Summertime = School Physical Time!

Summertime is the time many school aged kids get their annual check ups. In Kansas it is important that high school aged kids do their physicals after May 1st if they want to participate in a school sport. Other kids simply don't need to miss school on their birthday to do a physical. It's also good to avoid our office during sick season if possible. For all these reasons, summer time is a great time to have a well check. So if you haven't scheduled your physical exam yet, it's time to call! Appointments do fill in fast.

Why do healthy kids need to come in? It's recommended that kids have annual screenings for growth, development, injury prevention, and more. Actually there's so much that we are supposed to discuss and do at a well visit that it is impossible to do it all in a standard 20 minute exam. (See Drowning in a Sea of Advice for more.)

To help with this enormous volume of information, we use handouts and our website to share a lot so we can spend time at the visit discussing your other questions. Please take the time to register each of your children on our website so you will get a pre-visit e-mail. This is becoming even more important as we are trying to be your true medical home and provide the best care to every patient with their unique needs.

To register, simply go to www.pediatricpartnerskc.com and click on the "Create an Account" tab at the top of the page and fill in the information. (Note: Firefox seems to be the best browser for our website. If you are using Explorer or Safari and cannot get the site to load properly, try Firefox.)

Once you've registered the first child, it's easy to add family members. See our How To page for details!

By registering each child you will be able to not only receive these informational pre-visit e-mails, but also ask questions to our front office staff or your favorite providers in a confidential password-protected manner, and pay bills online. Everything is confidential and we will never sell your personal information. 

Our pre visit e-mails have age-specific information to consider before your visit. Please take the time to read through it. Each e-mail has a homework section that is especially important. If you do your homework before the visit, you will find the visit to run more smoothly and you will get more out of it.

This summer I am doing a test of sorts. We are including several printables on the pre-visit e-mail to make your office time easier. You can print your patient information sheet if needed (due once/year, usually at the annual checkup, so young children who come more often don't always need these). We are starting a pre-visit questionnaire that will help identify any concerns to address at the visit. I am hopeful that we will be able to cover more of your specific questions if we know you have read the information on the e-mail, so we don't have to repeat all of the standard things. This should allow much better use of time at your visit to address your concerns.

Watch for your pre-visit email and take the time to read it! I hope to see your kids for their well checks soon!

My child swallowed....

It happens all the time. Kids put things in their mouth that aren't supposed to be eaten. Parents often call about what to do when their toddlers or children swallow things. Most of the time things will just pass -- though I'm not a fan of watching the stools for the swallowed object because it just worries parents if they miss it.

The biggest risk group is children between the ages of 6 months and 6 years, but anyone can be at risk. I have seen an older school aged child swallow a magnet after putting 2 small strong magnets on either side of their tongue to look like a tongue piercing. Adults have been known to swallow things such as needles (many sewers put the needle in their mouth if you think about it).

If you are around kids it is a good idea to know child CPR and refresh your skills every couple years. Classes are often held at local Red Cross stations, hospitals, or fire departments. You can also find classes by searching "CPR" and your zip code. For great information on signs and symptoms of choking and general treatment of choking, visit this KidsHealth Choking link.

If your child seems to put more non-food items in his mouth than other kids, he is at risk of pica. Pica is when a person compulsively puts non-foods in his mouth. For more see the KidsHealth Pica link.

Always keep the poison control number (1-800-222-1222) stored in all your phones! You will see below that I refer to them often. If you call your doctor about a potentially toxic substance, chances are we will refer to poison control. They have the best database of substance risks and their treatments. Don't delay treatment by calling the doctor!

For more information: http://www.aapcc.org

Here's a list of common things and what to do.

