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Daily Dose

Breastfeeding

1:30 to read

August is National Breastfeeding Awareness Month as well as World Breastfeeding week. The theme this year is “Sustaining Together”  which means getting a mother’s “community” around her to help her with her breast feeding.  In my mind this means getting the father involved in being there for his wife, followed by the hospital nurses in the nursery, the lactation nurse if your hospital has one, your pediatrician and then any close family members who may be involved in helping a new mother.  

 

Although breast feeding is “a natural process” it sometimes takes one baby or mother or both a bit longer to “figure out” the latch, how to hold the baby comfortably for a feeding and how to be successful with breastfeeding. One of the first hurdles is assuring a new mother that she is “not doing it wrong”. While there may be some tips…there is not ONE WAY to breastfeed.  At times too much pressure from outside influences may actually cause more anxiety and I often find myself telling a new mommy that it just takes “practice, practice, practice…you cannot mess this up on day #1!!”. 

 

But, for some new mothers, breast feeding causes a great deal of  anxiety and they may need a bit more reassurance and support to hang in there and see how it goes… reminding them that a baby does not always nurse for the same amount of time, that they may eat in 2 hours one time and not want to eat for 3 hours the next. They are newborns and not robots…and  we all eat a bit more or less at different times of the day. It is hard to “schedule” a new baby’s feedings and the best advice is to try and watch your baby’s cues and cries.  While one baby may be a bit sleepier in the first few weeks,  another may wake on its own..but either way it is important to try and feed the baby every 2 -3 hours to get breast milk and breast feeding established. Lots of poops and wet diapers is also very reassuring that something is working!

 

This is where the baby’s father may be extremely helpful. He can make sure that the mother is getting “fed” as well.  She needs plenty of healthy meals and lots of fluids to ensure breast milk production.  He may also get up with the baby and change the baby before the feeding and then bring the baby to the mother to nurse.  Encouraging his wife is equally important. There are times when some of those hormonal changes in the new mother makes her feel weepy, sad or inadequate as a new parent….and he can reassure her as well. (even if he is unsure of himself - fake it a bit).  Partnering from the beginning of parenthood is important for both a father and a mother.

 

In some cases if a baby is not feeding well or the baby is premature a mother will need to pump breastmilk and offer the baby a bottle. This is tiring for a new mother and so the grandparents may also help both new mother and father and offer to help feed the baby so the parents may get some rest (which is also important for milk production) or even wash the bottle and breast pump. Every little bit will help.

 

In my experience a new mother who has a lot of support and encouragement is more successful with breastfeeding.  After the first few weeks of breast feeding the “newness” wears off and breast feeding usually seems to get easier and easier. Once parents see that the baby is gaining weight and the mother’s milk supply is equilibrating to her baby’s needs and breast and nipple tenderness is going away, many a new mother tells me how happy she is that she continued to “work on breast feeding her baby”. 

 

Lastly, there are some situations where a mother may not be able to breast feed her baby and she should not be “mommy judged” or shamed for this.  Not everyone knows a new mother’s medical history, or the reason she chose not to breast feed.  

 

 

Daily Dose

Mumps Outbreak!

1:30 to read

The latest infectious disease outbreak is in the Boston area where several colleges have reported cases of mumps. Mumps is a viral illness that causes swelling of the salivary glands as well as other symptoms of fever, fatigue, muscle aches and headache.    Harvard University has been hit the hardest and has now documented over 40 cases this spring.  Boston is a city with numerous colleges all in close proximity, and there are documented mumps cases at Boston University, University of Massachusetts  and Tufts as well.  These Boston area colleges are all in close proximity and are merely a walk, bike or train ride away from one another, so these students, while attending different universities may all co-mingle at parties and athletic events.

Mumps is spread via saliva (think kissing), or from sharing food, as well as via respiratory droplets being spread after coughing or sneezing. It may also be spread via contaminated surfaces that will harbor the virus. People may already be spreading the virus for  2 days before symptoms appear and may be contagious for up to 5 days after their salivary glands appear swollen….so in other words there is a long period of contagion where the virus may inadvertently be spread. It may also take up to 2-3 weeks after exposure before you come down with mumps.

All of the students who have come down with mumps had been vaccinated with the MMR vaccine (mumps, measles, rubella).  Unfortunately, the mumps vaccine is only about 88% effective in preventing the disease. Despite the fact that children get two doses of vaccine at the age of 1 and again at 4 or 5 years….there may be some waning of protection over time. This  may also contribute to the virus’s predilection for young adults in close quarters on college campuses. Something like the perfect infectious disease storm!

