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Daily Dose

Your Child's Well Check

2.00 to read

From the moment your baby is born until you send them off to college, your child will be seeing his/her pediatrician for “well child check-ups”. These are regularly scheduled visits which occur quite frequently when you have a baby or toddler and become a yearly visit once your child is over the age of 3. The well child visit is an extremely important part of a pediatrician’s job, and is also your child’s medical home.

In fact, one of the most rewarding aspects of being a pediatrician is having the privilege to observe a child from birth through their teens, in a sense, “helping to raise them”. Therein lays the reason for check-ups.

When you see your pediatrician for a check-up, I’m sure you get your child’s weight, height, BMI, (and blood pressure once they are older), as well as their growth percentiles.

The doctor also does a physical exam on your child, which is hopefully all normal. But there is a lot more than that to your visit. This is the time for your doctor to discuss your child’s milestones; whether that is sitting up for the first time, first words or how they are performing in first grade.  These conversations continue for all of your child’s school years as well.

It is also the time to discuss multiple other topics which should include sleep habits, nutrition and safety which is pertinent to all age groups. As your child gets older the conversation should include discussions about school performance, bullying, studying, screen time, family meals, exercise, and the child’s interests.

For the teen patient I think it is important to discuss sexuality, peer pressures, driving, and the adolescent’s long term goals.  The list goes on and on, but certain topics should certainly be yearly discussions which are then tailored to the age of the child.

 As a child gets older it is important to have some time where the doctor may be alone with the adolescent who may want some “private time” with the doctor. It is equally important that the exam includes time spent with the both the parent and the adolescent to wrap up the check up and answer any questions that a parent may have had that their adolescent did not.

For my patients 18 and older, I find that many times their parents do not come for their check-ups as the relationship has now become a bit more about a young adult with their doctor. Everyone is different and there is not a “right” way to handle the adolescent, but it is more important to have an open rapport and conversation between patient and doctor.

Lastly, every check-up should have time for questions. It is helpful if parents have a list of questions ready for the doctor.  Young parents often have simple questions as they are new parents. So, they often start off with “I think this is a stupid question…” but, there is not a “dumb” question as they have never been parents before.  For parents with older children the questions are often more lengthy and may even require another visit or phone call to follow-up or complete the conversation.  In either case, the check-up is the place for questions.

I really enjoy my patient’s check-ups and continue to realize the importance of the well child exam and the doctor-patient relationship. Don’t miss them.

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

Daily Dose

Tooth Fairy

1:30 to read

A baby gets their first tooth around 6 months and that is a milestone event for their parents to record.  But for a child, the milestone is loosing their first tooth, which typically happens between 5-6 years of age. Just like the order that the teeth erupted, the lower central two teeth get “wiggly” first and with a little bit of “coaxing” out one comes.

 

Some children cannot wait to get that tooth out and wiggle and pull on it all of the time and are not a bit “queasy” about losing the tooth. For others it is quite traumatic and dramatic. The child may leave that tooth hanging by a thread and not “allow” anyone to touch it or help pull it out….in a few cases I have known the child to swallow the tooth as they refused to pull it.  Don’t worry…your child will not choke or get a bowel obstruction from swallowing a tooth….but they may want to search their “poop” in hopes of finding the tooth. In the case of a swallowed tooth I would suggest writing a letter to the tooth fairy explaining the predicament rather than the former idea.

 

So…the tooth fairy is a very special person!!  The tradition of putting a tooth under your pillow and waking up to find the tooth gone and a “reward” under the pillow has been around for years. I am really not sure where it started..but it certainly continues in most households. Interestingly, it seems the tooth fairy has invested well and the money left under the pillow is certainly more than the quarter I remember receiving, and more than the silver dollars and $2 bills the tooth fairy often left under our children’s pillows. i am not sure I agree that a $10 or $20 bill is “age appropriate”, but I digress.

 

When I am seeing a child who has recently lost a tooth it is a good conversation starter to find out “who pulled the tooth” and “what did the tooth fairy leave for you?”.  I get all sorts of interesting and cute stories from my young elementary patients.  The next question I ask is if they spend the money or save it?  It is split about 50/50 among “spenders and savers”….will see if that tendency continues as they get older.

 

But, just the other day I saw a little boy who had lost his tooth the night before and was so excited to tell my about the tooth fairy. When I asked him what she had left for him he told me he had gotten a $5 bill!  When I asked him what he was going to do with the money….he quickly replied, “I am going to Target!”.  Don’t you think that would make a good commercial!?!?  

 

Kid’s say the funniest things!

 

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

Your Baby's Umbilical Cord

1.15 to read

I get a lot of phone calls several days after parents head home with their newborn regarding their baby’s umbilical cord.  The umbilical cord really is the lifeline for the baby for 9 months, but once the baby is delivered, and the cord is clamped, it becomes a nuisance and “grosses” many parents out.  So often parents don’t even want to touch the cord and one of my patients told me....”why can’t it just dry up and fall off immediately?”. My only answer to that is, “God did not make it that way?”.

