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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. 

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Daily Dose

Toddler Constipation

1:30 to read

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

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

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

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

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

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

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

Daily Dose

Stranger Danger

1.30 to read

We had a question via our iPhone App from an aunt who wanted to talk to her twin 4 year old nephews about “stranger danger”. Unfortunately, this topic has been in the news quite frequently lately with child abduction cases being reported all around the country.

The National Center for Missing and Exploited Children has numerous resources for educating children about safety.  Interestingly, most perpetrators are not actually strangers, but are often someone the parents or another adult knows and may have been around the child on occasion. So, it seems that “stranger danger” may not be the appropriate term to use when teaching our children, especially younger, children about safety. It is important that the conversation about safety begins with children at young ages. It is often easier to use teachable moments to begin the conversation with young children. 

Talk to your child about “safe” strangers, as it is hard for a child to understand why you are talking to grocery store clerks, or people on the playground in the park, and yet they are strangers. It may be best to teach a child to watch out for dangerous behaviors from adults, rather than saying “never talk to strangers”.  Talk about adults who might approach them for directions, or to find a missing pet and role play as to what they should  do. At the same time, teach them that they can turn to “strangers” such a store clerks or mothers with children for help if they are scared.

While talking about this subject use a calm reassuring manner.  You do not want to make your child “too” anxious as most people they will meet are not dangerous, and children do need to interact and trust numerous people around them that they will meet in  different situations.

Another good way to discuss the issue of “stranger danger” is by reading books to young children that deal with the issue. Several good books that I like are:  The Berenstein Bears Learn About Strangers; A Stranger in the Park; I  Can Play it Safe.  There are many other books out there too, so head to your library  or your local bookstore to get some more recommendations. The librarians are often helpful with finding “age appropriate” books.  Lastly, this is not a one time conversation, but should be discussed at different ages and stages of your child’s life.

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

Daily Dose

Kids & Cellphones

1:30 to read

There is a new study out from the National Toxicology Program in which rats were exposed to radio frequency radiation for nine hours a day for two years beginning in utero.  They compared these rats to those that were not exposed and interestingly some of the male rats developed tumors in their hearts and brains and the controls did not.

I am writing about this as another deterrent to giving children a cell phone at a young age and for not having a home phone. While it is too early to say if this study has any bearing on humans and obviously the exposure was heavier than normal, this may serve as another deterrent to giving children a cell phone at a young age. It may also help to bring “land lines” back into the home. 

Call me old school, but I continue to believe and counsel patients, having a home phone is still important.  Without a home phone how can you call your child when you are away and they may be home with a babysitter….and not depend on the caregivers cell phone?  I also think that some children may be ready to stay at home for 30 min to an hour at a time while their parents go to the store, or pick up a sibling from school etc. before they are ready for a cell phone. By having a home phone the child has a means of contacting their parents, neighbors or emergency personnel and don’t risk losing a cell phone or any of the other numerous issues associated with owning a cell phone.

A home phone also gives children an opportunity to learn how to answer a phone and begin “screening” phone calls for the family and to learn phone etiquette….which is not always taught when parents are answering the cell and handing it off to their child.  What about the days when we were taught to say “Hello, Hubbard residence” when answering the phone?  Or having your mother sit by your side while you called a friend’s house and started off the conversation with, “may I please speak to…Sally?”. Phone etiquette was such an important part of every child’s life.

Once your child does have a cell phone it also seems that they may spend more time isolated from the family when on the phone….and may spend longer amounts of time on the phone than when the phone was in the family kitchen. Even my grown children often go outside to take their cell phone call….wonder what they are talking about, me?  I digress….

The American Academy of Pediatrics continues to recommend that parents should limit the use of cell phones by children and teens. A cell phone is not a toy and emits radiation.  Keeping this source of radiation away from our children for as long as possible seems prudent while more research continues…and this study just gives parents a bit more ammunition when their 6 year old starts off with, “everyone else has a cell phone…when can I have one?”.  

 

Daily Dose

Baby's First Foods

1:30 to read

Have you heard of “baby led weaning” (BLW)? Many of my patients who have infants that are ready to start “solid foods”, also called complementary foods, have questions about this method. Most babies begin eating foods along with breast milk or formula somewhere around 5 - 6 months of age.  So BLW is not really “weaning”,  as your infant will continue to have breast milk or formula in conjunction with foods…so this really should more aptly be named “baby self feeding”. 