• Balloons: Balloons are statistically some of the most inhaled or ingested foreign bodies. One reason is they are so popular with kids, and often are found at parties or other large crowds, where toddlers and young children are often less directly supervised. They can suffocate a child quickly if they are inhaled. Call 911 if there is any difficulty breathing, drooling, or other signs of distress. If swallowed, they will pass on their own.
• Batteries: If you think your child has swallowed a battery, whether or not he appears distressed, immediately take him to an emergency room. If there is distress, call 911. Batteries can cause voltage burns or leak, causing acidic burns as soon as four hours after being swallowed. X-rays will confirm if the battery is in the chest or abdomen. They usually need to be removed to prevent serious injury. Be sure to keep all of your batteries, especially the small button batteries, safely stored away from children.
• Bugs: Most of us has swallowed a bug some time in our life. You might not even know if a small one hides in your soda can and you take a big gulp. A little extra protein, right? Unless your child chokes, or if it has a stinger (bee, wasp) there is nothing to worry about. If he's choking, follow choking instructions (link at top). If you suspect a bee or wasp was swallowed, especially if your child seems to be reacting to a sting in the mouth, or there's sudden difficulty breathing, drooling, or choking, call 911. Serious reactions to stings in the mouth can occur.
• Buttons: Buttons, much like coins, are generally harmless unless they get stuck. See the information on coins. Unlike coins, they are not easily seen on X-ray, which can make identification of a stuck coin a little trickier, but if you suspect an issue, talk to your doctor.
• Cleaning products, laundry detergent, and other chemicals: These are highly dangerous and you should call poison control with any suspicion of ingestion or 911 if there are signs of distress. These should always be stored away from children to prevent the possibility of swallowing in the first place. Even the "green" products are usually not safe with ingestion.
• Coins: Coins are some of the most frequently swallowed objects. These usually pass through the body without any problems. Unfortunately many parents never see it come out the other end. Since it is so common you would think there would be a consensus as to how to manage it. There isn't. Of course if there is any distress, drooling, breathing difficulty or coughing, your child should be seen immediately, ideally in an ER so that an immediate surgical consult can be made if necessary. If it was inhaled into the windpipe instead of swallowed into the esophagus or stuck high in the esophagus causing compression on the wind pipe, it may need to be removed. As for kids who swallow coins and have no symptoms, it isn't as clear cut. Some doctors get X-rays for all children who swallow a coin to be sure it isn't stuck in the esophagus (about a third of those stuck eventually end up passing, but most need to be removed). Others only X-ray if there are symptoms. Some remove the ones in the esophagus immediately, others will wait up to 48 hours if there is no distress. Generally once it reaches the stomach it will pass.
• Crayons or play doh: I used to wonder why so many things were labeled "non-toxic" -- at least until I had a child of my own. They put everything in their mouth! These are generally safe (again, unless they choke), although it is possible that these things contain lead or other contaminants. If your child frequently puts them in the mouth, it is probably a good idea to not allow them near your child and talk to your doctor about pica (see link above for more information). 
• Dirt or rocks: Unless your baby chokes or bites down on a rock and breaks a tooth, dirt and rocks are generally harmless. If your child seems to crave these and eats dirt compulsively, see the pica link above.
• Energy drink: Energy drinks are a popular choice for many, but they contain caffeine and other stimulants that can make them dangerous for children. Call poison control for instructions.
• Grass or plants: Unless the grass was recently chemically treated or if the plant is poisonous, there is little to worry about here. If you're unsure about a plant being poisonous, contact poison control. If there is choking, do CPR or call 911.
• Gum: Contrary to popular belief, the occasional swallowed gum does not stay in your gut for years. It isn't digested like other foods, but unless it gets stuck along the way, it finds its way out just like all your other food. 
• Hand sanitizer: Hand sanitizer in small amounts, such as putting fingers in the mouth after rubbing sanitizer on the hands, is generally safe. Larger amounts can be dangerous and you should call poison control if you suspect ingestion.
• Magnets: A single magnet is not a worrisome as multiple magnets, but since it often is not known exactly what a child swallows, it is always recommended to take your child to be evaluated if there is a suspicion of swallowed magnets. They will need X-rays and if there are multiple magnets, they must be removed to prevent perforation of the gut.
• Medicines, vitamins, supplements: If your child swallowed (or potentially swallowed) a medication or supplement, call the poison control number ASAP. Have the bottle with you so you can answer their questions.
• Nicotine: Sadly ingested nicotine has been an increasing problem since e-cigarrettes have been on the market, but even regular cigarettes, cigars, and their ashes pose problems. Effects of nicotine poisoning include vomiting, sweating, lethargy and tremors in mild poisoning and confusion, paralysis, and seizures in severe poisoning. If you even think your child has eaten a nicotine product, call poison control (or 911 if significant symptoms).
• Pet food: As disgusting as it smells to me, kids love to eat pet food. The biggest risk here is choking. If they choke, use your CPR skills. If you're not confident with CPR, call 911 and they will walk you through it.

