Tuesday, December 27, 2011

Homework Battle Plan

Any parent with school aged children knows that homework can be a battle.  Even good students can procrastinate, prefer to play, or have practice after school leaving little time for homework.  Then there are the kids who struggle...

I think I threw my son's middle school homeroom teacher for a loop on back to school night.  She mentioned that I can always look on line to see the assignments, and I replied something to the effect of, "I don't have homework, so I'll never look.  It is his responsibility to know what is due."  I am not an absent parent.  I do ask about his day, what he's doing in class, and what his plans are with friends.  He knows I care because I show interest in him, but I don't micro-manage his day.  I do not want to be the parent responsible for the college kid who fails because Mommy can't manage his schedule.  Of course, I know my son and he's self motivated and capable of keeping track of assignments.  Another child might need more help, but at this age I would recommend covertly looking at the assignments and guiding with questions and looking for the student to offer solutions and plans to get the work done.

How can you help your kids with homework without letting it become your problem?  I am a firm believer that kids are the students, not the parents.  Kids need to take ownership of their homework and all other aspects of school.  Of course, for many kids this is easier said than done, but I hear all too often of college kids who have Mommy call the Professor to question a grade.  That is totally unacceptable.  Kids need to practice ownership from early on.  Parents need to guide always, but manage less and less as the kids grow.

Not every solution comes from a cookie cutter mold.  Kids have different personalities and abilities.  You know your kids best.  Think how they work and what makes them tick.

Many parents underestimate the problem with missing out on basics:  sleep, nutrition, and exercise.  If kids don't get the amount of sleep they need, healthy foods, and regular exercise, they will not be as successful academically.  I have blogged on this previously, and really feel that finding balance is important for everyone.

Kids have different problems with homework at different times, and they each deserve their own solutions. Not one of these "types" fits every child perfectly. Most kids have more than one of these qualities, but tend to fit into one type best.

Procrastination:  There is always something more fun to do than work.  Kids will put off overwhelming tasks or big projects because, well, there's a lot to do.
Ask not only what homework they have for tomorrow, but if there are any big projects due in the future.  See if they can estimate how much time it will take to do the project and help them plan how much to do each night to get it done on time.  
Breaking big assignments or long worksheets into small pieces with short breaks in between can help kids focus.  Use a timer for breaks or do a fun quick activity, like silly dance to one song.
Allow kids to have some "down" time after school for a healthy snack (brain food) and to run off energy.  Limit this time with a timer to 30 minutes or so.  The timer helps kids know there is an end point to the fun, and then it's time for work.  Play can resume when work is done correctly.
Poor Self Confidence: Kids who are afraid they won't understand their homework might fear even starting. They blame the teacher for not teaching it correctly. They might complain that they are stupid or everyone else is smarter. They blame the class for being too loud, causing distraction and therefore more homework.  They might complain of chronic headaches or belly aches.
Be sure to praise when kids do things right and when they give a good try.  Be honest, but try to think of something positive to tell them each day.  When they don't meet expectations, first see if they can see the mistake and find a solution themselves.   Guide without giving the solution.  Then praise the effort!
Find their strengths and allow them to follow those.  If they are poor in math but love art, keep art materials at home and display their projects with pride.  Consider an art class.  Remember to budget time.  Over scheduling can result in anxiety, contributing to the problems. 
Perfectionist:  While the desire to do everything right has it's benefits, it can cause a lot of anxiety in kids.  These kids think through things so much that they can't complete the task.  See also the "poor self confidence" section above, because these kids are at risk for feeling they are failures if they don't get a 100% on everything.  They can have melt downs if the directions don't make sense or if they have a lot of work to do.
Help your child learn organizational techniques, such as write down assignments and estimate time to do each project. Plan how much time to spend each day on big projects and limit to that time.  Help them review their progress in the middle of big projects to see if they are on track.  If not, have them establish another calendar and learn to review why they are behind.  (No self-blame.  Is it because one step took longer than projected, they were invited to a movie and skipped a day, they got sick and were not able to work...  This helps plan the next project and builds on planning skills.)
 Remember to give attention and praise for just being your kid.  These kids feel pressure to succeed, but they need to remember that they are loved unconditionally.  
If you notice they have an incorrect answer,  state "that isn't quite right. Is there another way to approach the problem?"  
Not everything is about the grade.  Praise the effort they put into all they do, not the end point.  Make positive comments on other attributes: a funny thing they said, how they helped a younger child, how they showed concern for someone who was hurt.
Encourage them to try something new that is outside their talent.  Not only are they exploring life, but they are developing new skills, and learning to be humble if they aren't the best at this activity.  Help them praise others.  Model this behavior in your own life.  

Co-dependence:  Helicopter parenting is a term often used to describe the parent hovering over the child in everything they do. This does not allow a child to learn from failing. It does not allow a child to grow into independence.  It allows the parent to "own" the problem of homework.  These kids call home when they leave the homework or lunch on the kitchen table for Mommy to bring it to school.  These kids grow up blaming everyone when things don't go their way and Mommy can't fix it. They don't learn to stand up for themselves.  They seem constantly immature with life situations.
Young children need more guidance, but gradually decrease this as they get older.  Teachers can help guide you on age appropriate needs.  Most parents must sign a planner of younger kids, but as kids get older the kids become more responsible for knowing what the homework is.  Many schools now have websites that parents can check homework assignments, but be sure the kids own the task of knowing what is due too.  
Have a place that children can work on homework without distraction (tv, kids playing, etc).
Be available to answer questions, but don't do the work for them.  If they need help, find another way to ask the question that might help them see the solution. Get a piece of scrap paper that they can try to work through the problem.  If they have problems with reading comprehension, have them read a few lines then summarize to you what they read.   They can take notes on their summary, then read the notes after the entire chapter to get a full summary.
Busy, busy, busy:  Some kids are really busy with after school activities, others just rush through homework to get it done so they can play.
Set limits on how much screen time (tv, video games, computer time) kids can have each week day and week end.  A maximum of 10 hours per week of screen time is recommended by experts.  If they know they can't watch more than 30 minutes of tv, they are less likely to rush through homework to get to the tv.  
Ask kids to double check their work and then give to you to double check if you know they make careless mistakes.  Don't correct the mistakes, but kindly point them out and ask if they can find a better answer.  Once they learn that they have to sit at the homework station until all the work is done correctly, they might not be so quick to rush. 
If kids have after school activities the time allowed for home work and down time are affected.  Avoid over scheduling, especially in elementary school.  Be sure they have time for homework, sleep, healthy meals, and free time in addition to their activities.  Are the activities really so important that they should interfere with the basic needs of the child? Is the child mature enough to handle the work load?
Kids who are in constant motion can't seem to sit still long enough to do homework.  Be sure they have the proper balance of sleep, nutrition, and exercise or all else will fail.   Praise their efforts when they are successful.  Set a timer after school to let them play hard for 30 minutes, but then make them sit. Help little ones organize what needs to be done and break homework into several smaller jobs.  Set regular 5 minute breaks every 30 minutes so they can release energy.  Set a timer to remind them to get back to work and compliment them when they get back on task.
Struggling despite help:  There are many reasons kids struggle academically.  Reasons vary, such as behavior problems, anxiety, illness, learning disabilities, bullying, and more.