So, in a nutshell the umbilical cord is made up of 3 blood vessels, actually 2 arteries and one vein.  When the cord is cut and clamped the vessels begin to clot and eventually the cord detaches, typically in 7-14 days and then falls off.  

In the interim the cord is developing a scab so it may “ooze” a bit and there may even be dried blood on the baby’s diaper or around the edge of the cord.  A tiny bit of blood is to be expected, and parents don’t need to be worried that the baby is bleeding!!!  I like to explain that it is the first time as a parent that you might need to clean off a little blood, the same way that you will again when this sweet newborn becomes a toddler and falls down and skins their knee.

On occasion the hospital forgets to take the cord clamp off before the baby is discharged and the family comes in with the baby for their first visit with the cord clamp still on.  Poor parents have no idea that this is typically removed before discharge...somewhat like leaving the store with the magnetic tag on the outfit....just no alarm to let you know it is still there. In that case they are amazed when we pop off that yellow or blue plastic attached to their baby!

Lastly, the newborn baby can have some time on their tummy, if they are awake, even with the remnant of the cord still on. It will not hurt the baby at all and early tummy time is important...just NOT when a baby is sleeping!

I have to admit that I opened the baby book 30 years later and that dried umbilical stump was in there..Yes, I too was a first time mother.....don’t save it!

Daily Dose

Breastfed Babies & Diaper Rash

1:30 to read

I was shopping at Target just the other day and happened to be in the “baby aisle” looking for one of those snack cups with the lids to let little fingers get in and not let the puffs fall out.  I needed it as part of a baby gift basket.  Useful for sure!!

So…while I am browsing, I see a young mother and her mother looking at diaper creams and obviously trying to decide which one to buy. I could’t resist offering help (always worry about being intrusive). When I asked what they were trying to treat the mother said, “ my new baby has this raw and red diaper rash right around his bottom”.  “He is just 12 days old and I change his diaper all of the time….how could he possibly get a diaper rash? What am I doing wrong?”

As we say in Texas, “bless her heart”!!! I asked if she was breast feeding,  and she was,  then I immediately knew what she meant. A breast fed infant will poop ALL OF THE TIME.  Many times you change a new diaper and as soon as the next diaper is put on the baby stools again. There are many times when your infant may poop a bit of stool during sleep and when you get them up they have a dirty diaper…all normal. No new mother guilt!!

The good news is that a newborn who is stooling a lot is probably getting plenty of breast milk as well…and that means they are gaining weight too!  The flip side is that it is not uncommon for a newborn to get that raw red bottom during the first month or so of breast feeding.  After that time, the stools do slow down a bit and diaper rash is less common.

The best remedy I have found for treating that tender new bottom is a combination of a diaper cream that contains zinc (Destin, Dr. Smith’s, or Boudreaux’s Butt Paste) and a bit of a liquid antacid (Mylanta, Maalox, Gaviscon). I put  a blob of diaper cream in my palm and then pour a bit of the antacid into it and mix….you can’t use too much of the liquid or it will run off.  Then I take that combo and coat the baby’s bottom. You can’t over do it. Use it with each diaper change.   It seems to do the trick and is easy. Several years ago I told a mother about the concoction (she had 4 children and was very sleep deprived) and I  just said use some antacid if you have some. She called later in the day and said she had tried to crush up the tablets and mix it with diaper cream and it wasn’t working.  I have since learned to be a bit more specific about a LIQUID antacid.  

 

 

 

 

 

Daily Dose

When Is The Best Time To Potty Train?

1:30 to read

Every parent wants to know, when is my child ready to potty train? A study that was recently published  in an issue of the Journal of Pediatric Urology is one of the first to show that timing of potty training children seems to be more important than the technique.

I found this quite interesting as the lead author, Dr. Joseph Barone stated, this is the first study “that gives parents an idea of when it’s a good time to toilet-train”.  The best time to potty train has typically been thought to be somewhere between the second and third birthday, but that is a wide range. This study suggests that age 27-32 months is the appropriate time to move a child out of diapers. In the study, children who were toilet trained after 32 months  were more likely to have urge incontinence, and problems with daytime wetting and bedwetting when they were between the ages of 4 and 12 years. This data was gathered from a retrospective study of children who were being seen by pediatric urologists for problems with urge incontinence (daytime wetting episodes) and their answers to a questionnaire on when they started potty training and what method they used, was compared with children who did not have urge incontinence.  The results showed that the mean age for  children with the wetting problems to have been trained was 31.7 months while those children who did not have problems were toilet trained at 28.7 months. 