• Pop-top from a can: The flip top that opens a soft drink can is usually not a concern unless a child chokes on it. It generally will pass through the intestines if swallowed, but if there are signs that it was inhaled or is stuck in the intestine, a child should be seen. These do not show up on X-ray because they are made of aluminum. 
• Poop: This one is gross, but happens more than any parent wants to know. Many babies stick their hand down their diaper and then the hand goes to his mouth. While this is really gross, it does not cause any danger to the child. If it is his own poop, he will not be exposed to any new germs. If your child finds someone else's poop, usually animal poop, there is a little more concern for infection but still pretty low risk. Symptoms of nausea, vomiting, diarrhea, and low grade fever usually happen within 30 minutes to 4 hours after the ingestion if they are affected. In this case, treat symptoms as you would any other stomach bug and call your doctor. For specific information of various types of poop (even raccoon!) check out the Illinois Poison Control blog on poop. 
• Salt and baking soda: These common kitchen items do not raise fear in many people, but if either is taken in large amounts, they can cause serious problems. One tablespoon of salt in a toddler can cause seizures due to electrolyte imbalances. More can be deadly. One tablespoon of baking soda changes a body's pH and can cause serious injury. If your child swallows either of these, call poison control immediately. 
• Sharp objects: Any pointed object such as toothpicks, wire, chicken bones, open safety pins and hair pins can pierce the gut. If you think or know your child has swallowed one of these, get the child to the emergency room immediately. 

Screen Free Challenge

Are you up for a challenge?

Join thousands of other families who want to reconnect by going screen free for the week of May 5 – 11, 2014.

What does screen free mean? To put it simply: do not use anything with a screen unless it is directly related to work or school. Televisions, computers, smart phones and other screens are all a part of our world, but they can overtake our lives. By consciously avoiding non-essential screen time, we can reconnect with our family and friends and even ourselves.

Does going screen free for a week sound impossible?

For many people screens are an essential part of our lives. We use online calendars so we can remember our daily schedule and share it with family. We use online resources to make purchases, or research a topic. Computers help us conduct business and more. Texting allows quick communication. Less essentially we use screens to keep up with friends or to share what we’re up to. We play games. We watch movies and television shows. We use screens as a cheap babysitter. It is a huge recreational pastime. It’s easy and inexpensive.

But there are many costs.

• Do your kids complain that you’re always on your phone or computer? Maybe they don’t verbalize it but they might show it with disruptive behaviors. And remember you’re their role model. They will do as you do. But they’d rather spend time with you. Even the teens who deny it. 
• Do your children throw a fit when you tell them to turn the screen off? This can be a sign of addiction, or at least poor self-control. Aggressive tendencies are often exacerbated by screen time.
• Children lose time outdoors and in other active and creative play because they’d prefer to watch television or play a video game. Screen time is directly correlated with obesity, behavior issues, and sleep problems. Active play and social interactions can help with each of these problems.
• Infants and children learn best through human interactions and exploration, yet a screen sometimes mesmerizes them for hours at a time. Some of us feel comforted that our kids are learning by playing some of these games or watching certain “educational” programs, but this is often not the case. Studies do not show beneficial learning, especially in young children, with screen interactions. In many cases time spent on these games and programs is detrimental to their development.
• The typical school aged child has more screen time than ANY other activity except sleep!