If they are struggling academically, talk with the teacher to see if there are any areas that can be worked on in class or with extra help at school.  Can the teacher offer suggestions for what to work on at home?
If kids have chronic pains or school avoidance, ask what is going on.  Depression and anxiety aren't obvious and can have vague symptoms that are different than adult symptoms.  Bullying can lead to many consequences, and many kids suffer in silence.  If your child won't talk to you, consider a trained counselor.
Talk with your pediatrician if your child is struggling academically despite resource help at school or if he suffers from chronic headaches or tummy aches.  Treating the underlying illness and ruling out medical causes of pain is important.  Depression, anxiety, ADHD, and other learning disorders can be difficult to identify, but with proper diagnosis and treatment, these kids can really succeed and improve their self confidence!

Friday, December 9, 2011

Help us help you!

Hello.  This is Dr. Stuppy.  I'm returning your call about...

That is how my phone calls start, then they take various turns.  Some are easy, some not so easy.  I'd like to discuss what makes a phone call to the doctor's office more productive, so we can help you better.  All examples are entirely fictitious, made up of 12 + years of phone call experiences.

Many calls start off like this:
Hi. This is Mary Sue. My son has a rash and I want to know what to do.
Me: ????? I must ask many questions for more information.  
Some callers don't seem to know what to say, so they only answer direct questions.  How old is your son? When did the rash start? What does it look like? Has it changed? Does it itch or hurt? Any other symptoms? What have you used to treat it? Did that help? Has he had any new ingestions, lotions, or creams? Does he have a history of allergies? Anyone else with a rash that looks like this? On and on...

Or like this:
Hi.  Thanks for calling back. My son Jack is 3 years old.  Well, really his birthday isn't until next month, but he's almost 3.  He has had a fever for 2 days, maybe 3 days because he felt warm but he wasn't acting funny or sick that first day he felt warm.  He actually was fussy last week, but I don't think he ever had a fever then.  I was thinking maybe he didn't sleep well last week, but I don't know why.  I took his temperature and it was 100.3, that was on Tuesday around 7am.  I gave Tylenol, and it went down to 97.9, but then 4 hours later it was back up to 99.7....  
My thoughts so far: Get to the point. 
Sorry, but that's true.  I care about my patients, but so far this phone call has taken me quite a bit of time and I really know nothing except this almost 3 year old has an elevated temperature (not even a true fever).  

When parents call, they need to summarize with pertinent facts.  While they shouldn't leave out important helpful information, they don't need to mention every time they took a temperature.
Much like the evening news: they can't do a play by play of every football game.  There's no time and it serves no purpose.  A few highlights of the game and the score.  That works well.  People get a pretty good idea of how the game went.  

It's the same thing with phone calls to your doctor's office or on call provider.  We have thousands of patients.  Not all call the same day, but during peak cold and flu season last year our office took 50-90 calls/day (the highest numbers on Mondays).  One phone nurse has 8 hours to answer up to 90 calls in addition to filling out insurance forms and other tasks.  (We have great nurses that help out if they have time, but if the phones are busy, I guarantee the office is busy too!)  They simply can't spend 15 minutes chatting about every detail.  That's for your friend and you to discuss over coffee.

After hour phone calls during the winter are also more frequent.  It is not uncommon for me to be on the phone with one parent and another call comes in.  This is at the same time I am trying to watch my son's game or go to the grocery store.  I really don't want to sit and chat.  I don't have time for play by play action.  Again, I really care about my patients, but I can do a better job at answering your questions if you are clear and concise.

Things that help us help you over the phone:

  • Know what is going on.  When a parent calls and the child is at daycare or grandma's so the caller doesn't know details, we can't really help.  Write down the pertinent facts to get them straight if you need to.
  • Start with your child's full name and birth date.  Include any significant past history, such as your infant was born at 28 weeks gestation, or your coughing 3 year old has a history of wheezing.
  • Give pertinent facts related to the concern.  
  • If your child has a fever, give the number of days of fever, the maximum temperature, and how it was taken.  If you have given a fever reducer, share that.
  • Briefly describe symptoms and what you have done to help them as well as if your child responded or not to the treatment.  Remember treatments are not only medicines, but if you use a vaporizer or saline for a cold, or have stopped dairy and used G2 for vomiting, let us know. 
  • If your child has a rash, it is typically best for us to see the rash, but if you call about a rash describe it in terms of location, color, and size (many find it helpful to relate to common objects, such as quarter-sized).
  • Note if there is a pattern to the symptoms, such as headache every day after school or barky cough only at night.
  • Let us know any medications your child typically takes in addition to ones you have tried for the current symptoms.  
  •  Leave out details that don't help.  Trends and generalizations work well.  If we want more details, we can always ask. 
Examples of good call starters:
  • I am calling about Joe Smith, birth date 9.12.08. He has had a fever for 3 days, up to 101.3 under the arm. It comes down with ibuprofen, but is right back up in 6 hours.  He also has sore throat and headache. He's drinking well but not eating much for 3 days.
  • Sally Smith, birth date 9.12.11, has vomited 6 times in the past 12 hours. If I give formula it immediately comes up. She is now dry heaving and hasn't had a wet diaper in 12 hours. She doesn't have a fever but looks tired and it is hard to wake her to drink. She doesn't have diarrhea. Her older brother had the stomach flu a few days ago but is now better.
  • John Smith, birth date 9.12.11, was in the NICU for 2 months due to prematurity. He has been fussy all day and is now breathing fast and hard and is not able to drink more than a few sucks at a time. He doesn't have a fever, but I'm really worried. 

Remember:  Our website has many pearls of wisdom.  Often when we give advice it is already stated on our site.  Parents sometimes call multiple times because they can't remember what we said.  This is frustrating on both ends of the phone.  We wrote it down for a reason.  Use our site!

Things that cannot be done by our on call providers:

  • Prior authorization for an ER or urgent care visit.  These must be done during office hours, and most of the time our office is not involved.  These are typically done by the location at which your child is seen.
  • "Allow" you to leave a busy ER.  It sounds silly, but I have had many calls from the waiting room at ER/Urgent Cares with parents asking if I think it okay that they leave due to a long wait. If you thought it necessary to go in the first place, I would be open to a malpractice lawsuit if I told you to go home without being seen.  You should ask their triage nurse who can make that assessment.
  • Refill medications.  We typically expect that your child is seen prior to most prescription refills for best medical care.  If it is urgent that your child have a refill, such as an inhaler, they should be seen to evaluate the concern. There are exceptions to every rule, but don't be upset if the on call provider refuses to call out a prescription. 
  • Make a diagnosis.  We cannot see the ear, listen to the lungs, or feel the belly over the phone.  A physical exam and sometimes labs or radiology studies are needed to make a diagnosis.  If your doctor claims to be able to diagnose by phone to call out prescriptions, I would suggest that they are not doing the best of care.

Some things are best done with a visit for further evaluation.  

  • Difficulty breathing.  If a child is having difficulty breathing and you don't have treatments at home that work, he needs to be seen as soon as possible.
  • Dehydration.  An infant who hasn't urinated in 6-8 hours or an older child who hasn't urinated in 12 hours might be dehydrated and should be seen as soon as possible.
  • Some fevers. Temperature above 100.4F under the arm in an infant under 3 months or under immunized child can be serious and should be seen as soon as possible.  Fevers lasting more than 3-5 days or with other concerning symptoms require an evaluation.
  • Uncontrollable pain.  If you have used standard pain relievers and your child is still hurting, we cannot do anything by phone that will improve the situation. A careful exam might find a treatable cause of pain.
  • Most rashes.  Though these don't necessarily need to be seen emergently unless there are other concerns, rashes cannot be evaluated on the phone and a physical exam is needed.
  • Chronic problems.  If your child has been dealing with anything for more than a few days, it might help to schedule a visit with your usual provider.
  • Diagnosis vs information.  If you want a diagnosis, we need to see your child.  We cannot tell if the ear is infected or if your child has Strep based on symptoms alone.  If you want advice of what to do with symptoms, we can generally give advice.  Remember that our website also has most of this information too!
  • Behavior problems.  These are best discussed with your usual provider, not an on-call provider who doesn't know your child. Most of these build up over time and are not emergent issues.
  • Injuries.  If your child has a moderate or severe head injury, possible broken bone, laceration, or other injury symptoms they require evaluation.  Lacerations must be repaired as soon as possible, so don't wait until office hours the next day!
Help me help you!  Let me know what else you need to know to be an educated caller.  I'd be happy to answer questions about when to call, what to ask, and what to expect.  If I left any questions unanswered, please ask!

