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Your Toddler

AAP: Winter Car Seat Safety

2:00

So far in Texas, this year’s El Nino weather pattern has made for a pretty mild winter compared to previous years. But, other areas around the country are being hit hard with a wintery punch and it’s only a matter of time till temperatures drop and snow and ice find their way to the Lone Star State.

Winter can be a bit tricky for child car seat use. While it sounds like the opposite might be true, bulky clothing such as coats and snowsuits should not be worn under the car seat harness.

More padding - more cushion right? That seems logical until you know what happens when a car crashes. In a wreck, fluffy padding immediately flattens out from the force, leaving extra space under the harness. A child can then slip through the straps and be thrown from the seat.

So how can you keep your little one warm and protected while buckled up? The American Academy of Pediatrics (AAP) has these tips to help strike a comfortable and safer balance.

·      Use a coat or blanket over the straps. You can add a blanket over the top of the harness straps or put your child's winter coat on backwards (over the buckled harness straps) after he or she is buckled up. Some parents prefer products such as poncho-style coats or jackets that zip down the sides so the back can flip forward over the harness. Keep in mind that the top layer should be removable so your baby doesn't get too hot after the car warms up.

·      Use a car seat cover ONLY if it does not have a layer under the baby. Nothing should ever go underneath your child's body or between her body and the harness straps. Be sure to leave baby's face uncovered to avoid trapped air and re-breathing. Many retailers carry car seat bundling products that are not safe to use in a car seat. Just because it's on the shelf at the store does not mean it is safe!

·      Dress your child in thin layers. Start with close-fitting layers on the bottom, like tights, leggings, and long-sleeved bodysuits. Then add pants and a warmer top, like a sweater or thermal-knit shirt. Your child can wear a thin fleece jacket over the top. In very cold weather, long underwear is also a warm and safe layering option. As a general rule of thumb, infants should wear one more layer than adults. If you have a hat and a coat on, your infant will probably need a hat, coat, and blanket.

·      Don't forget hats, mittens, and socks or booties. These help keep kids warm without interfering with car seat straps. If your child is a thumb sucker, consider half-gloves with open fingers or keep an extra pair or two of mittens handy — once they get wet they'll make your child colder rather than warmer.

·      Get an early start. If you're planning to head out the door with your baby in tow on winter mornings, you need an early start. You have a lot to assemble, and your baby may not be the most cooperative. Plus, driving in wintry conditions will require you to slow down and be extra cautious.

·      Tighten the straps of the car seat harness. Even if your child looks snuggly bundled up in the car seat, multiple layers may make it difficult to tighten the harness enough. If you can pinch the straps of the car seat harness, then it needs to be tightened to fit snugly against your child's chest.

·      Remember, if the item did not come with the car seat, it has not been crash tested and may interfere with the protection provided in a crash. Never use sleeping bag inserts or other stroller accessories in the car seat.

·      Store the carrier portion of infant seats inside the house when not in use. Keeping the seat at room temperature will reduce the loss of the child's body heat in the car.

·      Pack an emergency bag for your car. Keep extra blankets, dry clothing, hats and gloves, and non-perishable snacks in your car in case of an on-road emergency or your child gets wet on a winter outing.

·      Make sure your cell phone is charged. If there is an emergency, you want to be able to reach 911 or call for assistance in case of a flat tire or engine trouble.

This is a time when there is a lot of holiday travel from state to state or just down the road to grandma’s house.

Remember, it’s not just children in car seats whose coats shouldn’t be tucked under the harness, adults and older children should make sure their coats are on the outside of the seat-belt.

Little steps can make a big difference in everyone’s safety.

Source: https://healthychildren.org/English/safety-prevention/on-the-go/Pages/Winter-Car-Seat-Safety-Tips.aspx

Daily Dose

Medicine Dosing Errors

1:30 to read

How do you give your baby/toddler/child their medications? In a recent article in Pediatrics it was found that up to 80 percent of parents have made a dosing error when administering liquid medicine to their children.  The study looked at children eight years old or younger. 