Just think of all the free time you will make by turning off the screens. Have every member of your family make the commitment and help each other find new ways to connect.

Because most of spend over 2 hours a day with recreational screen time, we can capture that time to play a game with our kids, take a walk, read a book, write poetry, do a craft project, clean out the garage, garden… the list goes on. Let your kids do things and experience life instead of letting them watch or play with something someone else created for them. And it’s okay to just spend time together talking. Sometimes it’s those simple times that become our most special memories.

Unplug. Start with just one week. See where it takes you!

101 Screen Free Activities

Related posts:

Screen Free Week April 29-May 5, 2013

Screen time: Do you have a love - hate relationship with it?

Quest for Health: Why Screen Free?

Quest for Health: Screen Free Week Reflections

Resources and More From Around the Web:

Screen Free Week is Just around the Corner!

Following FTC Complaint, Baby App Developer Stops Making Educational Claims

These Apps Will Not Educate Your Baby

ScreenFreeWeek.org

Screen time: Do you have a love - hate relationship with it?

Screen time. Parents often have a love - hate relationship with it. We've all heard the warnings that it is bad for our kids, but we've experienced the benefits of it keeping our kids occupied while we get things done. And some programs and games have an educational component -- do we group those in the same category as purely entertaining ones?

Most parents by now have heard the recommendations that kids under 2 years should have no screen time. At all. And older kids should have no more than 10 hours / week total.

Most parents are also fully aware that their kids exceed those guidelines. Some by a little. Others by a  lot. There are all kinds of reasons parents have for allowing this. Some are good reasons, others are not.

To be honest, there is still a lot we don't know about screen time. Research continues. When I was a child, television and movies were just passive watching. Thankfully there wasn't much offered, and with a limited number of channels, we usually stuck to watching tv only on Saturday mornings. Other times we played outside. Shows were not as action packed and overstimulating as those of today. Compare Mr. Rogers to pretty much any show designed for kids today with quick scene changes, music in the background and motion everywhere. Now there are interactive games, many of which are educational, or at least they seem to be teaching letters, counting, or other skills. There's even Wii and Kinect that use whole body movements to get kids off the couch. One can get a good workout with some of the games, but Wii bowling is nothing compared to real bowling.

So how do you count educational and active game time? Should it be included in that 10 hours/ week, or should you allow extra time for it? Are e-readers a form of screen? They often allow interaction like a computer and many can show videos and offer games.

Short answer about counting total screen time: We don't know.  Experts can give thoughtful opinions, but really at this point it's all educated guesses.

Some studies show that kids learn better when things are presented on a computer or video format. Maybe it keeps their attention better than a paper workbook. I love the ability to hold my finger on a word in an electronic e-reader and have the pronunciation and definition pop up. How many times as a young reader did I simply skip over words I didn't know? My daughter likes to increase the font size so only a sentence or two are on the screen. She feels like she reads faster because she "turns the page" more often. Does this build her confidence reading? Does it actually slow her down? I don't know. But she's happier to read and it seems to work for her. (This does drive me nuts if I pick up the Kindle after she's changed the settings... but I can change it back to my preferences easily.) Are kids losing the ability to find things in alphabetical order, such as using an encyclopedia to look something up, since they just hit "search" and find the answers? Does it matter?

Parents must really pay attention to what kids are watching and playing as well as how much time they are spending on a screen. For every minute they are on a screen they aren't interacting with people to work on social skills, they aren't outside playing games and getting exercise. If the games they are playing help develop thinking skills, strategy, math, reading, and more, then some screen time every day can benefit. If the content has violence or other age inappropriate material, it can be very detrimental. If they are online playing against other people, dangers multiply. While I can see kids who hate to read actually not notice how much they must read to play a game on a computer or tablet, are there better ways to get them pumped into reading a book?

There's a time and place for everything. The dinner table and bedroom are never a good place for online/screen time. Watch and play with your kids. They will love the time with you and you can better supervise what they're exposure is and modify it as needed.