Dr S

Monday, December 5, 2011

How to get kids to take medicine

A recent facebook post discussed how to give medicine to children, but left out how to give liquid medicine. A reader asked for advice, and I wanted to expand my original answer.

The article:   Medical Mom: A spoon full of sugar helps the medicine go down

The facebook question:   She gives great advice on pills, but what about liquid medications that kids just WON'T swallow? I've tried putting it in his cheeks, but the flavor they mixed it with he hates :(

Of course, there is so much to giving medicine to kids.  They already feel sick for most of the medicines we give, and anything is distasteful when you feel sick, regardless of the flavor the pharmacist adds.  Some medicines have a horrible aftertaste that is difficult to mask.  Some upset the stomach.

If medicine is vomited within 30 minutes, it generally can be given again. If your child vomits more than 30 minutes after the medicine is swallowed, do not offer it again.

I don't miss the days of liquid medicines! My son (who suffered from many ear infections) spit out most medicine (and often vomited what he swallowed).  My daughter didn't need as many medicines as him, but as the expert vomiter (she would vomit whenever she didn't get her way as an infant) and expert manipulator, she had unique issues to get the medicine down.

Needless to say, I learned a lot of tricks trying to get them to keep medicines down.

Most liquids taste better cold, so check with your pharmacist if the medicine can (or should) be refrigerated.  Also ask if it can be mixed with juice or foods.  Some should be given on an empty stomach without food and only sips of water. 

Be sure you have a properly sized medicine syringe or medicine cup for all liquid medicines.  Shake the bottle well before dispensing.

If it can be mixed into juice, jelly, or yogurt, be sure to mix in a small enough volume that you can ensure your child will take the entire amount.  You can measure the amount of medicine in a syringe, then fill the remainder of the syringe with drinkable yogurt, juice, or whatever liquid is okay to mix with the medicine.  (Always ask your pharmacist first!) 

Sometimes using a medicine that comes in a capsule that can be sprinkled onto a spoon of yogurt, jelly, or applesauce works well.   Yogurt tubes are especially great for this if your child eats these. Put the contents from the capsule on the top of the open tube, and they suck it down as they enjoy the yogurt.  Ask your pharmacist if you can mix the medicine with foods first!  

For infants: Try squirting it in the inner cheek and blowing on the face. I don't know why, but it seems to make infants swallow.  You can also put it in a nipple and allow them to drink from the nipple, which bypasses most of the taste buds on the tongue! After the medicine is swallowed, use the nipple for water or formula/milk to rinse all the medicine down as long as it does not need to be given on an empty stomach. 

Preschoolers: This age might feel "big" if allowed to hold the medicine cup themselves.  Supervise closely so they don't spill it.  Praise when they did it!

Preschool and up: Offer a chocolate syrup chaser. Syrup is thick and masks a lot!  Another trick is to offer a popsicle (or ice) first.  This numbs the taste buds, making the medicine taste less noticeable.

Holding the child's cheeks to make them pucker their lips until swallowed sometimes works (though I found kids can still spit it out that way!) 

You can also have the pharmacist flavor most medicines, and if you pick the right flavor, it can help. Ask for suggestions, since the flavor added might not be the best for the particular medicine. 

Bribery works with preschoolers and up. (A thing I promised myself I would NEVER do... but once I had kids and realized bribery works, I reserve it for the really important things.)

As for most of my behavioral advice: praise a job well done! If they took the medicine, tell them you are happy they did.

When you think your child is able to swallow pills without choking, teach with small candies, such as Tic Tacs or mini M&Ms.  I always suggest using a cup with a straw, since when you drink out of a cup you tilt your head back, narrowing the throat.  A straw allows you to keep your neck neutral. Once swallowing a small candy is mastered, you can use real medicine capsules or tablets, as long as the dose is correct for the child's weight.

Sometimes making a game of it works. My husband came up with this trick for our daughter when she was 5-6 years old.  Remember she was the expert manipulator.  She threw a fit about taking a medicine and made getting out of the house for school on time difficult a couple of days. He suggested that if she was ready for school by 7:15, she could throw a fit for 10 minutes. If she wasn't ready until after 7:20, she could only throw a fit for 30 seconds.  Either way we would set the timer for her fit, then she would take the medicine.  Of course we knew she'd never be ready early (and she really couldn't tell time well in kindergarten) so when it was time for medicine, we set the timer for 30 seconds and told her to throw a good fit.  She threw a great fit, then took the medicine without a problem. It was as if owning it worked for her, and she then took the medicine each day for the rest of the week after setting the timer for a fit.  By the end of the week she could hardly throw a fit she was giggling so much!

The most important thing is to remember why you are giving the medicine.  If it is an antibiotic or other medicine that is important to completely take, then it is more important than if you are simply trying to give a fever reducer.  A fever reducer might make your child feel better, but it really isn't required.  If it is required, then you need to play hard ball and do whatever it takes to get the medicine down.  

What has worked for your kids to take medicine?  Please share your tips!

Saturday, December 3, 2011

Fever is...

fever, temperature, sick

Fever is scary to parents.
Parents hear about fever seizures and are afraid the temperature will get so high that it will cause permanent brain damage.  In reality the way a child is acting is more important than the temperature.  If they are dehydrated, having difficulty breathing,  or are in extreme pain, you don't need a thermometer to know they are sick.
Fever is uncomfortable.
Fever can make the body ache. It is often associated with other pains, such as headache or earache.  Kids look miserable when they have a fever. They might appear more tired than normal.  They breathe faster. Their heart pounds. They whine.  Their face is flushed. They are sweaty.  They might have chills.
Fever is often feared as something bad.
Parents often fear the worst with a fever: Is it pneumonia? Leukemia? Ear infection?  
Fever is good in most cases. 
In most instances, fever in children is good.  It is a sign of a working immune system.  
Fever is often associated with decreased appetite.
This decreased food intake worries parents, but if the child is drinking enough to stay hydrated, they can survive a few days without food.  Kids typically increase their intake when feeling well again.  Don't force them to eat when sick, but do encourage fluids to maintain hydration. 
Fever is serious in infants under 3 months, immune compromised people, and in under immunized kids.
These kids do not have very effective immune systems and are more at risk from diseases their bodies can't fight.  Any abnormal temperature (both too high and too low) should be completely evaluated in these at risk children.   
Fever is inconvenient.
I hate to say it, but for many parents it is just not convenient for their kids to be sick.  A big meeting at work.  A child's class party.  A recital.  A big game or tournament.  Whatever it is, our lives are busy and we don't want to stop for illness.  Unfortunately, there is no treatment for fever that makes it become non-infectious immediately, so it is best to stay home.  Don't expose others by giving your child ibuprofen and hoping the school nurse won't call.
Fever is a normal response to illness in most cases.
Most fevers in kids are due to viruses and run their course in 3-5 days.  Parents usually want to know what temperature is too high, but that number is really unknown (probably above 106F). The height of a fever does not tell us how serious the infection is.  The higher the temperature, the more miserable a person feels.  That is why it is recommended to use a fever reducer after 102F.  The temperature does not need to come back to normal, it just needs to come down enough for comfort.

