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Daily Dose

Constipation

1:30 to read

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

 

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

 

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

 

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

 

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

 

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

 

 

Your Child

Helping Children Cope With Frightening News Events

2:30

Gone are the days when most Americans got their news from 3 or 4 sources around the evening dinner hour. Today, thousands of news reports (some real, some fake) instantly flood our phones, computers, TVs and radios, sometimes with real time graphic images.

While some news events may be difficult for even adults to comprehend (with all our life experience and knowledge about current affairs), children don’t have that advantage when they hear and see things that feel threatening to their safety and family stability.

The Journal of American Medical Association, (JAMA) Pediatrics, has published a free online patient’s page dedicated to How to Talk to Your Children About Tragedies in the News.

The amount of information available on current events is almost instant. Sometimes parents don’t have a chance to screen what their children see and hear, so it’s important to know how to talk with your children about what they are experiencing.

The JAMA article is broken down into different age groups. Your approach should differ depending on your child’s age and ability to understand complicated situations.

A good place to start in discussing a tragic event is by asking what your child has already heard. After you listen carefully, you can ask what questions they have. It is important to be honest about what happened and to focus on the basics. It is not necessary to share every detail, and it is important to avoid speculating about what might happen next. Listen closely to your child for misinformation or underlying fears. Remind your child that you are there for him or her and will keep them safe. A key underlying message for parents to convey is, “It is ok if this bothers you; we are here to support each other.”

For very young children, news events can be frightening because they don’t understand context. Children may wonder; is this going to happen to us? Is this happening in our neighborhood? Are my friends ok? Are we next? News media coverage can include graphic images and sounds. It is best to share information with children by discussing it rather than showing the media coverage. Young children may have more questions about whether they are truly safe and may need help separating fantasy from reality. Some children may become clingy or regress in behavior such as wetting the bed or sucking their thumbs. It is important to be patient and to support your child if he or she reacts in this way. Do not ignore your child’s fears or brush them off. Realize that children see the world from a different perspective.

For older children and teenagers, it may be more difficult to avoid exposure to these events in the news. Kids on social media outlets often see stories and videos on their phones while at school or out with friends.- before you have a chance to preview the news. When there is a concerning news event and you have the opportunity, try to preview it before showing it to them so that you know what to expect and what key points to discuss. Then watch it together. Older children and teenagers may want more information about the tragedy and the recovery efforts. They may have opinions about the causes as well as suggestions to prevent future tragedies or a desire to help those in need. Listen to what they say and validate their concerns. If they’ve already seen something tragic, again, ask them what they think about it and talk about their concerns and what they see as a next step in coping.

Other ways you can help your child manage unsettling news are:

  • Be a calm presence. It is okay for children to see adults be sad or cry, but consider excusing yourself if you experience intense emotions.
  • Reassure your child of his or her safety. Consider reviewing your family’s plans for responding to an emergency.
  • Maintain the routine. To give your child a sense of normalcy, keep up your family’s usual dinner, homework, and bedtime routine.
  • Spend extra time together. This can foster your child’s sense of security. Encourage your child to express his or her feelings.
  • When possible, do something to help. Consider ways that you and your family can help survivors and their families.

Like adults, some children may have difficulty with events for a variety of unexpected reasons. Think back to 9-11. How many of us were prepared to watch the towers collapse and the horror and anguish of the families that were missing relatives and friends in the buildings? How we feared that there was a possibility that our country was under attack. It was one of the most devastating events our country has ever experienced in the modern age of instant media information.

Time has helped us put that day in perspective, but the repeated showing of the planes flying into the towers gave many Americans PSTD symptoms. It was almost too much to comprehend. Remember that when your child is scared or anxious about a current event. Help them realize that tragedies do happen, but we can and most often, do survive.

Some signs that a child is not coping well include sleep problems, physical complaints such as feeling tired, having a headache or stomachache, or just feeling unwell. Changes in behavior may include regressive behavior such as acting more immature or being less patient, and mental health concerns like sadness or heightened depression or anxiety. Sometimes it can be hard to tell if a child is reacting in a typical way to a tragic event or if there is something else going on.

Talk with your child’s pediatrician if you are concerned about your child’s reaction.

These are uncertain times. Everyone seems to be a bit on edge, wondering when the next shoe will drop. Have a plan on how to talk to your youngster about current events. Most of all have patience and be a good example of calmness and reassurance; that no matter what happens, you have their best interests at heart.