More information:
Media Resolutions Every Family Should Make in 2014 has some tips to help monitor and limit screen time.
For information on internet safety, check out YourSphere for Parents.
American Academy of Pediatrics Media page.

Shorted at the pharmacy

Has this ever happened to you? Your baby has an ear infection, so you pick up the antibiotic and diligently give it as directed on the bottle. Every day you remember it because you want the infection to go away. But as the days pass, you notice there isn't enough in the bottle to give the full 10 days of medicine.

We get frequent calls from worried parents that they run out of medicine before the full course is completed.

Since pharmacists give exactly the amount calculated for the dose to be dispensed, it is understandable that it doesn't quite last that long.

Why?

A little medicine will stick to the insides of the bottle. A few drops can be lost on a syringe. If you're using a dosing cup, it can be over or under filled by a few milliliters (or more if you look at an angle) each time you use it. Add a few milliliters with each dose, often twice a day for 10 days, it is easy to see how you can be off by a couple teaspoons by the end of the 10 day course.

photo source: Shutterstock

When I was in training, I was taught to increase the dispense volume by 10- 20%. This means if a child would take 5ml twice a day for 10 days I would give 110 - 120 mls.

5ml x 2 x 10 days = 100 ml

10% x 100 ml = 10 ml "extra" or 20% x 100 ml = 20ml "extra" 

100ml + 10ml = 110 ml or  100ml + 20ml = 120 ml

Pharmacists no longer will give extra volume. If the dose is 5 ml twice a day for 10 days, they will only give 100ml. That means there is no wiggle room. Small drops of "waste" all add up by the end of the bottle and you will come up short.

What you can do to help:

Can you tell from the poor photo quality that this was taken by me with old dosing devices I found at home?

• Only use a medicine dispensing container, such as a syringe, dosing spoon, or dosing cup. A cereal spoon varies in size and is not reliable.
• Shake the bottle before dispensing liquid medicines.
• Tighten the lid after use to decrease the risk of spills.
• Store the medicine away from kids. 
• Refrigerate medicines if needed - the label should state this.
• Measure carefully. 
• If the dosing device is labeled with a different measurement type (such as tsp vs ml) be sure you know the conversion-- if not, ask the pharmacist before you make the purchase.
• Syringe: Use the smallest syringe that will fit the entire dose. For instance, if your child needs 0.6 ml, but you use a 10ml syringe, it will not be accurate. Be sure to hold the syringe straight up and down, not at an angle, or one part of the liquid will be higher than the other. Also be sure the syringe is marked for the dose you need to give-- don't guess where 3.75 is between 3 and 4. 
• Medicine cup: I find it helps to put the medicine cup on the counter to level it out, then I get my eyes at the level of the cup to measure. Again, be sure it is marked for the volume you need.
• Medicine spoon: Hold it at eye level straight up and down to align the medicine with the appropriate line.
• If you use a syringe, see if the pharmacist has a syringe adapter for the bottle (as pictured above) to be able to hold the bottle upside down to avoid sticking the syringe into the bottle and losing medicine on the outside of the syringe.
• Don't share medications. 
• Don't save "leftover" medicines for another time. Liquid medicines tend to expire pretty quickly and no prescription medicine should be used without a professional evaluating the need for it.

Despite your best efforts, it is possible that you will run out of medicine before the full number of doses you were supposed to give. 

• If it is an antibiotic: There is research supporting shorter courses of antibiotic work as well as the traditional 7-10 days for some infections, so you might just need to have your doctor check to be sure the infection cleared before filling another prescription. 
• If it is a long term medicine that needs to be taken daily: Talk to your doctor to see if they can help get a little more medicine per bottle if you routinely are short at the end of the month.

Developing healthcare responsibility in your children

I am writing this fully knowing I am at risk of upsetting some parents. But this is the time of year we see more school aged kids for their annual physicals, so it is the time of year I think about how parents could help their kids grow into independent adults or hinder that growth by trying to be a good parent.

source: Shutterstock

I read an article recently (The Overprotected Kid) that really hit home with me about how parents try so hard to keep their kids safe that we sometimes prevent them from learning about real life. Although the article is based on allowing kids to roam and play with things that haven't been engineered to keep them safe, it did touch on the fact that parents hang around to answer for kids and speak up for them.

