Daily Dose

Have Your Child's Blood Pressure Checked

1:00 to read

When you take your child in to the pediatrician for a check-up do they check their blood pressure? The American Academy of Pediatrics (AAP) recommends that children, beginning at the age of three years, should routinely have their blood pressure checked.  

In certain circumstances a younger child should have their blood pressure checked too. With the growing epidemic in obesity, pediatricians are seeing more children with abnormal blood pressure readings. It is important that the right sized blood pressure cuff is used for measuring a child’s blood pressure. There are standards for blood pressures for different age children. The standards are also based on a child’s height.

When a child’s blood pressure reading is greater than the 90th percentile for their age they are said to have pre-hypertension. The prevalence of childhood hypertension is thought to be between one and four percent and may even be as high as 10 percent in obese children. Obesity plays a role but, related to that is also inactivity among children, diet, and their genetic predisposition for developing high blood pressure. Then it is appropriate for further work up to be done to evaluate the reason for the elevation in blood pressure.

If I find a child with a high blood pressure reading during their physical exam, it is important to re-take their blood pressure in both arms. I also do not depend on automated blood pressure readings, as I find they are often inaccurate and I prefer to use the “old fashioned” cuff and stethoscope to listen for the blood pressure. If the blood pressure reading is abnormal, then I have the child/adolescent have their blood pressure taken over a week or two at different times of the day. They can have the school nurse take it and parents can also buy an inexpensive blood pressure machine to take it at home. I then look at the readings to confirm that they are consistently high. The “white coat” syndrome, when a doctor assumes that the elevated blood pressure is due to anxiety, may not actually be the case, so make sure that repeat blood pressures are taken. If your child does have elevated blood pressure readings it is important that further evaluation is undertaken, either by your pediatrician or by referral to a pediatric cardiologist.

That’s your daily dose, we’ll chat again tomorrow.

Daily Dose

Toddler Behavior

1:30 to read

Toddlers....you gotta love them but they can also drive you a bit crazy! I have seen several parents lately who have said, “he/she turned from a cute loving baby to a toddler overnight, what happened?”  What happened is that this cute baby reached somewhere between 12-18 months of age, and went to bed one night and read, “how to become a toddler....in 3 easy steps”.

I think of a toddler as being somewhere between 1-3 years of age.  They are now exploring the world on two legs and walking turns to running in a matter of weeks. Most toddlers can run faster than their parents.  They are also just starting to learn language and soon after finding Momma, Dadda, and uh-oh, they learn the word NO.  Oh dear, it doesn’t matter how much you try not to use the word, a toddler quickly learns to shake their head, stomp their feet and fall to the floor when they don’t get their own way....you don’t even have to say NO.

Toddlers are notoriously egocentric and narcissistic, it is all about ME. ( just wait for those teenage years).  They want everything to go their way, and are incredibly frustrated when it doesn’t.  This means that throughout the day when the meal is just not quite to their liking, or the toy you offer them is not the I-phone that they wanted to play with, or you take them to bed at the end of a long day....their reaction is the same, “I don’t like this!” and this means crying, throwing the toy or arching their back and flopping to the floor as you try to get them into bed.  You, the parent, are being totally appropriate and are teaching your child limits and boundaries and rules...they just don’t like it!! ( and who does, right?)

Toddlers are just beginning to comprehend that they cannot always get their way. They often lash out when frustrated with biting, hitting, and screaming while laying on the floor and acting like they are having a seizure.  All of this is inappropriate, age appropriate behavior. Our job as parents is to continue to be consistent and calm while redirecting their behavior.  It sounds much easier than it it. How can a 25-40 year old lose to a two year old....easy!

But, you cannot lose...you just re-direct..   If they are throwing food you take the meal away, they hurl a toy at their sibling, you put the toy up,  and you hug and kiss them and put that limp or screaming body to bed when it is bedtime.  Rules need to start at this age...you are setting up behavior for the rest of your child’s life.  Toddlers do turn into loving and well behaved pre-schoolers but it takes a lot of patience on a parent’s part to get there.  Be strong and consistent.   