 

In the study both English and Spanish speaking parents were asked to measure different amounts of liquid medicines using different “tools”, including a dosing cup, and different sized syringes. They also were given different instructions with either text only or text with pictures. The different dosing tools were labeled with either milliliters/teaspoon or milliliters only.  Lots of variables! 

 

Not surprising to me, the parents who used the texts/picture combination instructions and who also used the milliliter only labeled dosing tools had the lowest incidence of dosing errors.  When parents had to use any math skills to calculate the correct dosage there were more dosing errors.  Most dosing errors were also overdosing rather than under-dosing the liquid medications.

 

This was an important article not only for parents to realize that it is not uncommon to make an error when giving their child medication, but also for doctors who write the prescriptions.  Before electronic medical records and “e-prescribing” I would typically write medication instructions in milliliters and teaspoons…in other words “take 5ml/1 tsp by mouth once daily”.  With electronic record you can only make one dosing choice which I now do in milliliters. But, with that being said, I still get phone calls from parents asking “how many teaspoons is 7.5 ml?”.

 

Previous studies have also shown numerous dosing errors when parents use kitchen teaspoons and tablespoons to try and measure their child’s medication. 

 

Some over the counter drug makers have tried to cut down on dosing errors with their liquid medications by making all of their products, whether for infants or children, the same strength. The only difference is the dosing tool that accompanies the medicine (syringe vs cup).  Interestingly, these medications may have a price difference when they are actually the same thing.  

 

This study may help to find strategies for comprehensive labeling/dosing for pediatric liquid medications, which will ultimately reduce errors.  Stay tuned for more!

 

 

 

 

 

Daily Dose

No Screen Summer!

1:30 to read

Kicking off the summer and I have had a few parents announce that they have decided to have a “screen free” summer. When I asked them what this meant they said NO “ipads, phones, computers” for the summer and they have vowed that they will spend more time outside playing, reading, going on “field trips” and enjoying more family time.

 

I am thrilled that I have seen more than one family who has decided to adapt this summer rule and this means that the parents are also going to forgo a lot of unnecessary screen time. That is a difficult summer for parents as well.

 

Now…with that being said, there are some exceptions….namely car trips and travel. For those trips the I-pad or phone will be allowed but once the destination has been reached…they are going to be back on the “do not use” feature.

 

So far …week one…these families have already been enjoying the screen free decision and they have explored the library, the Arboretum and even the art museum. But, even if you don’t Iive in a big city you can find all sorts of things to do…start your own book club, go fishing, plan a lemonade stand or go visit a nursing home to brighten a elderly person’s day.  There are so many different opportunities, some of which your child can do on their own, and others which will involve the family.

 

It also doesn’t have to be “all or nothing”!! Especially if you have older kids. Maybe small steps with “screen free” days on alternate days. Or certain parts of the day devoted to family time and being screen free. There are many ways to approach a “screen free” summer without making it miserable and a constant struggle. Any commitment to taking some time away from the screen will be beneficial for everyone.

 

Let me know know how it goes….Be creative!

Daily Dose

Codeine & Children

1:30 to read

I order to keep us all safe, the FDA is constantly monitoring drugs and their side effects.  For many years codeine was prescribed for children for pain relief as well as to suppress coughs.  Over the last few years there has been more and more discussion about limiting the use of narcotics in children, but I continue to see some children who come from seeing other physicians and have received a prescription that contains codeine.

 

The FDA just issued new warnings against using prescription codeine in children and adolescents. The FDA reviewed adverse event reports from the past 50 years and found reports of severe breathing problems and 24 deaths linked to codeine in children and adolescents. Genetic variation in codeine metabolism may lead to excessive morphine levels in some children.

 

The FDA also performed a literature review which noted excessive sleepiness and breathing problems, including one death, in breast-fed infants whose mothers used codeine.

 

Due to these findings the FDA is now recommending that “codeine should not be used for pain or cough in children under 12 years of age”. They have also issued a warning that codeine should not be used in adolescents aged 12-18 “who are obese or have conditions associated with breathing problems, such as obstructive sleep apnea or severe lung disease”. In retrospect, codeine was prescribed to more than 800,000 children younger than11 years in 2011. Amazingly, codeine is currently available in over-the-counter cough medicines in 28 states.  