Fever is most common at night.
Unfortunately most illnesses are more severe at night.  This has to do with the complex system of hormones in our body. It means that kids who seem "okay" during the day have more discomfort over night.  This decreases everyone's sleep and is frustrating to parents, but is common.  

Fever is a time that illnesses are considered most contagious.
During a fever viral shedding is highest.  It is important to keep anyone with fever away from others as much as practical (in a home, confining kids to a bedroom can help).  Wash hands and surfaces that person touches often during any illness.  Continue these precautions until the child is fever free for 24 hours without fever reducers.  (Remember that temperatures fluctuate, so a few hours without fever doesn't prove that the infection is resolved.) 
Fever is an elevation of normal temperature.
Normal temperature varies throughout the day, and depends on the location the temperature was taken and the type of thermometer used.  Digital thermometers have replaced glass mercury thermometers due to safety concerns with mercury.  Ear thermometers are not accurate in young infants or those with wax in the ear canal.  Plastic strip thermometers and pacifier thermometers give a general idea of a temperature, but are not accurate.  
To identify a true fever, it is important to note the degree temperature as well as location taken.  (A kiss on the forehead can let most parents know if the child is warm or hot, but doesn't identify a true fever and therefore the need to isolate to prevent spreading illness.)  I never recommend adding or subtracting degrees to decide if it is a fever.  In reality, you can look at a child to know if they are sick.  The degree of temperature helps guide if they can go to school or daycare, not how you should treat the child.  Fevers in children are generally defined as temperatures above 100.4 F (38 C).

Fever is rarely dangerous, though parents often fear the worst.

This is the time of year kids will be sick more than normal.  With each illness there can be fever (though not always.)

What you can do:

  • Be prepared at home with a fever reducer and know your child's proper dosage (especially with the recent dosing changes to acetaminophen!) 
  • Use fever reducers to make kids comfortable, not to bring the temperature to normal.
  • Have an electrolyte solution at home in case of vomiting. 
  • Teach kids to wash their hands and cover coughs and sneezes with their elbows.  
  • Stay home when sick to keep from spreading germs.  It is generally okay to return to work/school when fever - free 24 hours without the use of fever reducers.  
  • Help kids rest when sick.
  • If the fever lasts more than 3-5 days, your child looks dehydrated, is having trouble breathing, is in extreme pain, or you are concerned, your child should be seen.  A physical exam (and sometimes labs or xray) is needed to identify the source of illness in these cases.  A phone call cannot diagnose a source of fever.
  • Any infant under 3 months or immune compromised child should be seen to rule out serious disease if the temperature is more than 100.5.

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Excessive milk can cause anemia? How?

A recent facebook posting recommending limiting milk intake prompted questions from followers about iron deficiency anemia from milk.  Nutrition and iron balance is actually a relatively lengthy discussion, so I will try to explain it here.

Short answer:  Cow's milk has little iron.  When kids drink a lot of milk, they don't eat iron-containing foods in sufficient volumes.  Cow's milk also has big proteins that can cause microscopic bleeding in the gut. The more milk consumed, the more bleeding (though usually still not seen in the stools).
More milk = more blood loss from the gut
                              but less blood produced because less iron in the diet
                                                 = anemia

Iron is used to build healthy red blood cells that carry oxygen throughout our bodies.  Too few red blood cells in the body is called anemia.  Red blood cells are made in our bone marrow and they live for about 3 months.  It is important for the body to continually make new red blood cells as it breaks down and removes old ones.

In general anemia can be caused from several factors:

  • too little blood produced (iron deficiency being a major risk for this)
  • increased blood loss (ie excessive bleeding)
  • increased destruction of blood cells in the body (typically from abnormal blood cells or infection)
Iron deficiency can be due to several factors:
  • poor iron absorption due to disease (some studies show milk inhibits iron absorption)
  • poor iron in the diet (the most common cause)
  • long term slow blood losses (such as heavy monthly periods or GI bleeding)
  • increased iron need (such as a growth spurt or pregnancy)

Why does preventing iron deficiency anemia matter? Because the most common symptom of anemia is no symptoms.  It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development.  Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).

Newborns are designed to drink their mother's milk.  Humans have learned to make formulas that can nourish babies if they aren't able to drink their mother's milk for whatever reason.  Cow's milk, soy milk, and goat's milk are not acceptable for infants due to the nutritional voids they have (not just iron).  After about 1 year of age babies tend to wean from mother's milk and/or formula onto whole milk.  (Newer recommendations allow weaning onto low fat milk--another topic entirely.)  Unfortified non-human milks contain very little iron.  The iron in human milk is better absorbed and iron is supplemented into formula.  If toddlers and children drink too much milk, they fill up on it and don't eat a variety of other food groups that include iron and other important nutrients missing in their milk.

Foods that are good sources of iron:

  • meats and poultry (especially organ meats, such as liver)
  • lentils, peas, and dried beans
  • eggs
  • oysters, clams, and fish
  • molasses
  • peanut butter
  • soy
  • pumpkin or sesame seeds
  • fruits such as prunes, apricots, and raisins
  • vegetables such as spinach, kale, broccoli, and other greens
  • whole grain fortified breads and cereals

Vitamin C increases iron absorption, so eat foods with iron and Vitamin C at the same meal!

Saturday, November 26, 2011

Sexual abuse

Recent news about a well known person repeatedly sexually abusing children over many years has many parents angry, confused, and simply aghast.

Many of us feel like we do all we can to protect our kids and our kids aren't at risk, yet statistics show that any child could be a victim.  Studies reveal that about 20% of women and 10% of men experienced sexual abuse as children.  Sexual abuse crosses all socioeconomic groups, all racial groups, all ethnicities, and all neighborhoods.  Often the perpetrators are the least suspected: a family member, a coach, a neighbor.

Signs of abuse in kids can be subtle.  They are often attributed to something else.

If kids do try to talk about feeling scared or not safe with someone: LISTEN.  They don't make this stuff up!

I appreciate the organizations that require background checks on all adults around kids.  I have had my background checked on many occasions:  job related, coaching my daughter's cheerleading squad, volunteering at my children's school, and volunteering at a local children's theater.  I was never offended by these requests and always supported these checks, but some parents grumble.  I suspect they just don't understand.  Many schools, sports organizations, and scouting organizations require teachers and volunteers to have routine background checks.   Does yours?

Do you ask if the adults supervising your children have had background checks?
Most do not.  
I am not even sure how I feel about this.  I suspect it gives a false sense of security, knowing that many abusers have many victims before being caught. They would have normal background checks.  They are often personable, friendly, someone who grooms victims and their families to gain trust. 

If background checks aren't full proof protection, what should a parent do?  I believe that the best protection about abuse is to show love to your children, educate yourself and them about abuse, and frequently talk with them.

Knowledge is Power!  