In the meantime there are some studies being undertaken to see if adolescents should receive a 3rd dose of the vaccine, but the results of the study are over a year away.

In the meantime, be alert for symptoms compatible with mumps and make sure to isolate yourself from others if you are sick.  Harvard is isolating all of the patients with mumps for 5 days….which could mean that some students might even miss commencement.  Doctors at Harvard and other schools with cases of mumps are still on the watch for more cases …stay tuned.

 

 

 

 

Daily Dose

Why Babies Develop Jaundice

It is not unusual to see a newborn appear slightly jaundiced during their first week of life.

I received an email via our iPhone App from a mom who asked "why babies get jaundice and why we check a bilirubin level on newborns?"

Most babies will develop physiologic jaundice (noted by yellow discoloration to their skin and whites of their eyes) due to the fact that a your-baby's liver is still not working at full speed when first born. Bilirubin, a breakdown product of the red blood cell, is metabolized through the liver. It is also excreted in the stool, and the young newborn is just getting all of those organ systems up and running in the first 24- 2 hours of life. As cute and snuggly as a brand new your baby is, it does take a few hours to days for everything to ramp up to full working speed. So, it is not unusual to see a newborn appear slightly jaundiced during their first week of life, and how I learned with my own first child, yellow is not a good color on most newborns. Stick with pink and blue. Sometimes babies will develop higher bilirubin levels than expected, (numbers in the teens) and depending on how old they are may require phototherapy to help breakdown the bilirubin. You might have seen those babies basking under the glow of "sunlamps" wearing your-baby sunglasses. The blue lights breakdown bilirubin in the skin. Excessive bilirubin can lead to a condition called kernicterus, and may actually cause brain damage. By following an infant's bilirubin levels and treating promptly you can avoid this, and I have never seen an infant develop kernicterus. Your pediatrician will discuss bilirubin levels with you while you are in the hospital with your newborn. If they don't bring it up, typically there is nothing to worry about. If you have concerns, you should ask. If your your baby seems to be getting more jaundiced once you are home, give your doctor a call, it may mean they need to have another bilirubin level drawn as occasionally a your-baby will develop more jaundice once they have been discharged. That's your daily dose, we'll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Newborn Schedules

1:30 to read

I am trying to decide if I am giving “old” advice when I am talking to new parents about their new baby. Here’s the dilemma…”when can I get the baby on a schedule?” This has become one of the first questions I am asked, sometimes even before the baby has left the hospital.

 

I know there are differing opinions on many things “pediatric”, but schedules for a newborn just is a hard thing for me to understand.  This tiny new baby is not a robot and has not been programed to eat at 8, 11, 2, 5, 8, and 11 and to sleep all night.   But….many new parents begin to try and get their baby on this schedule right away (I can name a few books that advocate this). That is all fine by me if I thought it worked….but I think it actually leads to many of the new parents coming in for their visits at 2, 4 and 8 weeks totally stressed out!  They seem to spend a great deal of time trying not to feed their baby any sooner than 3 hours and doing all sorts of things to try and get their baby to sleep thru the night without eating, which may actually be keeping them up longer than if they just fed their newborn based on their cues to eat every 2 -4 hours.

 

A new baby is really very immature neurologically (think startle reflex, no smiling), and at times may want to eat in 2 .5 hours rather than 3. Not because they are thinking about how long until  their lunch break or how they want to wake their parents up at night to mess around with them, but rather because they are hungry!

 

For most babies, not all, after 6-8 weeks of more “on-demand” feeding ( but no more often than every 2 hours during the day), with regular awakening between feedings during the day, a baby will suddenly begin to develop a rhythm and schedule. The idea that your baby will eat, “play and stay awake” and then sleep routinely beginning at birth is absurd to me. I know that sometimes they will stay awake longer than you want, and at other times they are so sleepy you can barely awaken them, but with practice and patience it will change.

 

Trying to keep a newborn from eating at 1 am or 4 am,  just makes you the parent more sleep deprived and your baby hungry. As their tummy gets bigger and their body starts to figure out circadian rhythm, life becomes easier. But an APP that tells me that “now is the time to feed the baby” is just NOT NECESSARY.  

 

The struggle to “get a baby on schedule” seems to be a favorite topic….but one day looking back and after the baby begins to sleep longer periods of time at night, you may realize it was actually easier than the next phases of parenting….when your child does walk and talk!

 

 

 

 

Daily Dose

The Reality of Teen Suicide

1.30 to read

I have been saddened by the recent suicide of Washington State quarterback Tyler Hilinski. It is hard for me to fathom the pain his parents are suffering at the loss of their son. There are really no words for the shock and grief that is felt on so many levels.

