bread and cheese.” “He just refuses all vegetables.” “She will just spit meat back out”. The most effective tool you have is yourself. If your kid sees you eating healthy foods and enjoying it, you are half way there. For the rest of the way – check out these articles.
Hassle Free Meal Time
Eat more fruits and veggies

Use a spacer everytime you use an inhaler.

Why everyone needs to use a spacer

With the inconsistent weather we have been having, I thought that a review on proper spacer usage with an inhaler would be good. Every single person who uses an inhaler should use a spacer… that includes you parents. It allows the medicine to get down in your lungs where it is needed, instead of losing most of it in your mouth.

Ask your PCP if you need a new one.

http://700childrens.nationwidechildrens.org/use-spacer-pediatric-inhaler/

Milk Alternatives

A question from a parent prompted me to look more closely into the different milk alternatives available.  The simple answer is read the labels!  There is a wide variety between types of milk and brands. 

You need to consider protein, vitamin D, calcium and fat.  For example, if you chose to go with almond milk which has calcium and vitamin D but little protein, then you need to make sure there is another source of protein in your kid’s diet.

Here are two websites that discuss the strengths and weaknesses of soy, almond, coconut, rice and hemp milk.
http://www.webmd.com/digestive-disorders/lactose-intolerance-14/options
http://health.clevelandclinic.org/2013/05/mooving-to-an-alternative-to-cows-milk/

Learning to swallow a pill

Learning to swallow a pill

There is no magic age when a child should start to learn to swallow a pill. I have seen 4 year olds that can swallow anything and some adults that still can’t swallow the smallest pill.

EASY-1 from NYU’s Child Studies Center. The secret lies in patience and in a system that teaches the skill by using gradual steps with candy “pills” of different sizes.
Supplies: Multi-colored round candy balls called mixed decors found in the cake-decorating section of a supermarket; tic-tacs
  1. Have your child swallow one of the multi-colored round candy ball “pills.” Some children may not need to start with the smallest size. The child should begin with the appropriate size candy “pill” that he can comfortably swallow. Starting with a bigger size enables the child to move up more quickly without wasting water swallowing nothing. Tell the child to place one ball as far back on her tongue as possible, take a drink of water from a cup (not a fountain) and swallow the “pill.” The child can have as many practice trials as she needs. Most children find swallowing these balls surprisingly easy, so the first attempt is almost always a positive one. Praise the child for both effort and success.
  2. After five consecutive successful attempts, the child may move on to the next size candy “pill.” The candy pill levels are:
    1. the multi-colored mixed decors
    2. color shots
    3. small silver decors
    4. snowflakes
    5. larger silver decors
    6. 1/2 of a cinnamon or fruit décor
    7. whole cinnamon or fruit décor, and
    8. tic-tacs
    Practice trials should be given at each level.
  3. If the child is unable to swallow a candy “pill” five times in a row, continue
    the procedure using the same size candy pill (even if the child has swallowed the candy four times in a row and then failed on the fifth try). Sessions generally last 10 to 15 minutes. However, it’s not advisable to prolong the sessions so that the procedure becomes aversive to the child. Consider the following factors:
    • the amount of candy the child has ingested
    • the amount of water the child has had to drink
    • the extent to which the procedure appears to be anxiety-provoking for the child.
  4. If the child moves to another size candy pill and is not successful, return to the previous size pill before ending the session, so that the session ends with success.
  5. In subsequent sessions always begin with the first size candy pill used at the first session. If the child swallows it easily on the first attempt, progress directly to the next size, and so on. If the child is unable to swallow the pill, move to the size below that. Give practice trials, using a criteria of 5 successes before trying the size that the child was unable to swallow again. Some children move through all the sizes easily in one session. Others may have more trouble and move up slowly over 2 to 6 sessions.
  6. Progress from the candy pills to actual medication. It is rare that a child progresses through the shaping program through the tic-tac level and then has difficulty in swallowing the medication.
If you struggle after going through the above program this website is more detailed.  It includes videos and varying positions for those who are struggling.
http://research4kids.ucalgary.ca/pillswallowing

Cook Children's news site

Cook Childrens News Site
This site was relatively new to me the first time I posted it.  Over time it has proven to be full of good information.  It is run by Cook Children’s in Fort Worth.

Healthychildren.org

AAP’s parenting website
This is one of my first go to websites for advice for parents.  It is run by the American Academy of Pediatricians and covers everything from measles to temper tantrums.  Go check it out!

Nightmares vs night terrors podcast

Are you waking to hear your child scream at night?  Take a listen: Nightmares vs night terrors

Vaccine podcast

Healthy Children's podcast gives their take on vaccines: Vaccines – questions answered

Constipation Podcast

Does your child have pooping problems?  Take a listen: Constipation

Bedtime podcast.

Bedtimes really are important
Yes, bedtimes really do make life easier.

Toddler tantrums podcast

Toddler Tantrums
Have your kids hit the terrible twos and threes? Check out this podcast.

Fever Podcast

What do you need to know about a fever?
Fever – a disease or symptom

Swimmer's ear podcast


Check out this podcast about swimmer's ear: Swimmer’s Ear

Parenting podcast

Radiomd Parenting Podcast

This is a series of short weekly podcasts put out by the website for parents provided by the American Academy of Pediatrics.
Please be careful where you get your vaccination information from.  There is a lot of misinformation out there!

CDC’s vaccine page
For all you wanted to know about vaccinations including:
http://www.cdc.gov/vaccines/vac-gen/evalwebs.htm – advice on evaluating information you find.
http://www.cdc.gov/vaccines/vac-gen/6mishome.htm#cause – Responses to common misconceptions.
http://www.cdc.gov/vaccines/parents/parent-questions.html – common parent questions.

Repost:

I have finally gave up on fighting posting errors on my old blog and so am reposting here.  The current plan is to resume a biweekly posting schedule.