  • Teaching kids about proper boundaries is important.  Let them know that their swim suit area is private, and no one should be able to look or touch there without permission from mom or dad.  
  • Young children should learn their full address, phone number, first and last name (and first/last names of parents).  
  • Remind kids that there are no secrets between kids and their parents.  They can tell you anything.  They can keep your birthday gift a surprise though!  Secrets that scare them are especially important to tell!  They will NEVER get in trouble for telling about a scary secret.
  • Know your children's friends, their friend's parents, teachers, coaches, piano teachers, etc.  Offer to help as much as possible at school and activities. 
  • Be sure there are no secluded areas in the places your child goes.  Kids should always remain in a group with adults.  A minimum of two adults is safest.  
  • For your protection, if you must take other kids to a public restroom, stand in the main door with it open and let the kids go into stalls alone.
  • Teach kids that adults will never need help from kids to find a missing puppy.  Adults can ask other adults, not kids, for directions if lost.  Give examples and role play. 
  • Caution kids when they wear shirts with their name clearly posted on the outside that strangers will "know" their name.  Stay especially close when your kids have their name displayed.  It is easier for a stranger to trick them:  "Johnny, your mom told me to come get you.  She is hurt. Come with me."  What kid wouldn't question that???
  • Question about new toys or gifts.  Kids might earn token gifts from coaches or teachers as a reward system, but if your child is getting bigger, more expensive gifts, that is a cause for alarm.
  • If kids are lost, have them find another child to ask for help.  Usually the other child has a safe adult with them that can help. (Plus kids are less intimidated talking to other kids when they are already scared and lost.) 
  • Parents of today need to learn about protecting kids on line.  Bullying now does not stop in the safety of one's home.  On line threats, photos, and comments follow kids everywhere and are very dangerous.  Keep computers in public areas, monitor cell phone use, teach kids to never give identifying information on line, and use a computer monitoring system.
  • Abusers often target kids who are feeling unloved.  They groom those kids (and their families) by befriending them, making them feel special, and giving them gifts.  The kids start to deeply care for that person, and then the confusion of feelings does not allow the child to easily tell on the person.   Show your kids love in many ways: time spent one on one talking and playing (not watching tv), show interest in your children's activities, give good touches (ruffling hair, pat on the back, hugs), and build your child's self confidence.  
Building confidence in kids is tricky.  Be careful in how you word things... it is always okay to say "I enjoyed watching your game," whether your child was the star player or had a horrible game.  You can say something about how proud you are of the effort they put into something even if the outcome wasn't good.  Try to avoid saying "better next time," since that means they didn't do well this time.  Praise frequently and honestly from the heart.
  • Create a safe environment at home. If kids witness fighting among parents, or parents don't treat others with respect, the children will learn that this is acceptable behavior.  They have a strong potential to get seriously injured at home or to enter abusive relationships as adults.  Seek help if your home is not safe!  Use a public computer if yours might be monitored and click here or call 1.800.422.4453 (1.800.4.A.Child) from a safe phone.
  • Learn more about protecting against abuse and what to do if you suspect it.  There are on line resources, such as TheSafeSide or PreventChildAbuse, and locally The Sunflower House to learn about abuse.  GetNetWise and NetSmartz411 have information about keeping kids safe on line.

Monday, November 14, 2011

Chores for kids become chores for parents?

As a parent I see the great value of chores for kids.

  • Anyone can learn the satisfication of completing a task, improving self confidence.  
  • Young children can improve self care competence such as with bathing and dental hygiene. 
  • Older kids can learn money appreciation and management if they are paid and expected to save some and share some of their well-earned money.  Learning to save for a large ticket-item and not spend frivolously is a great life lesson many adults missed.
  • Older kids can establish a great attitude about work and learn real-world skills such as laundry, cooking, and cleaning.  
  • Kids might even gain self esteem by the positive intrinsic reward of a job well done.  
  • They learn responsibility.

The downside?

Chores for the kids often make work on the parents harder.  (Who said parenting is easy?)

Parents must decide what tasks are able to be done by children at various stages of maturity.  There are on-line resources available to help guide parents.  This is one place I disagree with the WebMD list because they say a 10 year old can mow the lawn--not recommended by the AAP until 12 years!

Some good lists: Workingmom.com, Focus on the Family, Chores-Help-Kids

Parents must make sure the chores are completed or set a means of monitoring what is done. Ideally chores would be accomplished without fighting and whining, but how?  Verbal praise and acknowledgment is always a winner.  If parents choose to reward chores with stickers, gifts, or money, there must be a way to track when a task is complete.
Consistency is key in any form of discipline, and this includes the tracking of chores.  The biggest reason chores fail in my house is we (the parents) forget to check the lists to be sure the kids did them.  Having a consequence for not doing the expected chores versus getting a reward for doing the list... behavior experts disagree on these points.

Many behavior experts recommend to not remind kids to do chores.  They feel that the negative consequences of not doing the chores will teach the lesson better than the constant nagging to do the chores.  I have found that without reminders the chores are simply not done, but this does not mean I must always directly remind.  Praising the initiation ("I'm glad you are getting your homework done early tonight!"  "I see you remembered to sort your laundry, that's the hardest part!") is often an effective way to get kids to complete the task.  There is a fine line between nagging the kids to do the expected things and letting the chores slip by without being completed.

Over the years we have had many means of keeping track of chores in my family.

  • When the kids were young, we first tried a dry erase board, but that got erased too easily.
  • We then found a simple paper chart each week that had lists that could earn stickers. I liked the format because it separated tasks into the general categories below, but we often forgot to mark things off at the end of a busy day, so there was little reinforcement for the kids to do the chores.  The categories of chores:
  • Self: included things such as brush teeth, bathe, get dressed 
  • Home: included things such as pick up toys in living room
  • Room: included things such as pick up room, make bed
  • School: included things such as help a friend, homework, pack backpack
  • One of my favorites was a system called 10-20-30Go! that friends developed.  It was wonderful because it is based on the kids taking full responsibility for marking down what they did. It is simple and includes a strong family and faith base.  It was one of the longest running systems that worked for us, but as all systems, it also faded in follow through.   A big reason was that we often had activities that interfered with the family meeting night, no matter what night of the week we tried to do it.  (Family meeting nights are still a great thing, but difficult in a busy house!)  We also found that the kids didn't look forward to their allowance, so it was little reinforcement to do the tasks.  They might have been too young at the time.
  • Another favorite system of mine due to ease of use, cost (free), and kid -centered responsibility is MyJobChart.  It works well for kids who can use the internet fairly independently.  My kids can log in to their account and mark the chores as they do them, or once a day.  They earn points, which they can choose to share (with pre-determined charities), spend (on items I help pick), or save (for the future!)  I like many features of this system, but it still has periods that my kids forget about it for weeks, then periods that we all remember again.  They still do their chores (or they have no clean clothes the following week... or whatever natural consequence follows the forgotten chore) but they don't always mark them down for credit.
What do you find helps to keep your kids up to date on their chore list?

Saturday, November 5, 2011

New SIDS Prevention Guidelines

As pediatricians we practice a lot of preventative medicine.  Our patients are generally young and healthy... and we want them to stay that way!  One way we do this is to discuss safety at well visits.  We try to share safety tips on our facebook page, website, and here.

A big safety issue is the sleep position of babies.  Most parents by now have heard that it is safer to put babies to sleep on their back, not belly.  Occasionally we hear of young babies sleeping on their stomachs because parents have realized they sleep longer that way, and they do.  But this is dangerous. Babies don't wake up as much when on their stomach, this is true.  Some babies simply don't wake up.  Please put your babies on their back to sleep!

Parents often want to sleep with their babies because it also is associated with longer sleep time for the baby and more convenience for the parent (especially the breastfeeding mother).  Despite ease and convenience, this is not a safe sleeping arrangement for babies. Arguments that this is safe because world wide many families share beds is not often a valid argument. Americans tend to sleep on a bed with a headboard and bedding.  Babies can get their head stuck between the mattress and headboard (or wall).  They can suffocate from the bedding.  Parents can roll over in their sleep and smother the baby.  There are simply safer options for all to sleep better.