Story source: http://jamanetwork.com/journals/jamapediatrics/fullarticle/2646851

 

Parenting

Picky Eaters and Personality

1:45

If you have a child that is a picky eater, the reason may have more to do with his or her personality than the food you give them, according to a new study.

Researchers found that little ones who were more naturally inhibited also tended to be picky eaters.

"From the time they're very young, some infants are more 'approaching' and react positively to new things, whereas other infants are more 'withdrawing' and react negatively to the same stimuli," said study author Kameron Moding.

"But very few studies have examined whether infants show similar approach and withdrawal behaviors in response to new foods, so this is what we wanted to investigate," added Moding. She is a postdoctoral fellow at University of Colorado, Denver.

Researchers observed how 136 infants responded to new foods and toys during the first 18 months of life. They found that the children who were more reserved about playing with new toys were also more reserved about trying new foods.

The researchers determined that there might be a link between personality types and attitudes about food.

"It was striking how consistently the responses to new foods related to the responses to new toys," Moding said in a Penn State news release.

"Not only were they associated at 12 months, but those responses also predicted reactions to new objects six months later. They also followed the same developmental pattern across the first year of life," she added.

Getting some children to try new foods can be a challenge, but Moding says parents shouldn’t give up offering a variety of foods to their kids.

Keep trying! Research from other labs has consistently shown that infants and children can learn to accept new foods if their caregivers continue to offer them," Moding said. "It can take as many as eight to 10 tries, but infants and children can learn to accept and eat even initially disliked foods."

Story source: Robert Preidt, https://consumer.healthday.com/caregiving-information-6/infant-and-child-care-health-news-410/picky-eater-it-might-just-be-your-child-s-personality-725183.html

Your Child

FDA Warning: High Lead Levels in Herbal Remedy

2:00

The Food and Drug Administration is issuing a warning to parents and caregivers about high lead levels found in the herbal remedy, Balguti Kasaria Ayurvedic Medicine.

The herbal remedy is marketed for use in infants and children for various conditions such as rickets, cough and cold, worms, and teething. According to the product packaging, the product claims to help with digestion and bowel movement and improve the immune system.

The North Carolina Division of Public Health first reported high levels of lead after testing the product.

In addition, the Michigan Department of Health and Human Services notified the FDA that two children were found to have high levels of lead associated with the use of this product. The families of the children affected stated that they had the product mailed to them from India. At this time, the FDA has received one report of developmental delays in a child who was administered this product.   

Ayurvedic medicine is one of the world's oldest holistic healing systems. It was developed more than 3,000 years ago in India.

It’s based on the belief that health and wellness depend on a delicate balance between the mind, body, and spirit. Its main goal is to promote good health, not fight disease. But treatments may be geared toward specific health problems.

In the United States, it’s considered a form of complementary and alternative medicine (CAM).

Parents and caregivers should familiarize themselves with the symptoms of lead poisoning. High lead levels have also been found in toys, costume jewelry and other products that children use.

The symptoms are:

  • Developmental delay
  • Learning difficulties
  • Irritability
  • Loss of appetite
  • Weight loss
  • Sluggishness and fatigue
  • Abdominal pain
  • Vomiting
  • Constipation
  • Hearing loss
  • Seizures
  • Eating things, such as paint chips, that aren't food (pica)

Lead poisoning symptoms in newborns - Babies exposed to lead before birth might:

  • Be born prematurely
  • Have lower birth weight
  • Have slowed growth

The FDA is urging parents and caregivers to stop giving the product to children and to consult a healthcare professional. Balguti Kesaria is sold online and made by different companies, including Kesari Ayurvedic Pharmacy in India. The product has also been mailed or brought into the United States.

Story sources: Da Hee Han, PharmD, http://www.empr.com/safety-alerts-and-recalls/balguti-kesaria-ayurvedic-medicine-high-lead-levels/article/680132/

http://www.webmd.com/balance/guide/ayurvedic-treatments#1

http://www.mayoclinic.org/diseases-conditions/lead-poisoning/symptoms-causes/dxc-20275054

Your Child

Young Kids Overdosing on Dietary Supplements

2:00

It’s no surprised that the majority of American adults now take one or more dietary supplement daily. During the last decade, many households have switched from a simple multivitamin to more specific supplements for different dietary needs. It’s become a billion dollar industry even though many scientific studies have shown mixed results on the effectiveness of supplements on a person’s health.

What may surprise you though is the number of children that are accidently overdosing on dietary supplements found in the home. Children under the age of 6 are the most affected.

A typical scenario might play out like this.  A curious toddler opens a bottle of melatonin found on the kitchen counter, and accidentally overdoses on a supplement typically used by adults to help with sleep.

