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Daily Dose

The Questions About Fever Continue

Back in the office and boy is it busy. It is going to be like this for a long time and frantic phone calls and office visits regarding fever continue.Back in the office today and boy is it busy. It seems like this has been going on a while with frantic phone calls and office visits. Many many of the questions are about fever.  You've heard me say before "fever is our friend".

I am a firm believer that the more information a parent has the easier it is to make good decisions about the care of their child. This is true for fever fears too. So, here is more information beginning with the fact that you do not have to take your child to the pediatrician or ER every time your child has a fever. Now, that is not to say that there are not times that you NEED to call the doctor’s office. But, fever in and of itself, in a child who is two years or older, who does not have an underlying chronic disease, and has classic symptoms of a “flu-like” illness, with headache, sore throat, cough and general “feels bad” does not require an immediate phone call to the doctor or an office visit. It does mean that you need to treat your child’s fever (NO ASPIRIN) to make them more comfortable, and make sure that they are hydrated and keep them home until they have been fever free for at least 24 hours. That also means no fever off of all medications like acetaminophen and ibuprofen. Masking a fever with medications does not count. Watching Elmo or Disney for a few days while recovering is never bad for anyone. This is the one time to let them be couch potatoes. Kids will always feel worse when their fever is higher, and better when it comes down with fever reducers. Being able to play with toys, play on the computer, Nintendo and Wii are all signs that your child is handling the virus and that they are not terribly sick. You should be watching for that, and be reassured, that is a good sign. Campbell’s chicken noodle soup should see record sales this fall and all of those other comfort foods like popsicles and smoothies sound good to those with a fever. Children usually do not want a full meal when they are feeling badly and neither will you if you are unlucky to also fall ill. Just push fluids and as your child feels better their appetite will return. What to watch for! #1: Any signs of breathing difficulty, or color change in your child, but remember too that your chest can feel tight with the flu, without having respiratory distress. Take off their t-shirt or pajama top and really look at their chest to see if you see any difficulty breathing. Turn the light on if you are worried and look at their coloring. Fever also makes you breathe faster, so treat their fever and watch their respiratory rate as the fever comes down. A child playing a video game is usually not in respiratory distress (note from office visit today), and will be better off at home on the couch than waiting in an office full of more sick people. #2: Any child who has a rebound fever is worrisome. That means they have the typical two to four days of fever, power through it and then several days later develop fever again. Those children should all be seen to rule out secondary infection. #3: Children with prolonged fever, who seem to be worsening rather than getting better. #4: Children with underlying chronic diseases need to be seen sooner rather than later (or at least warrant a phone call to discuss with their physician). These are some guidelines to help reassure you that you are doing all of the right things at home. You can expect your child to be out of daycare or school for three to five days, minimum, so stock up with movies and cards and pretend that you are “snowed in”. Luckily the children we have been seeing thus far have not been too ill. I work in a pediatric office with 12 doctors, in a very busy practice, and we have not had one child hospitalized or even come back because they were getting sicker. We can only hope that this will be the case for the rest of this year. Keep up the hand washing and go get those regular flu vaccines. That’s your daily dose, we’ll chat again tomorrow. Send your question to Dr. Sue!

Daily Dose

Separation Anxiety

1.45 to read

I received an email from a mother who was concerned because her toddler son was crying when they left him at day care.  They were “alarmed” as he had not previously cried when they dropped him off and wondered if this was “normal” or a sign of a problem. Actually, this phenomenon should be quite reassuring to a parent as this is a sign that your child is developmentally on track, and has developed a healthy attachment to his parents. 

All children go through periods developmentally when they are more prone to separation anxiety.  As a new parent you are often concerned about “leaving” your child under the care of someone other than a parent. But, in actuality, it is far easier to leave a newborn or an infant than it is to leave a 8-9 month old.

By the time a child reaches this age they are beginning to show signs of stranger anxiety. In other words, they now recognize the faces and voices of their parents, routine caregivers, siblings etc.