Daily Dose

War On Zika Virus

1:30 to read

There seem to be updates everyday on the latest cases of Zika virus both in the U.S. (to date all of which have been imported) and in more and more countries in the Caribbean. At the same time, there is more information being released  by the CDC and the World Health Organization on the virus, its effects, how to diagnose it, who should be tested and prevention.  There are also many scientists around the world who continue to work on diagnosing, treating, and preventing the Zika virus. Despite all of this there is still a lot to learn and many questions still remain about this rapidly spreading virus.

The CDC has just documented the first case of the Zika virus being transmitted sexually in this country.  The case was actually confirmed in Dallas after the patient had returned from a trip to Venezuela and was diagnosed with Zika virus. Subsequently his partner, who had had unprotected intercourse within 2 weeks of the initial patient’s return, was diagnosed with Zika virus. Fortunately, there was not a fetus involved in this case and both of the patients have recovered. Because of this the CDC has now issued new guidelines stating “men who live in or travel to areas of active Zika infections and who have a pregnant sexual partner should use latex condoms correctly, or refrain from sex until the pregnancy has come to term”.  Questions still remain about possible viral transmission from saliva and urine and further information will be forthcoming. 

The CDC also changed the guidelines for pregnant women who have traveled to areas with known Zika virus and are concerned about possible exposure.  While they had previously recommended that only those with at least 2 symptoms of the virus (which include rash, fever, joint pain or conjunctivitis) be tested, they now have more data on the accuracy of the tests and the new guidance states “pregnant women without symptoms can be offered testing between two to 12 weeks after travel.” So if you are concerned consult your Ob-Gyn. 

I am also getting questions from young woman who have been “trying to get pregnant” or who are even “thinking about getting pregnant” and they want to know if they should “delay getting pregnant”?  While I am concerned about the spread of the Zika virus, I do not think that women in the U.S. should alter their plans to become pregnant.  But, at the same time, I am advising these women to change their plans and to cancel any and all travel to the Caribbean, Central and South American countries with known Zika virus until after they have conceived and given birth…so in other words for at least 9 -12 months and maybe more. Why risk an exposure when not necessary? 

While this virus is expected to spread to the U.S. this summer there is some thought that it may be our southern states with hotter and more humid weather who will have the greatest likelihood of seeing significant Zika virus. Again, this is based on historical as well as ongoing research.  What is known, is that the Aedes mosquito (the type that carries Zika) has previously been found in most states in the United States. I have had one mother who is pregnant call and ask if I thought she should leave the state of Texas this summer, and move north to a cooler climate!  While that seems a bit extreme,  no one knows what impact Zika will have here until the temperatures warm up. In the meantime I advised her to start wearing insect repellant that contains DEET or picardin, as well as to wear long sleeves and pants and to try and stay inside during peak mosquito hours (dawn and dusk), as we still have mosquitos in Texas even at this time of year.  Might as well get in the routine now.

Stay tuned…

Daily Dose

It’s The Season For Bug Bites & Stings

1:30 to read

Children love to be outside in the spring and summer when the daylight is longer and the backyard, playground, or campsite can become a magical play space. Insect bites are bound to happen. Most are just an annoyance, but make sure you know which ones to be concerned about and which ones may just require a hug and a kiss.It’s that time of year when insect bites and stings start showing up on your kids. Knowing how to prevent and treat common insect bites and stings, and knowing when to not overreact, can help keep your kids safe and healthy.