I find that parents often try to help their children during visits to my office by answering questions about their health, sometimes even what they are feeling. I'm sure they want to be sure I know their (parent) perspective. Maybe they are just trying to speed up the visit so they can leave and do the other things on their to do list. But it usually ends up taking longer, because I then spend more time trying to talk to the child.

When a question is directed at the child, let the child answer. If I need parental clarification, I'll ask for it. Obviously a pre-schooler needs more help than a high schooler, but if the teen has never had the opportunity to answer for himself, he might not have the skills and confidence to do it.

Sometimes a parent will start asking their child questions or tell them to tell me about .... I'm sure they are thinking that it is helping me, but it doesn't. (I'm not talking about the parent reminding the child to tell me something they previously discussed, I'm talking about the parent who in response to something I've asked tries to draw the child into conversation-- that's my job.) I have a set amount of time to assess a child's physical exam as well as other factors, and I have a process of evaluating all the points I must consider.

When I ask a child a question, I'm not only looking for the answer they are giving, but I'm also gaining valuable information about the child. Can they speak clearly? Do they understand a question that is age appropriate? Do they make eye contact? Are they developmentally mature for their age? Do they understand how their habits effect their health?

So often well intentioned parents pipe up and answer questions directed at the child. It doesn't matter if I'm looking directly at the child, the parent answers. Even if the child starts to answer. I will often redirect to the child for clarification and the parent still answers. Some of the kids roll their eyes. Others take it in stride without much of an expression at all, as if they're used to their parent taking care of everything. Some simply turn back to their hand held game and play, ignoring the grown ups in the room. Ugh! How does that help me get to know the kid?

Sometimes I wonder how the parent makes it through the day when the child is at school since they can't be there to speak up for the child all day there. It can be that bad.

I really worry about the older school aged kids, especially those in high school, who have parents answer for them. How will they be able to assume their healthcare responsibilties once they turn 18? If they don't know about their past medical history, allergies, and family medical history how can they eventually establish healthcare with a new physician without a parent? If they can't give a clear and concise summary of what their symptoms are for an illness, what will they do when you're not there?

And yes, I see parents piping up for their high schoolers.

I guess it's a learned behavior for all. Parents get used to answering the questions for pre-verbal kids, and they keep doing it.

Please stop.

Let kids in elementary school be prepared to order off the menu when the waitress comes to the table -- after discussing their choice before she gets there if they need help deciding on a healthy item. Have older elementary kids speak up at the store to ask for help when they need a dressing room or if they need a price check. Let them talk to their teachers first if they question a grade or need help learning a concept. Let them give their own health summaries at the doctor's office. You can be there for support along the way, but offer less and less as they get older and more experienced.

If your child has true inabilities to do these things there might be an underlying problem, such as anxiety or developmental delay. Those should be addressed. But by far and away most school aged kids can do these things. Let them.

They need to do these things to be able to one day live independently. Trust me, they will appreciate it some day! Too many college kids call home for parents to "fix" things that the young adult should be able to handle. But they can't jump into the deep end of the pool without learning to swim along the way.

Hair loss in children

Spring is a time I often hear complaints of hair loss. It only took a couple seasons to notice the pattern, both in the office and with my own hairbrush. I have long suspected that it is similar to our pets shedding unneeded hair this time of year, but have never been able to find supporting evidence, at least on a reputable site.

Notice the hair loss pattern.
Photo source: Shutterstock

What I do see reproduced on many sites (mostly hair clinic sites, nothing I would rely on for information) is that both Fall and Spring are a time of normal hair thinning. Studies link hair growth to sun exposure and melatonin levels. I am definitely not a hair expert, but wanted you to know some warning signs of abnormal hair loss and when it is safe to wait it out.