But, when a new person (and face) reaches out for a 9 month old it is not uncommon for that child to suddenly panic and burst into tears. This is not because the “stranger” has done anything at all, but because the child now understands being separated from their parent and may fear that the parent is leaving forever. 

The bond between parent and child has been successfully established, which is quite healthy. This is the beginning of teaching a child that a parent may leave for work, school or even a trip, but that they will return.  Just because a parent leaves for awhile, they are not gone forever. 

This first stage of separation anxiety can provoke feelings of anxiousness in both child and parent, but it is an essential part of normal development. Separation anxiety, like almost all behaviors, varies from child to child. While some childen are more clingy than others, some may just be “wired” in a certain way and are more vulnerable to separating from a parent. Regardless, it is important for a child to begin to deal with healthy separation. 

During the ages of 12 – 24 months separation anxiety seems to peak, and the period of crying or anxiety when a parent drops a child at day care or Sunday school, or even at a grandparents house may escalate. 

While a child may cry after being dropped off, most children will then calm down and may be distracted and will begin playing soon after the parent has left. Again, some children just seem to take longer to adjust, so don’t be alarmed if  one child cries for 2 minutes, while another may take up to 20-30 minutes to settle down. 

Toddlers do not understand the concept of time, and therefore each one may react differently.  While happily playing while the parent is gone, it is not uncommon for the child to cry again upon seeing their parent when being picked up.  For the toddler, the return of the parent may remind them of how they felt when the parent left earlier in the day. 

For most children separation anxiety decreases between 2 -4 years of age as you can explain, and a child can understand, where you are going, how long you will be gone etc. 

For children who have rarely been left with others, it may be more difficult at this age.  Remember, healthy separations are important for both parent and child, and the idea that no one will “babysit” or care for your child other than a parent is not realistic nor does it teach your child to build trust in others. 

The more experience a child has had with earlier normal periods of separation the easier different transitions will be.  Remember, they will all be going to school one day and you want to prepare them for that separation.

Lastly, every child has good days and bad days and almost every child will have a phase when it is harder to separate than others. Just remember to hang in there, be re-assuring to your child when you leave them, do not prolong the departure, and be understanding about their anxiety. As with so many experiences in parenting, “this too shall pass”. 

That's your daily dose for today. We'll chat again tomorrow.

Daily Dose

Shingles in Childhood?

1:30 to read

Is it possible for children to come down with shingles? I recently saw a 2 year old with a most interesting history who then developed a weird rash.   Funny thing, I read an article shortly after seeing this child that described his case perfectly, only wish I had seen this the week before.

So, this 2 year old complained that his leg hurt. Enough pain that he limped and woke up at night crying that his thigh hurt. He had no history of trauma and also was otherwise well, in other words no fever, vomiting, cold symptoms etc.

After several days of watching him without resolution of his pain the mother noticed 3 little spots on his thigh, which she thought might be a bite. The little boy was seen and the diagnosis of herpes zoster (shingles) was considered.  In children the differential diagnosis of localized leg pain in the absence of a rash would not normally include shingles.

According to the pedi dermatologist (that I consulted) shingles in children occurs more frequently on their lower extremities (not for adults) and may involve the back on the same side.   Unlike adults, most cases of zoster in children are only mildly painful and resolve fairly quickly.

Well, this little boy didn’t read the book and his rash continued to get worse and spread, and was quite painful for days. Prior to this, he was a perfectly healthy little boy and had received his first varicella vaccine when he was 1.  

Since the widespread use of the varicella vaccine (chickenpox vaccine, see old post), the incidence of chickenpox has decreased dramatically, and vaccination should also reduce the risk of developing shingles later in life. In otherwise healthy children shingles (zoster) tends to develop at a younger age among vaccinated children than in those who have had a “natural” chickenpox infection.  When shingles occurs after vaccination it represents either a new infection with wild-type virus (an exposure to chickenpox or shingles) or reactivation of the vaccine virus.