Unfortunately, teen suicide is not as uncommon as you might think. Each year, there are thousands of teens that commit suicide. Suicides are the 3rd leading cause of death for 15–24 year olds. In 2000, the CDC reported 1 out of 12 teens attempts suicide and up to 1 in 5 teens state that they have contemplated suicide at some point during their adolescent years. The statistics also show that the incidence of teen suicide has been increasing over the last years, which seems to correlate with the mounting pressures, both real and perceived, that our youth feel. As an adult I think "what could be that terrible to drive a teen to end their life when so much lies ahead of them?”.  But a teen’s brain is not fully developed, and as any parent with a teen knows, teenagers are often impulsive with little thought of the true consequences of their actions.

Teen suicides are usually related to depression, anxiety, confusion and the feeling that life is not worth living. An event such as a break up with a girlfriend or boyfriend, substance abuse, or failure at school may lead to suicide.

There are also gender differences among teens who commit suicide.  Teen girls are more likely to attempt suicide than teen boys. With that being said, teen boys are more likely to complete a suicide.  Girls are more likely to use an overdose of drugs to attempt suicide while boys are more likely to shoot themselves.  While a girl may use an overdose or cutting  as a “call for help”, there is often little opportunity for  intervention with a male who sustains a self inflicted gun shot or may even hang themselves.  Male suicide attempts are typically more violent and are 4 times more likely to be successful.

There are several things that parents, teachers and friends should be aware of as “warning signs” for adolescent depression and the possibility of suicide. A teen who suddenly becomes isolated, changes friends, has a change in their school attendance or grades,  has a substance abuse problem, is being bullied  or begins to make statements in reference to ending their life,  should be taken seriously. Professional help is absolutely necessary when dealing with these issues and parents should not attempt to “solve the teens problems” on their own.   

There are numerous resources available and the suicide prevention hotline at 1-800-SUICIDE is a 24 hour service. Lastly, over half of teen suicide deaths are inflicted by guns.   Firearms should not be kept in a home unless they are locked, and the key should always be in the care of a parent.  It might also be prudent not to have ammunition in the house if you do have a gun. If an impulsive, depressed teen has to go buy ammunition before attempting suicide they might be more likely have an epiphany and realize that things are not as hopeless as they think.  Any deterrent may be all that is necessary to prevent a suicide and the ensuing heartbreak for all those that knew them.

Send your question or comment to Dr. Sue.

Daily Dose

Brown Spots on Your Baby?

1:30 to read

I was examining a 4 month old baby the other day when I noticed that she had several light brown spots on her skin. When I asked the mother how long they had been there, she noted that she had started seeing them in the last month or so, or maybe a couple even before that.  She then started to point a few out to me on both her infant’s arm, leg and on her back.

These “caramel colored” flat spots are called cafe au lait macules, (CALMs) and are relatively common. They occur in up to 3% of infants and about 25% of children.  They occur in both males and females and are more common in children of color.  While children may have a few CALMs, more than 3 CALMS are found in only 0.2 to 0.3% of children who otherwise do not have any evidence of an underlying disorder.  

Of course this mother had googled brown spots in a baby and was worried that her baby had neurofibromatosis (NF).  She started pointing out every little speckle or spot on her precious blue eyed daughter’s skin, some of which I couldn’t even see with my glasses on. I knew she was concerned and I had to quickly remember some of the findings of NF type 1.

Cafe au lait spots in NF-1 occur randomly on the body and are anywhere from 5mm to 30 mm in diameter. They are brown in color and have a smooth border, referred to as “the coast of California”. In order to make the suspected diagnosis of NF-1 a child needs to have 6 or more cafe au lait spots before puberty, and most will present by 6 -8 years of age.

For children who present for a routine exam with several CALMs ( like this infant), the recommendation is simply to follow and look for the development of more cafe au lait macules. That is a hard prescription for a parents…watch and wait, but unfortunately that is often what parenting is about.

Neurofibromatosis - 1 is an autosomal disorder which involves a mutation on chromosome 17 and may affect numerous organ systems including not only skin, but eyes, bones, blood vessels and the nervous system. Half of patients inherit the mutation while another half have no known family history.  NF-1 may also be associated with neurocognitive deficits and of course this causes a great deal of parental concern. About 40% of children with NF-1 will have a learning disability ( some minor, others more severe).

For a child who has multiple CALMs it is recommended that they be seen by an ophthalmologist and a dermatologist yearly,  as well as being followed by their pediatrician.  If criteria for NF-1 is not met by the time a child is 10 years of age,  it is less likely that they will be affected, despite having more than 6 CALMs.