 

Lastly, the FDA “strengthened the warning” regarding codeine and breast feeding. They now recommend that breast- feeding women do not use codeine…which may change the post delivery pain protocol. Nonsteroidal anti-inflammatories (Ibuprofen) and acetaminophen (Tylenol) are preferred and are effective for mild to moderate postpartum pain. As a pediatrician it is important that I discuss this with new breast-feeding mothers as well. 

Daily Dose

National Safety Month

1:30 to read

June is National Safety Month…just in time for summer! It is a good reminder for all of us to try and prevent any injuries in our children. I do know from my own pediatric office that we see more injuries during the summer months. Whether it is from falls, bike accidents, pool incidents, household poisonings or burns, our phones stay busy.

 

So..this is the perfect time to re-think child proofing your home. Make sure that stairs are gated, both top and bottom. Cabinets need to have child proof latches to protect children from getting into breakable or sharp objects as well as medicines or household products that may be poisonous.  Put the number for Poison Control in your phone….1-800-222-1222. I am often surprised that a parent calls our office about a child who has “gotten into “ a possible poison…the first call should be to Poison Control. Keep the number posted in the house as well so a babysitter may also have it if necessary.

 

Learning to ride a bike a is “life skill” for sure….but that also includes learning to wear your helmet. I see most young children in our neighborhood who are still under the eye of a parent with a bike helmet, but once they are older I often see kids without helmets. Just saw a neighbor’s child ride down the street this evening..no helmet!!  Bike helmets are like a seat belt…not optional. Many “tween” boys will “debate” with me during their check ups about the need for a helmet,  as they tell me “ I am a great bike rider and don’t have wrecks”. Teach your children what the word ACCIDENT means and that just like a car…you never know what “the other guy may do”.  Accidents are NEVER planned and a bike helmet protects the head and brain. We can “fix” the broken arm or stitch a leg…but cannot “fix” a brain injury.

 

Texting and driving is unsafe and may even be illegal in your state. Texas just passed a law prohibiting texting and driving….but teens (and adults)  need to be reminded on a regular basis that texting is not allowed!!  Texting while driving is a leading cause of accidents and I just saw a mother who is pregnant, and was in the office with her 1 year old…she had just been involved in accident that totaled her car.  She was hit from behind by a teen who had been texting and never slowed down.  Fortunately both mother and child were buckled up and were not seriously injured.  If your child is found to be texting while they are driving you should have some serious consequences with both revoked driving privileges and no phone for a while. 

 

Lastly, this is a good month to remember to check your medicine cabinet and throw away any expired or unused medication.  There are some pharmacies that are having events where you can bring in expired medications and they will dispose of them properly. The number one place that  teens find drugs is in the home…keep all narcotics locked up and dispose of any unused medications!! I have had more than several parents who have told me that “drugs” had disappeared from their medicine cabinets after their own kids had had a lot of friends over…and who knows who may be “seeking” prescription medications. Locks on medicine cabinets and liquor cabinets are a must for families. 

What about taking a family first aid course at your local YMCA or Red Cross and spend a day getting your own family first aid kit together.  This is a great way to spend some time together and a productive activity. Have a fun and safe summer!!

Your Toddler

Is Your Child a Biter?

2.00 to read

At some time or another your sweet child is going to bite or wallop someone, most likely another kid. And yes, it's embarrassing to have to pull your child off another or to apologize to grandma because her grandchild just took a chunk out of her arm. 

Know that you’re not alone - all kids bite and /or hit. The key to stopping aggression in children is teaching them that there are alternative ways to handle frustration and biting is not acceptable behavior.

Not all biting stems from anger. The younger the child, the less chance that biting is an aggressive behavior. It can also be a simple case of exploration. Young children bite for many reasons, from painful gums because they are teething to seeing what kind of reaction they get. Children between the ages of one and three typically go through a biting phase they eventually outgrow.

While biting may be a normal phase kids go through, it’s something you want to discourage.

Let’s look at some of the reasons kids bite.