Babies and children may be more affected by bites or stings than adults. Let’s start with some common spring and summer insects. Spider bites Most spider bites do not actually penetrate the skin, and the majority of spiders found in the U.S are mostly harmless with the important exception of the black widow spider and the brown recluse spider, which are both dangerous to humans. Spider bites are fortunately uncommon. In many cases, presumed spider bites are actually due to another skin condition or an insect sting. The black widow spider is said to feel like a pin-prick, and some victims do not even realize they have been bitten. Sometimes you may notice double fang marks on the skin. The most common symptoms where the bite occurs are immediate pain, burning, swelling, and redness. Other symptoms may include chills, fever, nausea and vomiting, and severe abdominal pain. While black widow spider bites are hardly ever fatal, rare deaths have occurred from brown recluse spider bites and are more common in children than in adults. At first the bite of a brown recluse spider leads to a mild stinging, followed by local redness and severe pain that usually develops within eight hours but may occur later. Some reports of brown recluse bites describe a blue or purple area around the bite, surrounded by a whitish ring and large red outer ring in a "bull's eye" pattern. A fluid-filled blister forms at the site and then sloughs off to reveal a deep ulcer that may turn black. If bitten by a brown recluse or black widow spider - Cleanse the wound. Use soap and water to clean the wound and skin around the spider bite. - Slow the venom's spread. If the spider bite is on an arm or a leg, tie a snug bandage above the bite and elevate the limb to help slow or halt the venom's spread. Ensure that the bandage is not so tight that it cuts off circulation in your arm or leg. - Use a cold cloth at the spider bite location. Apply a cloth dampened with cold water or filled with ice. Seek immediate medical attention. Treatment for the bite of a black widow may require an anti-venom medication. Doctors may treat a brown recluse spider bite with various medications.

Bee Stings In most cases, bee stings are just annoying and home treatment is all that's necessary to ease the pain. But if you're allergic to bee stings or you get stung numerous times, you may have a more serious reaction that requires emergency treatment. Most of the time the symptoms from a bee sting will be minor. Your child may experience a burning pain, a red welt, and slight swelling. Some children may have a stronger reaction with extreme redness and swelling that gets bigger over a couple of days. Children, adolescents, and adults who are allergic to bee stings may have a severe reaction called anaphylaxis. About 3% of people who are stung by bees quickly develop these anaphylaxis symptoms. - Skin reactions in parts of the body other than the sting area, including hives and itching and flushed or pale skin (almost always present with anaphylaxis) -  Difficulty breathing -  Swelling of the throat and tongue -  A weak and rapid pulse -  Nausea, vomiting or diarrhea -  Dizziness or fainting -  Loss of consciousness -  Convulsions -  Fever -  Shock may occur if the circulatory cannot get enough blood to vital organs. For most Bee stings you can apply an ice pack or cool compress, a meat tenderizer solution which can be made by mixing one part meat tenderizer and 4 parts water. Soak a cotton ball in the solution and apply to the bite for 15020 minutes. A baking soda paste works well or a topical anti-itch cream such as Calamine lotion. Talk to your pediatrician about ways to prevent bee stings and possible immunotherapy if your child is allergic. Multiple stings can be a medical emergency in children, older adults, and people who have heart or breathing problems. If your child is allergic to bee stings always have an EpiPen available and use it right away as your pediatrician has directed. Wasps, hornets, and yellow jacket stings are similar to bee stings.

Fire Ants A bite that will get your child’s attention quickly belongs to the fire ant. Fire ants are so named because their venom induces a painful, fiery sensation. When disturbed, fire ants are very aggressive. To help children avoid fire ants, parents should regularly check their yards and their children's play areas for the presence of the ants and their mounds. Then they should either eliminate the ants or make sure children avoid them. If a child is stung, apply ice to the bite site for 10 to 15 minutes. Elevate the extremity where the child was bit. Clean and clip the child's fingernails to prevent any secondary infection that can result from scratching the bite. Check with the child's pediatrician for the correct dose of an oral antihistamine to reduce itching and inflammation A small percentage of children stung -- probably less than 0 .5 percent -- experience a severe (anaphylactic) reaction. These occur within minutes of a sting and vary in severity. A child who is stung and within minutes begins to experience hives, weakness, dizziness, wheezing, difficulty swallowing, shortness of breath or confusion should be taken immediately to the nearest emergency room. Watch the area for signs of infection over the next couple of days.