In that case, the doctor who treats the child may only have to deal with a very tired 3-year- old, but it might have been a far more serious scenario if a different dietary supplement, such as the energy product ephedra or the male enhancement herb yohimbe, had been swallowed.

"We see it all the time," said Dr. Barbara Pena, research director of the emergency medicine department at Nicklaus Children's Hospital in Miami.

From 2005 through 2012, the annual rate of accidental exposures to dietary supplements rose in the United States by nearly 50 percent, and 70 percent of those exposures involved young children.

"The biggest increase [in accidental overdoses] was in children under 6. It got our attention," said study author Henry Spiller, director of the Central Ohio Poison Center of Nationwide Children's Hospital in Columbus. Ninety-seven percent of the time, the children swallowed the supplements while at home, the study found.

The U.S. Food and Drug Administration (FDA) does not regulate dietary supplements, so there is no guarantee that the ingredients listed have been tested or that they are what they claim to be. The FDA can only take action if the supplements are shown to cause harm.

During the 13 years of the study, Spiller's team also found an increase from 2000 to 2002, when the rates of calls to U.S. poison control centers involving supplements rose 46 percent each year. From 2002 to 2005, the researchers found the rates of calls declined. Spiller suspects that is because the FDA banned ephedra in 2004, after supplements containing it had been linked with adverse heart events and deaths.

Overall, only about 4.5 percent of the cases in the study had serious medical outcomes. During the 13-year period tracked, 34 deaths were attributed to supplement exposure, Spiller said.

The supplements most often associated with the greatest toxicity were ephedra (ma huang,) yohimbe (found in male enhancement supplements and other products) and energy drinks and drugs.

Ephedra is now banned, but yohimbe is not. Nearly 30 percent of yohimbe exposure calls in the study resulted in moderate or major harm. Yohimbe can cause heartbeat rhythm changes, kidney failure, seizures, heart attack and death, the researchers noted.

Often, children find the supplements on a kitchen counter, Spiller said. Parents and others may equate dietary supplements with being natural, and therefore safe. Parents usually don't keep track of how many pills are left in a supplement bottle, he said, making it more difficult to tell poison control staff how many pills were taken in an accidental exposure.

Adolescents are also susceptible to overdosing on energy products loaded with caffeine and other ingredients that can cause abnormal heart rhythms or even a heart attack. 

Both Spiller and Pena suggest that parents and caregivers treat supplements the same way they do prescriptions or O-T-C drugs.  Keep all supplements in a locked cabinet or on a high closed shelf if young children are in the house or likely to visit.

Supplements are especially scary, Pena noted, because it's not always possible to know the potency of the product.

The study was published in the Journal of Medical Toxicology.

Story source: Kathleen Doheny, http://www.webmd.com/children/news/20170725/us-kids-overdosing-on-dietary-supplements#1

Your Baby

Preparing for Twins or Triplets

1:45

The number of U.S. parents expecting twins and triplets has reached an all-time high according to the National Center for Health Statistics. Multiple births make up a small portion of births in general, but since 1980, multiples numbers have been on the rise.

The number of twins born in the U.S. has increased the most. Along with twice the cuteness comes twice the workload. The American Academy of Pediatrics (AAP) offers parents of multiples some handy preparation tips:

Keep in mind that "multiples" are often born early and tend to be smaller than the average newborn. The AAP says parents may need to visit with their pediatrician more often than usual and reach out for help with feeding concerns or strategies.

And then there are the diapers- lots and lots of diapers! Go ahead and start purchasing your diapers ahead of time. The more you have stocked away before your little ones are born, the less worries you’ll have about running out when you need them most. Also, you’ll be able to gage about how many you’ll need when you start shopping again.

Having multiples also means fitting more safety seats into the car, more clothing, more food and possibly even a larger home! Check out how well your home is going to work for a larger family and plan accordingly.

One of the most important things for parents to consider is making sure that each child has their own identity. Multiples may share everything, but they are individuals and should be raised as such, the AAP advises. Identical twins, in particular, may seem like a duo, and parents might be tempted to give them the same things and the same amount of attention. But even genetically identical children have different personalities, thoughts and emotions. The AAP urges parents to acknowledge and support their differences to help them become happy and secure individuals.

If you have other children, remember they need special attention too. It’s easy to overlook the older kids when the new kids on the block are demanding so much attention.

As multiples grow, they may form exclusive bonds and may even communicate in a way only they can understand. Sometimes, they become unwilling to seek out other friendships. Giving multiples some time apart can help them develop friendships and ensure that other siblings aren't left out, the academy says.