  • They're in pain. When babies bite, typically it's because they're teething. They're just doing it to relieve the pain of their swollen, tender gums.
  • They're exploring their world. Very young children use their mouths to explore, just as they use their hands. Just about everything infants or toddlers pick up eventually winds up in their mouths. Kids this age aren't yet able to prevent themselves from biting the object of their interest.
  • They're looking for a reaction. Part of exploration is curiosity. Toddlers experiment to see what kind of reaction their actions will provoke. They'll bite down on a friend or sibling to hear the surprised exclamation, not realizing how painful the experience is for that person.
  • They're craving attention. In older kids, biting is just one of several bad behaviors used to get attention. When a child feels ignored, discipline is at least one way of getting noticed -- even if the attention is negative rather than positive.
  • They're frustrated. Biting, like hitting, is a way for some children to assert themselves when they're still too young to express feelings effectively through words. To your child, biting is a way to get back a favorite toy, tell you that he or she is unhappy, or let another child know that he or she wants to be left alone.

So, how do you prevent or teach your child that they can’t go through life biting others?

You start with consistent prevention and move on to discipline if they are older.

  • If your baby is teething, make sure to always have a cool teething ring or washcloth on hand so he or she will be less likely to sink teeth into someone's arm.
  • Avoid situations in which your child can get irritable enough to bite. Make sure that all of your child's needs -- including eating and naptime -- are taken care of before you go out to play. Bring along a snack to soothe your child if he or she gets cranky from being hungry.
  • As soon as your child is old enough, encourage your child to use words such as “I'm angry with you" or "That's my toy" instead of biting. Other ways to express frustration or anger include hugging (not hitting) a stuffed animal or punching a pillow. Sometimes redirection is helpful; shortening activities or giving your child a break can help prevent the rising frustration that can lead to biting and other bad behaviors.
  • Give your child enough of your time throughout the day (for example, by reading or playing together), so he or she doesn't bite just to get attention. Extra attention is especially important when your child is going through a major life change, such as a move or welcoming a baby sibling. If your child is prone to biting, keep an eye on any playmates and step in when an altercation appears to be brewing.

You’ve done all that is possible to prevent another biting situation, and low and behold your child is biting another. What do you do then?

When your child bites, firmly let your child know that this behavior is not acceptable by saying, "No. We don't bite!" Explain that biting hurts the other person. Then remove your child from the situation and give the child time to calm down. It’s important that you remain calm.

Seeing your child bite another is naturally going to create an unpleasant reaction in you. As soon as you witness a biting episode, your body tenses, your heart races, and even if you don't actually scream, you really want to. The angrier you are, the tenser the situation becomes. You are much more likely to strike your child when you let your anger get the best of you. Take a deep breath, assess the situation and intervene calmly. Remove your child, let him or her calm down and explain (yes, once again) that biting is not going to be tolerated. If your child is old enough to understand time-out, this is a good time to use it. If not, remove the child from the temptation. Playtime is over.

One way some parents handle biting is to bite their own child to show them how painful it can be. Doing what you are telling your child not to do sends a mixed message. It’s similar to hitting your child and then saying “don’t hit others.” Most likely your child will experience how painful it is because another child will bite them someday.

The point is not so much that biting is painful, the action itself is unkind, unproductive and wrong.

When biting becomes a habit or continues past the age 4 or 5, it may stem from a more serious emotional problem. This is the time to ask for help from your pediatrician, family doctor or a child psychologist.

If your child is bitten, wash the area with soap and water. If the bite is bleeding and the wound appears to be deep, call your child’s doctor. The bite may need medical treatment, which could include antibiotics or a tetanus shot or both.

Biting is a horrible habit to get into and a difficult one to stop. Start teaching your child early that momma and daddy are not putting up with it and that there are better ways to explore the world and handle frustration.

Source: http://www.webmd.com/parenting/guide/stop-children-from-biting

Daily Dose

Elf on the Shelf

1:00 to read

“Tis the season”, and many of the families I care for have gotten out their “Elf on the Shelf” to help keep the season as merry and harmonious as possible. I think “TEOTS” is genius, as it is a fun way to use positive reinforcement during the holidays as behavior modification.  That elf needs to stay around a bit longer…but then it would lose the appeal.  The anticipation of the elf arriving plays a major role don’t you think?  