Ticks Ticks are common in grasses and wooded areas. If you have pets make sure they are tick free. Ticks are usually harmless but they can carry Lyme disease. To remove a tick begin by taking a cotton swab or cotton ball. Dip the swab or cotton ball in a small glass container that you will be throwing out after use. Place a small amount of rubbing alcohol in the bottom of your container. Use at least 2 tablespoons of alcohol. Dab on the site of the tick on the child or pet. Do not let it run, that is why you are dabbing it rather than pouring it on the site. If there is excess, dab it with another cotton swab or cotton ball. Let this cotton ball or swab sit on the tick for 3 minutes. This suffocates the tick and he will back out for retrieval with tweezers. If that method is unsuccessful, use the alcohol swab again and let the area dry. Then take a clean, unused cotton swab and glob a dollop of Vaseline petroleum jelly on the site where you see the tick. Let this stay on top of the tick for 3 minutes. You will then remove the tick and the Vaseline petroleum jelly.

Mosquitoes Probably the most common insect bite in the spring and summer come form mosquitoes. Ivillage.com has these tips for treating and preventing mosquito bites. The usual reaction is a local skin inflammation that is red, raised and very itchy. If your child scratches the bite, it may become infected as well. Here's what you can do for your children to help ease the itch and pain caused by mosquito bites. Treatments: Apply anti-itch creams like calamine as needed to help prevent scratching • Use anti-inflammatory creams like cortisone cream to help ease the inflammation and itching • If there is severe itching and multiple bug bites use antihistamines like Benedryl. Because they tend to make children drowsy, they work particularly well at night. •  Antihistamines like Claritin, Allegra, and Zyrtec tend to be much less sedating, buit check with your pediatrician about the correct dosage and whether these products are safe for children. Other Suggestions:
 Keep your child's fingernails cut short to prevent scratching • Apply cold wet compresses to the area to ease discomfort • Have your child wear long pants and long sleeves (if the temperature is bearable) • Make sure window screens are used if you keep windows open in your home • Use insect repellant to help prevent bites from occurring Choosing an Insect Repellant DEET is the best insect repellant in terms of effectiveness against flies, gnats, chiggers, ticks and other insects. The higher the DEET concentration the better it works. For children, however, the EPA recommends a concentration of 10 percent or less to prevent side effects and toxicity.

Scorpions Scorpion bites are painful but mostly harmless. The only dangerous scorpion in North America, probably the most venomous of all North American bugs is the bark scorpion. Bark scorpions are found in all of Arizona, extending west across the Colorado River in to California and east in to New Mexico. Scorpions are related to spiders, ticks and mites. Usually, they only sting to protect themselves or of they feel threatened. Scorpions can get caught up in bedding or crawl in to shoes so always check your child’s clothing and bed if you suspect scorpions may be around.  Scorpion stings without a serious reaction can be treated with ice on the sting and over-the-counter pain medication. Bark scorpion anti-venom is available only in Arizona. Any sting that shows signs of a bark scorpion needs to be treated at a hospital. Anti-venom has been shown to significantly reduce the effects of the sting. Children love to be outside in the spring and summer when the daylight is longer and the backyard, playground, or campsite can become a magical play space. Insect bites are bound to happen. Most are just an annoyance, but make sure you know which ones to be concerned about and which ones may just require a hug and a kiss. For pictures of several types of insects such as Black Widow and Brown Recluse spiders, check out http://www.webmd.com/allergies/slideshow-bad-bugs

Daily Dose

Recurrent Ear Infections

1:30 to read

It is winter and fortunately while there is not much flu to date, there are certainly colds and coughs throughout the country.  It seems that every child I see has a runny nose.  Remember, a toddler will get anywhere from 5-10 colds a year for a couple of years as they start to have playmates and pass those pesky viral upper respiratory infections back and forth.  But for some young children, (especially those in daycare) those frequent colds may lead to recurrent ear infections (otitis).