And efforts to encourage multiples to spend time apart should start early to head off resistance. Most elementary schools place multiples in separate classes, the news release noted. Parents who are concerned about preventing separation anxiety can turn to their pediatrician for advice.

Don’t be afraid to ask for help! Multiples demand a lot of attention. If your budget allows, hire someone to clean the house a few days a week. Grandparents, uncles and aunts, brothers and sisters may be willing to pitch in and give you some much needed down time or date time.  Don’t forget about your friends – while you may think it’s too much of an imposition, they may love being able to spend some quality time with your children – then turn them back over to you!

Take turns getting up at night for feedings and changings. Giving your spouse a few hours of uninterrupted sleep will do wonders for your relationship.

There’s a lot to prepare for when multiples are involved but the rewards are great. It may feel a little overwhelming at first, but eventually you will figure out a routine that works for everyone.

Story source: Mary Elizabeth Dallas, https://consumer.healthday.com/women-s-health-information-34/birth-health-news-61/having-twins-or-triplets-what-you-need-to-know-before-they-arrive-715653.html

http://www.pewresearch.org/fact-tank/2015/12/11/twins-triplets-and-more-more-u-s-births-are-multiples-than-ever-before/

Your Teen

Overweight Girls Start Periods At Earlier Age

1.45 to read

Early-onset menstruation is linked to later health problems such as breast cancer, said Sarah Keim, a researcher at The Ohio State University College of Medicine in Columbus, who wasn't involved in the new study. Girls who get their period early in life are also more likely to have sex sooner than their peers, Keim added, which increases the risk of teen pregnancy and sexually transmitted diseases.It's nothing new that girls are getting younger and younger when they have their first period, but experts worry that the current obesity epidemic could be fueling that trend.