Once a child has received 2 doses of varicella vaccine as recommended, the immunity is “boosted” and should further reduce the risk of developing shingles. Varicella–zoster virus can be transmitted via contact with skin lesions of those who have either chickenpox or shingles.  Infection is less likely after exposure to shingles. Transmission of the virus occurs until all lesions have crusted over. In this case, the little boy was ultimately started on an oral anti-viral therapy with slow resolution of his rash and pain and a return to normal around his house.

Note to self: “weird” pain may precede the rash in herpes zoster by several days.  Even though unusual, herpes zoster may occur in a healthy child who no history of varicella exposure and who has received all or part of their chickenpox vaccine.

That’s your daily dose for today. We’ll chat again tomorrow.

Daily Dose

The Right Way to Take A Temperature

1:15 to read

During flu season and really throughout the year, the questions surrounding how to take a temperature in a child and how to treat a fever seem never ending. So I thought let’s jump right in with a discussion on taking temperatures in all age children.

There are many different thermometers out there, and many different methods for taking a child’s temperature. The one way that I know that is not accurate is by “touch of hand”. Many parents report that their child had a fever, but have never taken their temperature. Neither your hand, nor mine is accurate in detecting a fever in a child. I am not a fanatic about taking temperatures all day long but it is important to document your child’s body temperature with a thermometer if you think they have a fever. Also, a fever to a parent may mean 99.6 degrees (I know your child has a different body temperature than others), but in terms of true fever most doctors use 100.4 degrees or higher as true fever. For everyone!

Body temperature in infants is very important and a fever in a child under two months of age is something that always needs to be documented. The easiest way to take a temperature in an infant is rectally and is actually quite easy. Lay your child down, like you would be changing their diaper, and hold their legs in one hand while you gently insert a digital thermometer (lubricate it with some Vaseline, makes it slide in more easily) into their rectum (bottom). It will not go too far, don’t worry, only about 1/2”. Keep the thermometer in their bottom for about a minute and by then you will be able to see if they have a fever. Again, over 100.4 degrees. I use rectal thermometers in children up to about two as they are usually pretty easy to hold and it is not painful at all. It is also accurate. Keep this digital thermometer labeled for rectal use.

Axillary temperatures are taken under the arm and can also be taken with a digital thermometer. It is often confusing if your child’s temperature is in the 99 – 100 degree range, so if in doubt take rectal or oral temperature. I am not a huge fan of axillary temperatures, and it actually requires more cooperation than a rectal temp. Oral digital thermometers, which are placed under a child’s tongues, are easy to use in a cooperative child. By the time your child is three or four, it is fun to teach them how to hold up their tongue and then hold the tip of the thermometer under their tongue and close their lips.  Especially with digital thermometers, elementary children like to read you what the thermometer says, and discuss their temperatures. My children always loved to show me they were REALLY sick when it said 103 degrees. It is then a “sick day activity” to take the acetaminophen and watch your temperature come down over the next several hours. They loved making charts of their body temps. It won’t win a science fair but does keep them busy. Also, if they can play this game they are not too sick. Lastly, do not let your child drink a hot or cold beverage right before taking an oral temp (note for parents of older kids, remember Ferris Bueller?), as the reading may not be accurate.

There are also fancy tympanic (ear) thermometers and temporal artery thermometers. I still prefer digital in my own house, and never purchased a “fancy” thermometer. You can buy tons of digital thermometers for every child to have their own, and still save money. We also often hear parents report that there was over a degree of difference between the same child’s ear. I also do not like ear thermometers in little ones, as their ear canals are too small to get accurate readings. Now that you know how to take a temperature I will discuss fever in another post.

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

Your Baby

Baby's First Tooth!

Many dentists like to see a child by age one, not because there are a lot of problems to detect, but because it’s a good time to help parents learn more about dental health care and to establish a good relationship with the child.After all the crying, and teething fits, midnight trips to the crib, and endless time soothing and rubbing gums.... it’s finally here. Baby’s first tooth!  It’s also time to start thinking about your child’s dental health, and baby’s first visit to the Dentist.