Otitis media is an infection of the middle ear. In children,  an ear infection typically follows a common cold, which may be caused by a plethora of viral illnesses. It seems that the virus changes how the middle ear “functions” lots of complicated science about cilia, and mucous and eustachian tube function) which then leads to secondary bacterial infection and an acute ear infection.  It typically takes a few days to weeks of a cold, before developing an ear infection. I tell my patients, “you don’t usually see an ear infection in a young child on day 1 or 2 of a cold”.  If everything else seems okay, you might want to watch your child for a few days before having their ears checked.

The guidelines for treating acute otitis media (AOM) changed several years ago after studies showed that not all ear infections were caused by bacteria, especially in older children, and that with “watchful waiting” many ear infections would improve on their own.  So, for children between the ages of 6-23 months of age with bilateral or unilateral ear infections and signs and symptoms of pain (tugging on the ear, rubbing the ear, irritability and sleep interruption) and fever the recommendation is to treat the infection with antibiotics.  The recommendations get a bit trickier for children who do not have bilateral infections and who are considered to have “non-severe” AOM, in which case the doctor and parent may discuss the pros and cons of antibiotic therapy and in some cases may decide to defer the use of antibiotics for 48-72 hours and observe the child for worsening of symptoms or failure to improve at which time an antibiotic may be started.  “Watchful waiting” has helped to decrease the number of antibiotics prescribed for children.

For the younger children 6-23 months who are more likely to be “sicker” than an older child with AOM, the first line antibiotic to be prescribed is still Amoxicillin (unless the child is known to be penicillin allergic). Amoxicillin is the gold standard, “pink medicine” that many parents remember from their childhood…..tastes like bubble gum and needs to be refrigerated.  For children who have had recurrent ear infections other antibiotics know as “second line” drugs may be used.  Again, there are pros and cons to many antibiotics as well in terms of taste, how often they need to be given and side effects….so discuss this with your own pediatrician. 

For children 2 and older I am a big believer in “watchful waiting” and pain control.  So many of these children will do well with over the counter acetaminophen and ibuprofen as well as topical ear drops for analgesia.  I would guess that in my practice (not a valid scientific study) about 80% of my older patients do not fill a prescription for antibiotics….which as you know is a good thing (no one wants to be on an unnecessary antibiotic).

Unfortunately, there seems to be a “group” of children (typically the younger ones) who get recurrent AOM and spend many of their winter months in the pediatricians office.  More about those infections in another post.  

Daily Dose

What Are Breast Buds?

1.15 to read

I received a phone call today from a mother who was worried about the “bump” beneath her 12 year old daughter’s nipple. I do get this phone call quite often and even see mothers and daughters in the office who are concerned about this lump?  First thought is often, “is this breast cancer?”  The answer is a resounding “NO” but rather a breast bud.  While all mothers developed their own breast buds in years past, many have either forgotten or suppressed the memory of early puberty and breast budding.

Breast buds are small lumps the size of a blueberry or marble that “erupt” directly beneath a young girl’s areola and nipple. Most girls experience breast budding somewhere around 10-12 years of age although it may happen a bit sooner or even later. It is one of the early signs of puberty and estrogen effects.

Many girls will complain that the nipple area is sore and tender and that they are lopsided!! It is not unusual for one side to “sprout” before the other. Sometimes one breast will bud and the other is months behind. All of this is normal. 

While a lump in the breast is concerning in women reassure your daughter that this is not breast cancer (happy that they are so aware) but a normal part of body changes that happen to all girls as they enter adolescence.   Breast budding does not mean that their period is around the corner either, and periods usually start at least 2 years after breast budding (often longer).

Breast buds have also been known to come and go, again not to worry. But at some point the budding will actually progress to breast development and the continuing changes of the breast during puberty.