 

With the arrival of the elf I get to hear all of the cute family elf stories during the month of Dec. I also noticed that “TEOTS” has some new “gadgets” and outfits to add to the fun, such as a zip line to swing from and suctions boots so he/she can climb up walls. Ingenious right? Surely they will soon have an array of elf outfits so the elf can have some choices to wear during zip lining.

 

During the last year there was also a lot of discussion about what our children were hearing on the news and during presidential debates etc. It doesn’t matter your political affiliation, children were picking up on a lot of what was going on.  Even children whose parents were paying attention to all of the bullying during the debates and atrocious sound bites on the news by limiting TV and electronics told me that their children still overheard things. They were concerned about the messages that both candidates were sending…especially to children.  

 

So…when one of my families took out “TEOTS”  their son, who is almost 3, decided it was the year to name him. “Of course you can name your elf they said”.  The next day he announced that the was looking for the elf and asked his mother, “where is Donald Trump?”. She was a bit confused…until he returned holding the the elf and proudly announced, “ I found The Donald”!!

 

Out of the mouths of babes. More elf stories this month for sure!!

 

 

Daily Dose

Dog Bites

1:30 to read

I am a dog lover and we have always had a dog in our house….even before we had our children.  But, some dogs will bite and unfortunately there are more than 800,000 people every year who receive medical care for a dog bite…more than half of these are children.

 

Children are also more likely to be severely injured from a dog bite…and I was reminded of this today when I saw a very serious dog bite to a child’s face.  The child was brought to my office by his nanny after being bitten on his cheek by the family’s dog.  It was one of the worst bites I have ever seen! He was severely injured and should have actually gone straight to the ER….the good news is that he will ok, but he had to undergo surgery to repair the bite and will probably require another small surgery at some later date. 

 

In this case as in most, the dog bite occurs when a child is interacting with a familiar dog, and in this case it was the family pet. The little boy is a toddler with a twin sister and they were playing when he was bitten.  The dog had been around the children since they were born…and it is unclear what precipitated the bite.  Sometimes a dog becomes aggressive if they are bothered while they are eating or sleeping…and you know toddlers, they can “bother” anyone. 

 

One of my “boys” is also a dog bite statistic.  He was raised with dogs (my sweet lab Maggie is at my feet as I am writing), so I was totally caught off guard one night when the phone rang. My son had been spending the night at a friend’s house (he was about 10 years old) and the voice on the other end of the phone was the father of the friend (he too a doctor), informing me that my child had been bitten by their dog.  It seemed the boys were laying on the floor on blankets watching a movie and eating popcorn and for some “unknown “ reason the dog bit my son on his face.  The bite was not precipitated by anything…they had not been playing or rough housing with the dog and the dog had not been known to be aggressive. The next words out of the father’s mouth…”do you know a good plastic surgeon?” Not words you want to hear from another physician.

 

Thankfully, I did know a good plastic surgeon who I awakened after his long day in the OR….and he got out of bed and met us to suture my son’s face with over 20 stitches. Luckily it only involved his nose, cheek and chin, just barely missing his left eye. I am sure I cried more than my son.  He still has a scar across his nose..which only bothers his mother.  Incredibly, he never “blamed” their dog, went back to play at their house, and still loves his own dogs more than anything.  My brother who is a vet still thinks that any dog that bites without provocation should not stay in the home with children…but that is one vet’s opinion. 

 

It is especially important to teach your children never to approach a dog to pet it without first asking the owner if it is okay.  Children should learn to move slowly and let the dog “sniff” them first and to stay away from their face and tail. Teach your child how to gently pet an animal and to always be gentle.  If they are around a dog who is behaving in a threatening manner by growling or barking, they should slowly back away from the dog and try to avoid eye contact with the dog. If they are ever knocked over by a dog they should curl up in and ball and protect their face with their arms.

If your child is bitten and it is superficial it will probably just require care with soap and water. For bites that break the skin you should check in with your pediatrician.  Make sure you know the rabies vaccination status of the dog that bit.  You also need to make sure that your child is up to date on their tetanus vaccination. In some cases your child may also need an antibiotic.

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