It is generally recommended that an infant sees a dentist by the age of 1 or within 6 months after his or her first tooth comes in.

Many dentists like to see a child by age one, not because there are a lot of problems to detect, but because it’s a good time to help parents learn more about dental health care and to establish a good relationship with the child. The average age for continuing visits is about 2 to 2.5 years old depending on your child’s dental heredity and overall health. Many dentists like to see children every 6 months to build up the child's comfort and confidence level in visiting the dentist, to monitor the development of the teeth, and promptly treat any developing problems. What Happens at the First Dental Visit? The first dental visit is usually short and involves very little treatment. This visit gives your child an opportunity to meet the dentist in a non-threatening and friendly way. Some dentists may ask the parent to sit in the dental chair and hold their child during the examination. The parent may also be asked to wait in the reception area during part of the visit so that a relationship can be built between your child and your dentist. During the exam, your dentist should check all of your child's existing teeth for decay, examine your child's bite, and look for any potential problems with the gums, jaw, and oral tissues. If indicated, the dentist or hygienist will clean any teeth and assess the need for fluoride. He or she will also educate parents about oral health basics for children and discuss dental developmental issues and answer any questions. Topics your dentist may discuss with you might include: 1. Good oral hygiene practices for your child's teeth and gums and cavity prevention 2. Fluoride needs 3. Oral habits such as thumb sucking, tongue thrusting, lip sucking. 4.  Developmental milestones 5. Teething 6. Proper nutrition You will be asked to complete medical and health information forms concerning the child during the first visit. Come prepared with the necessary information. What's the Difference Between a Pediatric Dentist and a Regular Dentist? A pediatric dentist has at least two additional years of training beyond dental school. The additional training focuses on management and treatment of a child's developing teeth, child behavior, physical growth and development, and the special needs of children's dentistry. Although either type of dentist is capable of addressing your child's oral health care needs, a pediatric dentist, his or her staff, and even the office décor are all geared to care for children and to put them at ease. If your child has special needs, care from a pediatric dentist should be considered. Ask your dentist or your child's doctor what he or she recommends for your child. When Should Children Get Their First Dental X-Ray? There are no hard-and-fast rules for when to start dental X-rays. Some children who may be at higher risk for dental problems. Children prone to baby bottle tooth decay or those with cleft lip or palate should have X-rays taken earlier than others. Usually, most children will have had X-rays taken by the age of 5 or 6. As children begin to get their adult teeth around the age of 6, X-rays play an important role in helping your dentist. X-rays allow your dentist to see if all of the adult teeth are growing in the jaw, to look for bite problems and to determine if teeth are clean and healthy. Once a child’s diet includes anything besides breast-milk or baby formula, erupted teeth are at risk for decay. The earlier the dental visit, the better the chance of preventing dental problems. Children with healthy teeth chew food easily and smile with confidence. Start your child now on a lifetime of good dental habits.

Daily Dose

How To Break The Thumb Sucking Habit

I received an email via our iPhone App from a mom trying to get her son to stop sucking his thumb. The sooner you help your child break this habit, the better. I received an email via our iPhone App (do you have it?) from a mom who is trying to break her son's thumb sucking habit.  She writes "I've been trying to get him to stop for weeks and I'm failing, HELP!"