Recently the American Academy of Pediatrics (AAP) released new Sudden Infant Death Syndrome (SIDS) prevention guidelines.  AAP SIDS prevention Guidelines that are based on strong evidence:

  • Back to sleep every time.
  • Use a firm sleep surface covered with a fitted sheet.
  • Room share without bed share (put the baby in a crib or bassinet near the parent bed).
  • Keep soft objects and loose bedding out of the crib.
  • Pregnant women should receive routine prenatal care.
  • Avoid smoke exposure during pregnancy and after birth.
  • Breastfeed.
  • Consider a pacifier at nap and bed times, but do not attach it to the infant or infant's clothing or stuffed toys.
  • Avoid overheating.
  • Do not use home cardiorespiratory monitors as a strategy to reduce SIDS.
Other recommendations based on limited evidence:
  • Immunize in accordance with the AAP and CDC guidelines.
  • Avoid commercial devices marketed to reduce the risk of SIDS (postitioners, co-sleepers, wedges).
  • Supervised, awake tummy time is recommended to help development and reduce the risk of  positional plagiocephaly (a misshapen head from laying on one side routinely).
Other issues addressed:
  • Co-sleepers are not recommended.
  • Absolutely no bed sharing the first 3 months.
  • No bed sharing at any age if a person in the bed is a smoker.
  • No bed sharing with anyone who is excessively tired.
  • No bed sharing with someone who is using medications that increases drowsiness or impairs alertness (pain medicications, alcohol, illicit drugs, certain antidepressants).
  • No bed sharing with anyone who isn't a parent. This includes no bed sharing with siblings or other children.
  • No bed sharing with multiple persons.
  • No bed sharing on a soft surface (waterbed, old mattress, sofa, armchair)
  • No bed sharing on a surface with soft bedding, including pillows, heavy blankets, quilts, comforters.
  • Because of the high correlation with SIDS and suffocation on couches and armchairs, infants should not be fed on these when the parent is extremely tired and at risk of falling asleep.
  • When choosing a crib, be sure it has not been recalled and all the parts are put together properly.
  • Use only mattresses designed for infants.  Do not add any comforters, quilts, pillows, or other soft bedding to the sleep area.
  • Bumper pads are not recommended.
  • Infants should wear clothing that will keep them warm (not excessively hot) and that will not cover the head/face.
  • Keep dangling cords or window coverings away from the sleep area.
  • If infant slings are used, it is important to keep the infant's head up and above the fabric so the face is visible (unless currently breastfeeding).  
  • Infants should not routinely sleep in car seats or other sitting devices (strollers, carriers, or backpacks/slings).

NOT safe!!!!!!
Picture actually taken to show the person who gave the comforter and bumper pad set, then it was put away. 
Keep your baby safe by placing her in a safe place at all times.  It only takes one accident to have life-ending consequences.  To say that you've always slept with your babies and they are fine, so it's not a problem for babies to sleep with their parents is like saying you never wear a seatbelt and haven't had any problems.  Just wait until that first crash...

Thursday, November 3, 2011

Complimentary and Alternative Medicine

Complimentary and Alternative Medicine (CAM) means many things to many people, but the truth is  that many people use it to try to help a broad range of ailments without much guidance from their physicians.

Why?  Reasons vary.  Some feel that "natural is better."  Others feel that mainstream medicine is not working.  Many people see CAM as a lifestyle choice.  Some don't have access to (or money for) a doctor visit, and CAM is readily available at many locations.  There are many other reasons that people use CAM.
Is it safe? Is it reliable?  Depends on the CAM.

What is CAM?

CAM includes any form of medical treatment that is not a part of mainstream medicine.  It has gained popularity because it is holistic, and people like the idea of treating the whole person and not simply one condition.  It includes many categories of treatments, including natural products (vitamin supplements, herbal medicines, minerals, and probiotics), homeopathy (diluted substances that would typically cause symptoms used to treat those symptoms), acupuncture and manipulative treatments, Oriental medicine (energy fields), and mind-body medicine.

What are potential problems with CAM?
  • Homeopathic medicines and natural products are not regulated by the FDA.
  • Some therapies have been shown to be contaminated with heavy metals (such as lead)
  • Products have been shown to be inconsistent in the amount of active ingredient from bottle to bottle
  • Studies to show the appropriate dose have not been done in most instances 
  •  Studies to show effectiveness have not been done in many cases
  • Many don't share CAM use with their physicians.  Why?
  • Don't want to admit in case doc disagrees
  • Don't think about it and aren't asked specifically 
  • Don't think it will make a difference
  • Many docs don't know how to advise about CAM.
  • If parents ask about herbs, spinal manipulation, or other CAM treatments, physicians often don't have the answers.  
  • Physicians are taught to advise based on an evidenced based platform.  If studies haven't shown a treatment to benefit, we are less likely to recommend it. For many complementary and alternative medicines studies have not been done to show safety and efficacy.  
  • Studies that have been done typically were done in adults, not children.  Children handle medicines and therapies differently than adults, but research is often not done on them. 
  • CAM information does not often make news in medical journals and is not typically discussed at conferences, the places at which your physicians learn. 

Do I recommend CAM?

While there are many CAM treatments that I am not comfortable recommending, I often recommend things that are CAM.

The first and foremost form of alternative medicine I recommend to everyone is healthy diet and lifestyle.  This is widely accepted among mainstream medical doctors.  Healthy diet and exercise helps prevent many health problems, treat some health problems, and even helps mental focus and overall mental health.  

I believe there is solid research supporting fish oil, probiotics, and other vitamin supplements.  The American Academy of Pediatrics recommends Vitamin D for all children. 

I think that relaxation techniques, biofeedback, yoga, prayer, and meditation can all be beneficial and I cannot see how they would be detrimental if used properly.  

In the category of manipulative medicine, I have not been trained specifically, but I refer to physical therapists and sometimes chiropractors.  Massage therapy is a growing field, and has been recommended for children with muscle tightness affecting gait and for those with sports injuries.

Other CAM therapies are difficult for me to recommend.
Herbal therapies might be beneficial, but there is also potential risk of interactions with other therapies.  They are not regulated by the FDA and have been known to be contaminated with things such as lead. There also have been reports of the strength of the supplement to vary widely from what is listed on the bottle and non-listed ingredients to be in the supplement.  This can lead to unknown interactions and consequences.

Most studies of CAM therapies have been done on adults.  Children are not little adults.  Therapies such as lifestyle changes are safe, but those with herbal or homeopathic medications might not be.  There simply is not enough scientific data to support the use of these in children.

Studies do show that about 50% of children have used complementary or alternative medicine (higher numbers if you include vitamin supplements).  Unfortunately most of the time the physician is unaware of these treatments.  Many of the kids using these therapies are those with chronic conditions for which there is no traditional medical therapy that manages the condition well.  This means that more research is needed to show if they are safe or effective.  Are they worth the cost? Is there something better? Should physicians recommend them because they do work?

Why would parents use a treatment that isn't proven? They just want to help. Many parents think "natural" is better.
My answer to that: I would never give my kids organic marijuana to stimulate their appetite.  It is natural.  Organic even.   And it does stimulate the appetite, so it might work.  But I know there are risks to marijuana.  We've all heard those because it is a well known (and unfortunately misused) substance.  Many herbs and other treatments aren't as well known.