The biggest issue is truly the parental anxiety of watching for more cafe au lait spots and trying to remain CALM…easier said than done for anyone who is a parent. 

Daily Dose

Constipation

1:30 to read

Constipation is a topic that every pediatrician discusses….at least weekly and sometimes daily. It is estimated that up to 3% of all visits to the pediatrician may be due to constipation. Constipation is most common in children between the ages of 2 and 6 years. I have been reading an article on updated recommendations for diagnosing and treating common constipation. The most important take home message is “ most children with constipation do not have an underlying organic disorder. Diagnosis should be based on a good history and physical exam for most cases of functional constipation”.

 

Like many things in medicine….the evaluation and treatment of constipation has also changed a bit since the last guidelines were published in 2006. It is now appropriate to define constipation with a shorter duration of symptoms (one month vs two) and some of the most common diagnostic criteria (Rome IV Diagnostic Criteria) include the child having less than 2 stools/week, painful or hard bowel movements, history of large diameter stools (parents will tell me their 3 year olds “poops” clog the toilet), and some may have a history of soiling their underpants. 

 

By taking a good history you can avoid unnecessary tests..including X-rays which are not routinely recommended when evaluating a child with possible constipation.  In most cases physical findings on the abdominal exam will confirm the diagnosis in combination with the history. I often can feel hard stool in a child’s left lower quadrant and when asked the last time they “pooped”, no one can really recall. 

 

The preferred treatment is now polyethylene glycol (PEG) therapy. PEG is now used to help “disimpact a child” as well as to maintenance therapy.  Where as enemas were often previously prescribed, PEG therapy has been shown to be equally effective in most cases, is given orally and is much less traumatic (for parent and child!). PEG works by drawing more water into the stool, causing more stool frequency. There are many brands of PEG including Miralax and GoLytely among others. Miralax works well for children as it is tasteless and odorless and can easily be mixed in many liquids without your child knowing it is there. 

 

The guidelines now state that for children with functional constipation maintenance therapy with PEG should continue for as least 2 months with a gradual tapering of treatment only after a full month after the constipation symptoms have been resolved. I usually tell parents that this is equivalent to about how long it takes for them to forget that they have been dealing with constipation….and then begin tapering.

 

Lastly, there is no evidence that adding additional fluid or fiber to a child’s diet is of benefit to alleviate constipation….although it may “just be good for them in general”.

 

 

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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Daily Dose

Strep Throat

1:30 to read

During the “sick season” a common complaint among children (and their worried parents) is that a chid has a sore throat. While all children will at some point complain of a sore throat, most sore throats are due to a virus and are often the first sign of a cold.  

 

Many parents worry that their child may have strep throat which is a bacterial infection and requires treatment with antibiotics.  In fact, only about 10-20% of children with a sore throat will have strep.  More and more parents are bringing their children in to the office right after they “hear” that someone is their child’s class has strep (thank you social media).  In fact, their child may have not even complained about their throat until they were asked, “does your throat hurt”, or they may have only been sick for an hour or two.

 

How can you decide if your child might need to be seen at the pediatricians office if they have complained of a sore throat?

 

Strep throat is most common in school aged children 3-14 years of age.  It it typically not seen in young children (who cannot even tell you that they have a sore throat) or in adults over the age of 45.  With the advent of urgent care centers on every corner I am hearing more and more parents tell me “I have strep throat so I am worried about my child”, but when asked if they the parent are better on their medicine the majority say “not really”, and I am coughing and congested and not getting better. Their “strep throat” is more likely to have been the beginning of a cold. 

 

Children with strep throat typically do not have a cough, but do have swollen or tender lymph nodes in their neck (just under their jaw), have a temperature over 100.4 and have swollen inflamed tonsils that may or may not have exudate (white patches), and are between 3 - 14 years of age. 

 

By using these guidelines which are called the Centor Criteria your doctor is also deciding which patients should have a rapid (in office) strep test. Over testing (swabbing) with an in office rapid strep screen may lead to false positive results due to picking up the bacteria in a child’s (or adult’s) throat when they are simply carriers and do not have strep throat. Why is this important?   Over testing, may lead to over prescribing antibiotics and no one wants their child to be taking antibiotics unnecessarily. 

 

So, it is typically best to wait 24 hours or so after your child complains of a sore throat to take them to the pediatrician.  History of the illness and clinical findings are the two things that will determine if your child needs a “strep test” and should not be decided simply because “there is strep in their class”. In our office all children are examined by the physician prior to having a throat swab.

 

 

 

 

 

 

 

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What every parent needs to know about teen suicide.

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