{C}

Thumb sucking is an innate reflex and can even been seen on sonograms while a baby is still in utero. It is a common means of self-soothing for infants and young children. Most children will spontaneously stop thumb sucking by two to four years of age. But, like any habit, there are those for whom it is harder to stop. In most cases children four and older only suck their thumb (or fingers) when they are tired, bored or anxious.  Very rarely do they suck their thumbs when they are engaged in activities like school, playing on the playground, or on the computer. They are often quite aware of the habit and will not suck in front of their friends, or teachers, but when relaxed at home their thumb goes straight to the mouth. If your child is still sucking their thumb after the age of four, it may be time to sit down with them to discuss strategies to stop their thumb sucking. Talk about germs (especially during cold and flu season) and come up with some sort of system to remind them when they are sucking and also to reward them for not sucking their thumb. Make fun sticker charts, and have a goal for number of days without sucking when the reward becomes even bigger. You know what motivates your child the most, a new book, or toy or trip to get ice cream. Do not punish your child for sucking and praise them for all of their hard work. Habits are hard to break! Many times thumb sucking may be curtailed by applying one of the over-the-counter products (Mavala Stop, or Orally No Bite), which are harmless liquids that taste badly. Unfortunately, many kids will get used to the unpleasant taste and continue to suck. Same goes for nail biters (I have not been successful in my own home in this area). Many children will stop their daytime sucking but continue the nighttime habit. In this case you may also try using a glove or a thumb sucking apparatus that covers the thumb and even attaches to their pajama top to keep their thumb out of their mouths. Again, you need to have a motivated child to do this or it will not work. Lastly, discuss this subject with your pediatric dentist. Sometimes, just having them discuss thumb sucking with your child will be enough to get a child to stop the habit. Power of positive thinking! One final note:  There are expensive orthodontic appliances that may be used for older children that continue to have thumb sucking problems after their permanent teeth are erupting. Persistent sucking can lead to problems with a child’s bite and jaw formation and should be addressed by the dentist and or orthodontist. That’s your daily dose, we’ll chat again tomorrow. Send your question or comment to Dr. Sue right now!

Daily Dose

The Need to Stay Calm During Swine Flu Season

I have found myself sounding like a broken record for the past week, and feel certain that the record is going to continue to “skip” as the confusion over the use of antiviral for H1N1 (swine flu) continues.

In the last week I have not only been to the office, but also to a school board meeting and several social engagements after work, all which were opportunities to discuss the continued H1N1 outbreaks and anxiety associated with “swine flu”. I guess the good thing is that no one is discussing the economy; it is all chatter about flu. It is important to reiterate that H1N1 is another flu, really no different than seasonal flu which we experience every year in the U.S. The difference is that this is a new or novel flu virus and it has managed to spread, quite effectively, throughout the spring and summer months, and into the early fall, with a clear predilection for school aged children. With that being said, now that schools are back in session and our children are all together in close quarters, we are seeing an increase in H1N1 activity throughout the country. Because of the previous concerns about swine flu last spring and the uncertainty of how the population as a whole would handle this virus, there has been a great deal of anxiety associated with this particular virus. Fortunately, over the last five months, the data is showing that H1N1 has not caused more pediatric deaths than we see each year with seasonal influenza (which is still yet to come this winter). The MAJORITY of children with this virus are doing well, and are recovering within two to seven days, even without the routine use of antivirals like Tamiflu and Relenza. The CDC has reiterated that routine testing for influenza and use of antivirals is not necessary for the school aged child, without underlying chronic illness, who is not seriously ill. That is most of our children. Younger children, under the age of five, and especially under the age of two, needs to be evaluated and may or may not need antiviral treatment. That is a decision for their pediatrician to make. Despite these ongoing recommendations parents are frantically calling the office requesting that antivirals, like Tamiflu, be prescribed for their family, “in case” they are exposed to flu, get sick, feel like they might get sick, or as one mother actually said, “I’ll feel better if my son is just on Tamiflu all winter.” This is not going to help anyone. The exposures are going to continue throughout the winter. Not just at schools, but also at the grocery store, cleaners, church, after school events and the list is endless. We need to try and keep a level head and not horde a medication that others may truly need, or spend unnecessary valuable health care dollars on medicine that will be thrown out in a year, or have people start and stop Tamiflu and Relenza as they feel better. Just like antibiotics, overuse and indiscriminate use of antiviral medication will lead to resistant influenza strains. When we really need these drugs, we all want them to work, for our children, for ourselves and for all of those that may get seriously ill throughout this flu season. This “swine flu frenzy” is reminiscent of the hording of Cipro during the anthrax scare. I wonder how much Cipro was hidden away, “just in case you opened your mail and found a white powder.” As I recall, there were shortages of Cipro for months, and the same might happen with antiviral medications. It is easy to write prescriptions, but it is much harder to do the right thing and try and teach patients and families why doctors are not routinely prescribing antiviral medications. If things change and recommendations change doctors will let you know, but in the meantime, keep sick children home until they are fever free, read the information about those who might need to take an antiviral medication and keep washing hands. That’s your daily dose, we’ll chat again soon.