In this method you never offer your baby “mush” or pureed foods, but rather offer them foods from the table.   While I am a huge advocate of self feeding (old term is finger feeding), I also think that early on offering a baby “mushy” food on a spoon is an important milestone. In fact, for most babies at 5 -6 months, it is difficult to pick up a small piece of food to self feed as the pincer grasp has not developed. So, a baby is trying to get food to their mouths by cupping it or hoping it sticks to their hand while pushing pieces around their tray. Some parents will put the food into their baby’s hand.  But, by 8-ish months most babies have developed their pincer grasp and the finger feeding should be preferred.  

Parents are also concerned about starting solid foods and the possibility of choking.  I am always discussing how to make sure that your child avoids choking hazards with foods. In other words, no whole grapes, or hot dogs, or popcorn or chunks of meat.   Other hazards are raw carrots, apples, celery and any “hard” food that your baby might be able to bite a chunk of and then choke. But, if you cook the carrots and then cut them in small bites they are easily handled by a baby who is self feeding.  It is really all about the consistency of the food as once your baby has lower teeth they can easily bite/pry off a big “chunk” of food that could lead to a choking hazard.

Interestingly, there was a recent study that looked at the incidence of choking in children who started with self feeding vs those fed traditionally with pureed foods from a spoon. In this study of about 200 children between 6 - 8 months of age the incidence of choking was similar, while there were more gagging events in the BLW group.  Fortunately, “the choking events resolved on their own”. Gagging is quite different than choking. Some children will gag on pureed foods just due to texture issues. 

I am an advocate of what I am going to call parent led feeding followed by early self feeding of appropriate foods. By the time a child is 9 months of age they should be able to finger feeding the majority of their meals. But there are some foods that are just not conducive to finger feeding at all….yogurt, apple sauce, puddings…and they will be spoon fed until your child is capable of using a spoon which is anywhere from 12 -18 months.   But as a reminder, whenever you offer your child a finger food you should remember two things, #1 is the piece small enough that my child cannot choke and #2 is the food cooked well enough to not pose a choking hazard.  

Several years ago there was a 1 year old in our practice who was given a piece of an apple to chew on… she bit off a chunk of the apple, aspirated and died. It was a terrible accident.  I will never forget that….and re-iterate to all of my patients…a pork chop, or chicken leg or any number of foods can become a choking hazard if your child bites off a chunk. Children really don’t chew until they are around 2 years, they just bite and try to swallow so I pay a great deal of attention to what foods they are offered.

Old school and new school…the combo seems to make sense to me. 

Daily Dose

Birthmarks

1:15 to read

Many years ago when children asked their parents “where did I come from?” they answered “the stork brought you”.  The picture of the stork’s beak holding on to the baby’s neck and flying to drop the baby on the new parent’s doorstep was known by all….but things change and that visual is not known by my newest parents.  In fact they look at me with completely blank stares when I discuss the birthmark on the nape of their child’s neck.

But the term “stork bite” comes from that old story, and the red birthmark seen on up to 50% of babies necks is also called nevus flammeus or nevus simplex. They are flat, pink and irregularly shaped and while they occur most commonly on the nape of the neck, they are common on the forehead, eyelids and above the upper lip as well. They are due to capillaries close to the skins surface. The stork bites on the face typically fade over time while the ones on the nape of the neck may continue to be present but are obscured and typically forgotten once the baby has hair. Many people are not even aware that they themselves have one.

When I am doing a newborn exam I see so many of these little “flat red patches” that I often to forget to bring them up as they are small and typically fade….but sometimes a parent will specifically ask about them. After I apologize for not bringing it up….as I know they are small and fade, but they are concerned,  I tell them that they are “stork bites” and get that blank look.  Then I launch into the etiology for the name etc. But, things are getting ready to change as STORKS a new animated movie is just bring released.  The old myth of the stork is making a come back!

So…if your baby has this small birthmark, no need to worry.  Be assured that most will fade but if they have not resolved by the age of 3 or 4 years, there are now lasers available to treat them.

In the meantime..take your family to see "STORKS" so they are aware of where “you used to come from”!  We can still tell our children the myth of the stork and then make sure to discuss the truth about “where did I come from?”. 

 

 

 

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

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.  

 

 

 

 

 

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