Overweight or obese girls get their first period months earlier than their normal-weight peers, according to a Danish study. Early-onset menstruation is linked to later health problems such as breast cancer, said Sarah Keim, a researcher at The Ohio State University College of Medicine in Columbus, who wasn't involved in the new study. Girls who get their period early in life are also more likely to have sex sooner than their peers, Keim added, which increases the risk of teen pregnancy and sexually transmitted diseases. About 17 percent of American kids and teens are obese, according to the Centers for Disease Control and Prevention. For the study, researchers used information on body mass index (BMI) -- a measure of weight in relation to height -- and age at first period from about 3,200 Danish girls born between 1984 and 1987. The girls started their period just after they had turned 13, on average, which is about half a year later than in the U.S. Keim said part of the reason for this difference may be that African-Americans tend to start their periods before white girls. On average, a girl got her period about 25 days earlier for every point her BMI increased. For a female of about average height and weight, a one-point change in BMI is equivalent to about six pounds. Overweight and obese girls, for example, got their period three to five months before normal-weight girls, said Anshu Shrestha, a graduate student at UCLA School of Public Health, who worked on the study. There has been past research showing a link between BMI and when girls start menstruating. However, since this study was done more recently, it shows that the link is holding up in today's generation, Keim said. The researchers also found that a girl's mother's weight was related to when her daughter started menstruating, but less so than earlier work had hinted. For every point her mother's BMI when pregnant went up, the girl's period came about a week earlier, according to the new study, which was published in the journal Fertility and Sterility. Keim said the Danish findings reinforce the importance of keeping a healthy weight. "It's important for your entire life, starting from very early on," she told Reuters Health. "And it can even affect your children's health." Talking to your daughter about Menstruation. Most girls begin to menstruate when they're about 12, but periods are possible as early as age 8. That's why explaining menstruation early is so important. But menstruation is an awkward subject to talk about, especially with preteen girls, who are often embarrassed by this discussion. So what's the best way to approach this ticklish topic? If your daughter asks questions about menstruation, answer them openly and honestly. Provide as many details as you think she needs at the time. It's OK to let your daughter set the pace, but don't let her avoid the topic entirely. If she's not asking questions as she approaches the preteen years, it's up to you to start talking about menstruation. Don't plan a single tell-all discussion. Instead, talk about the various issues - from basic hygiene to fear of the unknown - in a series of short conversations. Consider it part of a continuing conversation on how the human body works. Remember, your daughter needs good information about the menstrual cycle and all the other changes that puberty brings. If her friends are her only source of information, she may hear some nonsense and take it for fact. To introduce the subject of menstruation, you might ask your daughter what she knows about puberty. Clarify any misinformation and ask what questions she might have. It may be helpful to time your conversations with the health lessons and sex education your daughter is receiving in school, or you could broach the subject before a routine doctor's appointment. You can tell your daughter that the doctor may ask her whether she's gotten her period yet. Then ask if she has any questions or concerns about menstruation. Girls might prefer to learn about menstruation from a female family member, but sometimes that's not possible. If you're a single father and you're not comfortable talking about menstruation, you might delegate these conversations to a female relative or friend. The key is to make sure the information is relayed somehow. The biology of menstruation is important, but most girls are more interested in practical information about periods. Your daughter may want to know when it's going to happen, what it's going to feel like and what she'll need to do when the time comes. - What is menstruation? Menstruation means a girl's body is physically capable of becoming pregnant. Each month, one of the ovaries releases an egg. This is called ovulation. At the same time, hormonal changes prepare the uterus for pregnancy. If ovulation takes place and the egg isn't fertilized, the lining of the uterus sheds through the vagina. This is a period. - Does it hurt? Many girls have cramps, typically in the lower abdomen, when their periods begin. Cramps can be dull and achy or sharp and intense. Exercise, a heating pad or an over-the-counter pain reliever may help ease any discomfort. - When will it happen? No one can tell exactly when a girl will get her first period. Typically, however, girls begin menstruating about two years after their breasts begin to develop. Many girls experience a thin, white vaginal discharge about one year before menstruation begins. - What should I do? Explain how to use sanitary pads or tampons. Many girls are more comfortable starting with pads, but it's OK to use tampons right away. Remind your daughter that it may take some practice to get used to inserting tampons. Stock the bathroom with various types of sanitary products ahead of time. Encourage your daughter to experiment until she finds the product that works best for her. - What if I'm at school? Encourage your daughter to carry a few pads or tampons in her backpack or purse, just in case. Many school bathrooms have coin-operated dispensers for these products. The school nurse also may have supplies. - Will everyone know that I have my period? Assure your daughter that pads and tampons aren't visible through clothing. No one needs to know that she has her period. - What if blood leaks onto my pants? Offer your daughter practical suggestions for covering up stains until she's able to change clothes, such as tying a sweatshirt around her waist. You might also encourage your daughter to wear dark pants or shorts when she has her period, just in case. Your daughter may worry that she's not normal if she starts having periods before, or after, friends her age do, or if her periods aren't like those of her friends. But menstruation varies with the individual. Some girls have periods that last two days, while others have periods that last more than a week. It can even vary this drastically from month to month in the same girl. The amount of blood lost each month can vary, too, usually from 4 to 12 teaspoons (about 20 to 60 milliliters). It's also common for girls to have irregular periods for the first year or two. Some months might even go by without a period. Once your daughter's cycle settles down, teach her how to track her periods on a calendar. Eventually she may be able to predict when her periods will begin. Schedule a medical checkup for your daughter if: - Her periods last more than seven days - She has menstrual cramps that aren't relieved by over-the-counter medications - She's soaking more pads or tampons than usual - She's missing school or other activities because of painful or heavy periods - She goes three months without a period or suspects she may be pregnant - She hasn't started menstruating by age 15 The changes associated with puberty can be a little scary. Reassure your daughter that it's normal to feel apprehensive about menstruating, but it's nothing to be too worried about and you're there to answer any questions she may have.

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Potty Training

Potty Training

Daily Dose

Radiation & X-rays

1:15 to read

Radiation exposure and the cumulative radiation a child receives continues to be a topic of research and study. The less radiation a child receives the better.  Ultrasounds are an imaging modality that does not expose a child to radiation. There are more and more instances where ultrasounds are being used rather than X-ray or CT scans. 

 

Pediatric ultrasounds are used to help diagnose appendicitis, pneumonia, congenital heart disease,  abdominal masses, kidney disease, thyroid masses, testicular abnormalities and a host of other issues during childhood. The fact that an ultrasound machine is easily transported to an infant or child’s bedside is another reason that ultrasounds are utilized whenever possible.

 

Interestingly, bedside ultrasounds performed in the ER by trained physicians are now being utilized to diagnose simple forearm fractures which are common during childhood.  The most  common being a “buckle fracture” (non-displaced fracture of the radius).

 

Ultrasound studies of the forearm in a child with a suspected fracture seemed to not only be accurate but were more timely and in studies were also associated with less patient pain. Win - Win - Win.

It may be awhile before this is the standard of care in every ER, but look for less X-rays and more ultrasounds over the next years. I wonder if one day there will be ultrasound machines in pediatric offices….who knows?!

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