Potty training continues to be at the top of the question list for parents with toddlers. I still believe and this study tends to support that children who are potty trained younger seem to have “less issues” than those that are older. That is not meant to say that your child will be potty trained by 28.7 months, but in most cases if you begin discussing the potty and following a child’s cues and follow through with reinforcement and consistency that the majority of toddlers may be potty trained by age 2 ½  (which would be 30 months). In my experience as both a mother and pediatrician, those toddlers who are put in pull ups and never asked about going to the potty or are not taken to the potty seem to be the ones that I see at 3 year old check ups still wearing their pull-ups. By this time if you ask them if they want to go potty they all say, “NO”.  I believe this is termed “the child directed approach” which seems analogous to me as saying “what time do you want to go to bed?”

In most cases, if a toddler is introduced to the toilet, goes with their parent to “sit or practice or watch Mommy and Daddy potty” during the early 2’s, and given some incentive to perform, whether that be a sticker or M & M or both,  they will become interested in the potty and then they will become ready to potty train. I guess this is a combination of both the parent directed and child directed approach. Once you see your child is interested you have to “go for it” and put them in good ‘ole cotton training pants and go to the bathroom frequently. You can’t ask if they want to go, again it is a statement, “time to go potty” and most will be trained by the “magical” 27-32 months of age. To me potty training is somewhat like a space shuttle launch. “The window is not that wide” and you have to potty train during that magical window or the launch window may not come around again for a long time!

That's your daily dose. We'll chat again soon.

Daily Dose

Anemia

1:30 to read

Adolescent females are at greater risk for anemia than adolescent boys. This may due to several reasons including the fact that adolescent girls lose blood each month during their menstrual cycles and many teenage girls eat less red meat than adolescent boys.  

 

While some adolescents with anemia (low hemoglobin and hematocrit) complain of headaches, irritability or fatigue (which are very common teenage complaints), others are completely asymptomatic.  It is recommended that teens have a screening complete blood count around the age of 13 and then every 5 years or so thereafter. At the same time, the AAP recommends more frequent blood counts in those with risk factors for anemia, including diets low in iron rich foods (meat, eggs, fortified cereals) teens who have significant physical activity (especially female adolescent athletes) those with vegetarian or vegan diets and for any adolescent girl with excessive menstrual bleeding. Obese teens also have a higher incidence of anemia and should be screened. This list includes many of my patients.

 

Interestingly, you can have low iron stores without yet being anemic.  I have now started looking at the serum ferritin levels in teens with risk factors for anemia, as I am finding that some of my athletic patients have low ferritin levels, with a normal blood count. Some recent studies have shown that low ferritin may impact athletic performance including fatiguability. While fatigue during exercise is a subjective symptom,  maintaining iron stores is important for overall health.

Lastly, iron deficiency may impact cognitive function in adolescents. There have been several studies showing that girls who had higher serum ferritin levels had statistically significant improvement on cognitive tests of verbal learning and memory…so it may be worth looking at levels in a teen who is suddenly having difficulty in school, without previous issues. One blood test!

Daily Dose

Read Aloud Challenge

1:30 to read

Have you heard about the 21 day Read Aloud challenge for the month of October?  Studies have continued to show the importance of reading to your child.  But, did you know the importance of reading aloud to your baby…from birth?  

 

Reading aloud and having your baby hear your voice plays an important role in early brain development.  In a recent study, only 15% of parents read aloud to their child from birth, and only 8% reported reading aloud for at least 15 minutes a day. 

 

The challenge is for parents and caregivers to include 15 minutes of reading aloud in their daily routine for 21 straight days.  I wonder why the challenge was not for the entire month?  

 

There are so many classic children’s books to begin reading to your child. I recently went to a clever baby shower where the guests were asked to bring their favorite children’s book and to write an inscription for the new baby. What a fun way to welcome a newborn to the family and to start their library. One day the child will probably really enjoy reading all of the inscriptions as well as the books.  

 

I still can remember having a baby boy on my lap and reading him stories that I am sure my parents had read to me. Some of my favorites….The Little Engine that Could (I still use that quote quite often), Caps for Sale, Madeline, Richard Scary books, Toad and Frog, Winnie the Pooh, Dr. Seuss (which is what some of my patients call me), Alexander and the Terrible Horrible No Good Very Bad Day (we still have these days as adults), Goodnight Moon, I Love You Forever. I know every family has their favorites.  

 

With another new grand baby due this month I am going to start the challenge myself. Whether it be a girl or a boy (will keep you posted), I am going to pull out all of those books I love (which are in boxes in the garage) and start my grandparent reading time every day. Fortunately for me, the new grand baby lives just blocks away and what a great EXCUSE for a short visit. 

 

So, no matter the age of your child, birth till 6 or 7 years for sure, commit to reading aloud everyday, for 15 minutes without the distraction of electronics. Once your child is reading, reverse the challenge and have them read aloud to you for at least 15 minutes a day.  Who knows…it may be so much fun that you start reading for longer periods every day!

 

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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