Most of us lose 50-100 head hairs a day. Long hair is obviously more noticeable when lost, since it plugs shower drains, accumulates on brushes, and is seen on our clothing. Simply seeing hair being lost is not a concern.

Hair loss causes

Some causes of hair loss are easily identified. Others are harder to identify because associated symptoms are vague and not always noted to be associated with hair loss. If you are concerned, make an appointment to discuss it with your child's doctor. Since this can be a chronic issue, it is not ideally handled at an urgent care or walk in clinic. If indicated by the findings of their exam, your child's doctor may refer to a dermatologist, endocrinologist, or other specialist, but many of these can be managed by the pediatrician.

• Traction: Braids or other hair styles that pull the hair shafts (as in picture above) can cause hair loss in a pattern easily identified by the hair style. Treatment is simple: stop styling the hair with traction. If continued, damage to the hair follicles might make regrowth impossible.
• Babies often have hair breakage from friction on the back of their head. It usually develops the first few months of life. When they start sitting up most of the day and sleeping on their tummies it regrows. (Note: Do NOT put your baby to sleep on his tummy to prevent this. Tummy sleeping is associated with SIDS.)
• Trichotillomania (or hair pulling disorder) is the compulsive urge to pull out (even sometimes eat) hair. It can be seen in infants and toddlers, but peaks in young school aged kids. Treatment can be difficult and involves behavioral therapy. There is some encouraging research into N-acetylcysteine (NAC) treating trichotillomania and other behaviors. 
• Ringworm of the scalp is a fungal infection that can cause hair to break, leaving the base of the hair in the scalp. The skin can appear red and/or scaly. It can be secondarily infected with bacteria, causing swelling, pain, and drainage. After the diagnosis is confirmed, an oral medication is needed. 
• Malnutrition can cause thinning of the hair, growth problems, behavior problems, muscle wasting, and abdominal swelling. Too little iron and/or protein in the diet can lead to hair loss. Biotin, zinc, and B12 deficiency are specific associations. In this country malnutrition is very uncommon. Treatment involves improving nutrition and addressing any underlying condition causing the malnutrition.
• Too much Vitamin A has been linked to hair loss. If your child takes supplements, be sure to let your doctor know when you are discussing hair loss.
• Hypothyroidism (low thyroid levels) has many symptoms, including thinning of hair. Not all need to be present, and some symptoms can be there without hypothyroidism because they are vague and common issues. Hair may become brittle and break off more easily. Hypothyroidism can cause kids to feel tired and not have much energy. Constipation is a frequent complaint. Heartbeats might slow and kids may feel cold when others are comfortable. Skin is often dry. Kids can slow their growth and may become overweight. Blood tests can help identify hypothyroidism and thyroid hormone replacement can treat it.
• Uncontrolled diabetes can affect hair growth and loss. Working with an endocrine specialist is important to get diabetes under control.
• Polycystic ovarian syndrome (PCOS) can affect hair thickness. Girls with PCOS can have excessive hair growth on their body but male pattern hair loss on the head, acne, obesity, diabetes, heart disease, high blood pressure, and abnormal menstrual cycles. Blood tests along with a history and physical can help identify PCOS. 
• Medications can cause hair loss. The most commonly known type are chemotherapy drugs, but also some acne medicines, anabolic steroids and lithium can cause hair loss. If hair loss is a concern, be sure your doctor knows all the medicines and supplements you give your child.
• Alopecia areata causes patches of hair loss. It is an autoimmune disease --the body's immune system attacks the hair follicles. The patches can be small or cover the entire head (or even body). Skin in the area is normal. See the link above for more information.
• Hair treatments: chemical treatments, such as coloring, straightening, bleaching and curling can lead to hair loss. Heat from a hair dryer, curler, or flat iron can break hairs. Even combing wet hair leads to more breakage because wet hair is more elastic. Limiting these treatments can allow hair to re-grow.
• Severe stress, including that from infection or surgery, can lead to sudden hair loss. Because hair grows slowly, this is seen many weeks to months after the event. It will re-grow, usually within 6 -12 months.