How to improve the safety of CAM use in your children:

  • Discuss any therapy you are using with your health care provider. If you have more than one provider, be sure all know each treatment you are using.
  • If you use a CAM provider, be sure to check the education and training of that person.  Are they licensed to practice?  Be sure they have experience with the age group of your child.  (This actually goes for any health care provider you choose!)
  • Ask your pharmacist if there are any known interactions with the supplements and medications you are giving your child.  Be sure to list all prescription, over the counter, and supplements given.
  • Store all medications, supplements, and vitamins out of reach of children.
  • If you notice any ill effects that might be related to CAM or other treatments, be sure to discuss with your provider!


AAP News 2008; 29;1
PEDIATRICS Volume 120:1, July 2007
PEDIATRICS Volume 125:2, February 2010
National Center for Complementary and Alternative Medicine (NCCAM)

Thursday, October 20, 2011

Cold and Flu Season is Upon Us!

photo source: Shutterstock
As cold and flu season approaches, I have been thinking about how our kids are managed when they become sick.  Not only what we do to treat symptoms, but how, when, and where patients get medical advice and care.

We are a busy society.  We want things done now.  Quickly. Cheaply. Correctly.  Resolution so we can get back to life.

Illness doesn't work that way.  Most childhood illnesses are viruses and they take a few weeks to resolve. There's no magic medicine that will make it better.

Please don't ask for an antibiotic to prevent the runny nose from developing into a cough or ear infection.  

Don't ask for an antibiotic because your child has had a fever for 3 days and you need to go back to work.  

Don't ask for an antibiotic because your teen has a big test or tournament coming up and has an awful cough.  
Antibiotics simply don't work for viruses.  They also carry risks, which are not worth taking when the antibiotic isn't needed in the first place.

Many parents in this community have grown accustomed to using after hour urgent cares  because they are convenient.

Convenient isn't always the best choice.  Many times kids go to an urgent care after hours for issues that could wait and be managed during normal business hours.  I know some of this is due to parents trying to avoid missing work or kids missing school, but is this needed?  Can it hurt?

Some kids will get unnecessary tests, xrays, and treatments at urgent cares that don't have a reliable means of follow up.  They attempt to decrease risk often by erring with over treating.  Our office does have the ability to follow up with you in the near future, so we don't have to over treat.  
Urgent cares don't have a child's history available.  They might choose an inappropriate antibiotic due to allergy or recent use (making that antibiotic more likely less effective).  They might not recognize if your child doesn't have certain immunizations or if they do have a chronic condition, therefore leaving your child open to illnesses not expected at their age.  We know that parents can and should tell all providers these things, but our own new patient information sheets are often erroneous when compared to the transferred records from the previous physician... parents don't think about the wheezing history or the surgery 5 years ago every visit.  It is so important to have old records!
There is some evidence that treating things too soon does not allow our bodies to make immunity against the germ.  A great example of this is Strep throat.  Years ago we would go to a doctor when our sore throat didn't get better after a few days.  They would swab our throat and send the swab for culture, which took 2 days. We would treat only after that culture was positive.  That delay in treatment allowed our bodies to recognize the Strep and begin making antibodies against it.  Now kids are brought in the day they have symptoms, and if the rapid test is positive, they immediately start antibiotics.  The benefit? They are less likely to spread Strep to others and they can return to school 24 hrs after starting the antibiotic.  The negative? They might be more susceptible to recurrent illness with Strep, so in the end are potentially sick more often and end up missing more school.
Receiving care at multiple locations makes it difficult for the medical home to keep track of how often your child is sick.  Is it time for further evaluation of immune issues?  Is it time to consider ear tubes or a tonsillectomy?  If we don't have proper documentation, these issues might have a delay of recognition.
Urgent cares and ERs are not always designed for kids.  I'm not talking about cute pictures or smaller exam tables.  I'm talking about the experience of the provider.  If they are trained mostly to treat adults, they might be less comfortable with kids.  They often order more tests, xrays, and inappropriate treatments due to their inexperience.  This increases cost as well as risk to your child.  We have been fortunate to have many urgent cares available after hours that are designed specifically for kids, which does help.  But this is sometimes for convenience, not for the best medical care.
Cost.  As previously mentioned, cost is a factor.  I hate to bring money into the equation when it comes to the health of your child, but it is important.  Healthcare spending is spiraling out of control.  Urgent cares and ERs charge more.  This cost is increasingly being passed on to consumers.  Your co pay is probably higher outside the medical home.  The percentage of the visit you must pay is often higher.  If you pay out of pocket until your deductible is met, this can be a substantial difference in cost.  (Not to mention they tend to order more tests and treatments, each with additional costs.)

What about our urgent care in our office?  We offer a walk in urgent care as a convenience for parents who are worried about their acutely ill child.  It is within the medical home, which allows us access to your child's chart. We can keep all treatments within this medical record so it is complete.  Our staff follow the same protocols and treatment plans as scheduled patients, so your child will be managed with the protocols our physicians and midlevel providers have agreed upon.  Essentially we have a high standard of care and want your child to receive that great care.

So what kinds of issues are appropriate for various types of visits?  
(note: I can't list every medical problem, parental decisions must be made for individual situations)

After hours urgent care or ER:
  • Difficulty breathing (not just noisy congestion or cough)
  • Dehydration
  • Injury
  • Pain that is not controlled with over the counter medicines
  • Severe abdominal pain
  • Fever >100.4 rectally if under 3 months of age
Pediatric Partner's Urgent Care:

  • Fever 
  • Ear ache
  • Fussiness
  • Cough
  • Sore throat
  • Vomiting and/or diarrhea
  • Any new illness

Issues better addressed with an Appointment in the Medical Home:
  • Follow up of any issue (ear infection, asthma, constipation) unless suddenly worse, then see above
  • Chronic (long term) concerns (growth, constipation, acne, headaches)
  • Behavioral issues
  • Well visits and sports physicals (insurance counts these as the same, and limits to once/year)
  • Immunizations - ideally done at medical home so records remain complete 
If your child gets a vaccine at any other location, please send us documentation (including the date, brand, lot number, and place administered) so we can keep the records complete.
Remember our website offers answers to questions and many treatments to try at home for various illnesses and conditions!

Wednesday, October 19, 2011

Starting Solids-- The Old and the New and the Myths

Many parents are excited yet apprehensive to start foods with their infants.  So many questions, so many fears.  So much food introduction guidance has changed in recent years, that what you did with your older kids might not be current.  Change takes time, so not everyone agrees on the "new" rules.  Talk to your own pediatrician to see their take on it all!

The older "rules" for starting foods were so confusing... different sources will vary on these rules.
photo source: Shutterstock
  • don't feed before 6 months is now ok to feed at 4 months if baby's ready
  • don't give nuts, eggs, and other "allergy" foods until ____ (2/3/5 years, varying by expert) is now it is okay to give allergy foods unless there is a family history of food allergy
  • don't start more than one food every 3-5 days is now  introducing multiple foods at one time is ok
  • start with rice, then add vegetables, then meat., wait until last for fruit is now begin with any foods, but try to make nutritious choices, such as meat which is high in iron and protein
Variations of this were plenty, depending on the provider's preferences.  
No wonder there is so much confusion!!!!

New rules are much easier.  I like easier.

  • Start new foods between 4 and 6 months, when your baby shows interest and is able to sit with minimal support and hold the head up.
  • Don't give honey until 1 year of age.
  • Don't give any textures your baby will choke on.

That's it.  Nothing fancy.  Any foods in any order.  Multiple new foods on the same day are okay. Common sense will hopefully guide types of foods.  Nothing too salted. Try nutritious foods, not junk.  

These minimal rules can make parents weary.

What about food allergies if foods are given too early?

