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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

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

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.

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

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

Your Chid's Fever

1:30 to read

Now that you have taken your child’s temperature, what do you do with the information? As discussed previously, a fever is defined as a body temperature above 100.4 degrees. If you take your own temperature all day long it will be quite variable as will your child’s, and body temperature often goes up as the day goes on.

If your child has 100 degree temperature in the morning, the mother and pediatrician in me thinks that by the end of the day they may be running 101 degrees or higher. I would keep that child home that day to see what happens with the temperature. If you’re wrong and their temperature stays down, back to school or day care the next day. If it goes up you have not exposed everyone else throughout the day. All infant’s under two months of age with a documented temperature (preferably rectally) above 100.4, should be seen by their doctor. That is a phone call day or night, to find out if your doctor wants to see you in the office or go to ER etc. Do not give this age infant any acetaminophen, before talking to your doctor. Many times this age child will be admitted to the hospital, so be prepared for that discussion with your doctor.

Once your child is over two months of age but still younger than six months, it is important to discuss your child’s fever with the nurse or doctor. There are certain things they will ask you that will help determine if your child needs to be seen that day or night. After six months of age it is easier to judge a child’s degree of illness by not only the reading on the thermometer, but by how they are acting. The hardest thing to teach any parent (me included) is that the height of the fever does not necessarily correlate with degree of illness.

During flu and viral season, it is not uncommon to see temperatures in the 103 - 104 degree range. Try not to react to the number on the thermometer, but rather look at your child. Go ahead and treat the fever with either acetaminophen (Tylenol) or ibuprofen (Advil or Motrin) and then watch your child over the next 30 – 40 minutes. Reducing their fever will often improve how sick they look. Whenever a pediatrician walks into a room the first thing we do is look at how the child is interacting with the parent. Whether that is a toddler in a lap, or a big kid on the table, a quick look at a child is really worth a thousand words. If your child will smile (okay just briefly), make good eye contact, responds to the pediatrician by kicking and screaming (a toddler for sure), can play on the Nintendo DS, eat cheerios or candy or chips (I know, they won’t eat well when sick, do you?) and tell you just how crummy they feel, they are probably okay. I describe this as pitiful, and pathetic, but not critically ill. That is what we are trying to distinguish on a busy day in the office, and that is the same thing you want to look for in your own child.

It takes practice, but as a parent, you will be dealing with children and fevers for the next 21 years and you too will get better at dealing with fever. It is always scary the first time you see your child sick, but fever is not the enemy. It actually means that your child’s body is fighting the infection. So remember the mantra: Fever is your friend. I think we will be saying this a lot this winter. More fever topics later.

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

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.

 
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

Start Good Homework Routines Now

Now that school has started homework has too. For most children homework starts in first grade and continues through out high school. There are often lots of complaints and frustrations about getting homework completed, both from the children and their parents. Like so many things, the best way to begin the school year is with a good plan for getting homework completed.

It is also easier to start younger children with good study habits that will then be maintained throughout their school years. With that being said, do not throw in the towel if you have an older child who still needs a little coaxing and guidance on getting homework done. It is never too late to make changes for the better! To begin with homework needs to be a child’s responsibility. Parents are important helpers with homework, but should not be the doers of the homework. Everyone is a little different as to when homework should be completed. For some it is easiest to come straight home from school and start homework. For others they need some “down time” and may need to run around outside to get rid of some energy before starting homework. You know your child the best, but either way, having a routine to getting homework started is the key to getting it completed. Secondly, good study habits require a good study area. Buying an inexpensive desk to set up a quiet study area will be useful for many years. Setting up this area can be fun for children too and teach responsibility for taking care of their study area. As children get older they will be used to getting their study area organized and this will carry them all of the way through college. Teachers have set expectations for homework, and are a valuable resource in helping you as a parent to know what to expect for the year. Some teachers assign more importance to homework than others; so it is important know this early in the year. Review these expectations with your child too, so that everyone is on the same page. Homework can also be a good time to watch your child at work. This is the only time that you really have a chance to observe how your child is learning. Does it seem that they have a harder time in one area than another? Are there problems with comprehension, or focus? These parental observations are important if there seem to be consistent issues, and if so make an appointment with your child’s teacher to discuss your concerns. Again, doing the homework for them will not correct the issue and tackling learning problems is better at an earlier age. By following good homework basics your child should become independent with their homework and be on the road to a lifetime of good study habits. That’s your daily dose, we’ll chat again tomorrow.

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