Daily Dose

Pain When Going to the Bathroom

1.30 to read

I was on call the other evening and working late in the office and happened to see several little girls (between the ages of 4-10) who all had the complaint of “it stings when I pee-pee”, otherwise known as pain with urination or dysuria. Interestingly, one of the patients had only complained several times that day, while the other little girl had a long, yet intermittent history of pain with urination.  

Whenever you hear pain with urination most parents will think of a urinary tract infection (UTI) Urinary tract infections are fairly common in this age group (about 5% of pre-pubertal girls will get one), but even more common than a UTI, is vaginal irritation that causes pain with urination as the urethra  becomes inflamed.   

Little girls love bubble baths and all of those lovely scented soaps and potions for the bath. They also love to sit in the soapy water and play or wash their hair and rinse all of that shampoo into the bath tub as well. Because the female urethra is short it is easily irritated by the chemicals and then gets inflamed. The next thing you know your little girl is complaining of pain when she heads to the potty. 

If your daughter simply has some pain with urination and is otherwise well, no fever, no blood in the urine etc. and she has been guilty of taking frequent bubble baths, you might try stopping the bubbles and see if the pain goes away. In many cases of little girl with painful urination, simply stopping the baths solves the problem. If the pain is due to soap and bubbles, these little girls typically do not have accidents or night time awakening either. Pushing fluids also helps. 

I also recommend to older girls taking showers as this typically solves the problem as well. Girls love bubbles but it’s the boys who can tolerate bubble baths due to their different anatomy! 

If stopping bubbles doesn’t do the trick you will need to see your pediatrician to rule out an infection. Remember, this type of pain with urination is often intermittent and does NOT cause fever or blood in the urine. Any of those symptoms in a child is a call to your pediatrician to be seen. 

Daily Dose

Preschool Nutrition Can Be Challenging

1.30 to read

Does your child eat three meals a day with healthy snacks along the way? I often find myself talking to parents about establishing healthy eating habits especially when you have a preschooler. Preschool children, specifically the two to five-year-old set are notoriously picky eaters, and parents need to recognize that this is developmentally appropriate, although frustrating for parents.

This is an appropriate time to begin teaching children the importance of healthy eating habits to encourage a lifetime of good health and prevent obesity. A good place to start to get information is “MyPyramid for Preschoolers”, a website sponsored by the U.S. Department of Agriculture. This website not only covers what your children should be eating, but also is full of good advice on handling picky eaters, how to monitor your child’s growth and ideas to encourage physical activity.

The website encourages parents to lead by example and let your children see you eating a wide array of foods including fruits, vegetables, and whole grains throughout the day. There are ideas for healthy snacks that can be eaten on the run, as you get back into carpools and after school activities. Even the toddler set is busy after school!

Remember: do not let food choices become a battle or an issue. Do not make negative food comments around your children, and keep trying new things. It may take up to 20 attempts or more before your child will try something new, but if you don’t keep trying you will never know if they might really like broccoli.

Also, no “yucky faces” for the adults and older children while at the table and eating their meal. That will only discourage your toddler from trying unfamiliar foods. Put on that happy face, even if it is not your favorite food, it might be your child’s.

The most important message is to make mealtime and snack time pleasant and healthy. Even a toddler can help with planning and preparing a meal. This website is really quite good and interactive as you can enter your child’s first name, age, gender and typical amount of activity and the site will generate a plan just for your child! Can’t be easier than that.

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

 

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