Research does not support the thought that starting foods earlier lead to allergies.  In fact, there is research to support that starting foods earlier might prevent food allergies.  A full 180 degree change!  Pregnant women and breastfeeding mothers no longer have to avoid nuts or other allergy foods in most cases.  If there is a close family member with a food allergy, it might still be beneficial to wait to introduce that food.  Talk with your pediatrician in that case.
I admit that I was initially nervous about telling parents it was okay to give nut products in infancy.  Not just the allergy aspect, but also choking risks.  ~ Back to the no textures your baby will choke on... nuts are hard and round-- two no-nos, peanut butter is thick and sticky-- another choking risk.   
Any of the more allergy prone foods should first be offered in small amounts at home.  These foods include nuts, egg, and fish.  Do this only if there is no one in your house who is allergic to that food.  Have diphenhydramine allergy syrup around just in case, but remember most kids are NOT allergic, and starting younger seems to prevent (not cause) allergy.  In the case of nuts, since there is also a choking risk, you can try a food cooked with nuts or nut oil.

What about saving the fruit for last so they don't get a sweet tooth?
Babies who have had breast milk have had sweet all along! Breast milk is very sweet, yet babies who are graduating to foods often love the new flavors and textures with foods.  Formula babies haven't had the sweet milk, but they can still develop a healthy appreciation of flavors with addition of new foods. Saving fruit for last simply doesn't seem to make a difference. Adding fruits alone is not very nutritious though, so fruits should be added along with other more nutritious foods.  The more colors on our plates, the healthier the meal probably is!
I thought they couldn't have cow's milk until after a year?
Cow's milk is not a meal in itself (like breast milk or formula). It is missing many vitamins and minerals, so babies need to continue breast milk or formula until at least a year.  Cow's milk may lead to allergies or eczema, including formulas made with cow's milk.  Milk products, such as cheese and yogurt can be given to babies as part of an otherwise well rounded diet as long as they don't show any allergy risks to milk.  Regardless of dairy intake, it is recommended for infants under 6 months to have 400 IU Vitamin D/day and those over 6 months to take 600 IU Vitamin D/day as a supplement.

I thought they should have cereal first...
Rice cereal has been the first food for generations, probably because grandma said so.  There has never been any research supporting giving it first.  With white rice and other "white" carbohydrates under attack now, it is no wonder the "rice first" rule is being debated. Despite being fortified with vitamins and iron, it is relatively nutrient poor, so choosing a meat or vegetable as first foods will offer more nutrition.  

Shouldn't we wait on meat?
Waiting on meat due to protein load was once recommended, but no longer felt to be needed. Pureed meats (preferably from your refrigerator... baby food meats are not very palatable!) are a great source of nutrition for baby!  Some experts recommend meat as the first food due to its high nutritional value and low allergy risk.  

How do we know what they're allergic to if we start several new things at once?
First, most kids are not allergic.  
Second, if they are allergic to a food, it is often days/weeks/months before the allergy is recognized. Waiting 3 days between food introduction simply doesn't allow recognition unless it is hives or anaphylaxis, and there are a small number of foods that account for most of these reactions. If your child has one of these reactions we can test to see what the offender was.  This is recommended with severe allergies since people with one allergy might have other allergies, and identification for avoidance is important.  
Allergy symptoms can be broad and often are not specific: dry skin (eczema), runny nose, hives, swelling of lips, difficulty breathing, vomiting, diarrhea, or blood in the stool.  If you think your child is allergic to a food, discuss with your doctor.  Severe symptoms (anaphylaxis) demand immediate attention!
How do we know when to start foods? I wanted to start to help baby sleep through the night, but I heard starting too soon increased obesity and diabetes.
When babies are able to sit with minimal support and hold their head up and when they show interest in food by reaching for it they might be ready.  They can wait until 6 months to start foods, but some studies show poor weight gain and nutritional balance as well as resistance to foods if started after 6 months.  
In formula fed babies it has been shown to increase the risk of obesity at 3 years (6x!) if foods are started before 4 months of age.  That risk is not seen in exclusively breast fed infants or those who begin foods after 4 months of age.
It is still an old wive's tale that starting solids will help baby sleep through the night.  Babies tend to sleep longer stretches at this age, so it is no wonder that this myth perpetuates.  Start foods because you see signs that baby is ready, not because you want longer sleep patterns!

How do I know how much to feed my baby?
Babies will let you know when they are full by turning away, pursing their lips, spitting out food, or throwing foods.  As they eat more food, they will need less breast milk or formula.  In general a baby who is gaining weight normally will self regulate volumes.

What's better: baby foods bought at the store or home made foods?
Marketing and ease of preparation has made pre-prepared foods for us all common place.  It does not mean they are any better.  They cost more than home made foods.  I didn't make baby foods when my kids were babies because I thought it would be too hard, but now I puree foods to put into recipes (my kids are like many who aren't fans of veggies and I want to improve their nutrition).  It really isn't hard.  You can take whatever you are cooking for your family and put it in a food processor or some blenders and with a little water to get it to a texture baby can eat: voila!  Home made food.  There are of course many baby food cook books and ideas of how to freeze meal-sized portions so you can make multiple meals at one sitting. There is help for parents who want to safely prepare baby food at home on How to Make Your Own Baby Food from What to Expect. (link updated 9.16.17)
My baby only wants table foods. Is that okay? Don't they need pureed foods first?  He doesn't have many teeth!
Pureed foods are what most babies start with due to the easy texture, but some babies quickly develop the ability to pick up small pieces of food with the pincher grasp (finger/thumb) and want to feed themselves.  If they are able to get the food in their mouth, move it to the back safely with their tongue, and swallow without choking, they are ready to  feed table foods... at least with some textures. Beware of chewy or hard foods as well as round foods ~ these all increase the risk of choking.  
Most babies will be able to eat table foods between 9 and 12 months.  They tend to not have molars until after 12 months, so they grind with their gums and use all their saliva to help break down food.  They need foods broken into small enough pieces until they can bite off a safe bite themselves.  
Don't put the whole meal on their tray at once... they will shove it all in and choke! Put a few bites down at a time and let them swallow before putting more down.  Rotate food groups to give them a balance, or feed the least favorite first when they are most hungry, saving the best for last!
This is a great time for parents, sitters, and other caregivers to take a refresher course on CPR in case baby does choke.  Infants and young children are more likely to choke on foods and small objects, so it is always good to be prepared!  

How much juice should my baby drink?
In general I think babies don't need juice at all. They can practice drinking from a cup with water.  Juice adds little nutritional value and a lot of sugar.  Eating fruit and drinking water is preferable.  If they do drink juice, it should be 100% fruit or vegetable juice, not a fruit flavored drink!  No more than 4 ounces/day of fruit juice is recommended. 

What about organic? 
There is not enough evidence to recommend organic food, since the nutritional components of the foods are similar regardless of how they were farmed.   
Organically grown foods do have lower pesticide residues than conventionally farmed produce, but it is debated if this is significant or not to overall health.  Conventionally farmed produce have the pesticide levels monitored, and they fall within levels that are felt to be safe.
Organic farming rules also dictate no food additives or added hormones, which is also an area of study for health risks and benefits, but not enough data is available to give an educated opinion yet.  
Organic farming is generally felt to be better for the environment, but the sustainability of that is questioned.  
Organic farming might increase the risk of bacterial and fungal contamination or heavy metal content, so it is very important to wash fresh fruits and vegetables well prior to cutting or eating (as you should with all fresh foods).  
For more information, see the USDA site.
A backyard garden can be inexpensive, organic, and a great way for your kids to learn about growing and preparing healthy foods!