Reassurance is really all you need and if your daughter is self-conscious this is a good time to start them wearing a light camisole of “sports bra.”  

Daily Dose

Toddler Constipation

1:30 to read

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

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

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

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

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

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

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

Daily Dose

Early Talkers

1:30 to read

Is your child a precocious talker?  Most children start to acquire words around 12-15 months, but that means 5-10 words and building. By the time a child is 18 months old they are often mimicking when you ask them to say a word, and some are putting 2 words together. This is all very normal development. But there are few children who are just “early talkers” who are speaking in full sentences by the time they are 18-24 months! 

I think having such a verbal child during the early toddler years is both a “blessing and a curse”. I know that from raising my own children, where my oldest was quite verbal by 20 months, and was “bossing us around” before age 2!!  I also see this same dilemma in my little patients.  While some parents are worried that their 2 year old does not put 3-4 words together, others want to know how you can stop the chatter.  Parents.....we always have issues. 

Example:  When I come into the exam room for a 2 year old check up, the precocious talker looks up and says, “Hi Dr. Sue...what took you so long?”.  Or they may tell their parent that they “don’t need any help” as I ask them to climb on the exam table. Recently a little boy looked right at his mother and said, “I’ve got this”, when I asked him to take off his shoes.  

On another day a little girl was impatient to leave and kept asking her mother if they could go to the park after they left my office.  The mother kept telling the little girl, “maybe” . Finally, exasperated, the 2 year old said, “what’s the answer, yes or no?””  How do you keep a straight face? 

A verbal child can bring you to your knees, both laughing and sometimes wanting to cry.  How can a 2 year old know just what to say to make a parent feel inadequate?  Is it inborn? This seems to be especially true if you have had another child and the 2 year old is instructing you on how to parent “their baby”.   

So, if your child is a talker write down all of those clever sentences they blurt out......one day you will look back and laugh.  I often saw myself in my 2 year old as he told complete strangers , “my mommy says my baby brother cries all of the time, and he has colic!”  Out of the mouth of babes, and I still remember it.  Bittersweet.

Daily Dose

Red Cheeks In Winter

1:15 to read

Why do children get red cheeks in winter?

It is the time of year for cold temperatures, low humidity and dry skin. It is funny, every year as the temperatures drop, I we start seeing these cute little babies and toddlers who have those bright red cheeks. I always say that they “look like British babies”.

Dry skin is just one of the many issues we see with colder temperatures, and babies red cheeks are one of the most evident. During the winter months we all experience dry skin and using moisturizer becomes very important.

I have written previous blogs about eczema, and while chapped skin is not synonymous with eczema, there are some similarities. The most important thing to prevent dry skin while the weather is cold is to use a moisturizer, and applying moisturizer is best on damp skin. After bathing your baby or child, pat them dry until they are just “a tad bit moist” and then take a moisturizer and apply it to the almost dry skin. The thicker the moisturizer the better, so a cream is preferable to a lotion. It will take a little more time to rub the cream in when the skin is a bit moist, but it will help the moisturizer penetrate the skin. The same thing goes for the face.

I always found that the best time for me to moisturize those rosy cheeks was really after the child had gone to sleep. When my children were younger I found that if I put the cream on when they were awake, that they either rubbed their faces more, or if they were verbal, complained about lotion on their faces. So…I decided that it worked best to have their bedtime routine, with baths, books, and prayers, and then once they were asleep I would slip in and lather up their faces and also even used Chap Stick on their dry little lips. Now, there is no science in this routine, but it seemed to work, and they were much more tolerant of lubricants when asleep than awake.

We are definitely in the low humidity season and the heat is on in the house (I am typing this as I sit by the fire with a blanket over my feet), so you can expect several months of dry skin and chapped cheeks. If moisturizers like Vanicream, Cerave, Aquaphor and Eucerin go on sale, stock up!!  April is a long way away.

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