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Daily Dose

Giving Your Child Medicine

1:15 to read

Since I recently wrote an article about teaching young children to swallow pills, here is another reason to teach this to children sooner than later. The American Academy of Pediatrics has a new policy statement encouraging parents, physicians and pharmacists to use only metric measurements on prescriptions,medication labels and dosing cups to ensure that kids receive the correct dose of medication.

In other words, no measuring medications with teaspoons or tablespoons and especially not the ones in the cereal drawer.  Because spoons come in many sizes, they are not precise enough to measure a child’s medication.  For infants, toddlers and young children, a small error in dosing, especially if repeated for many doses, may be toxic.  

These recommendations also mean that doctors, like myself, need to prescribe medications in metric units like milliliters rather than teaspoons. We also need to instruct parents to use metric dosing devices, and not any measuring devices that have confusing markings with both teaspoons, tablespoons and milliliters. The medication should also come with an appropriate sized dosing device to avoid the possibility of two and three fold dosing errors.

The recommendations also call for manufacturers of over the counter medications to eliminate labeling, instructions and dosing devices that contain units other than metric units...no more 1 teaspoon, but rather 5 milliliters.

I am going to make a conscious effort to make sure that I am now writing my prescriptions with the correct units and help make dosing errors less of a problem and all medications safer for my “little” patients.

No more kitchen spoons!!!

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. 

Your Child

Pre-teen Football Linked to Brain Changes in NFL Players

2:00

The start of a new school year also brings after-school sports programs. Late summer and fall is prime football season for many middle and high schools. In some states, it’s a hallowed tradition that boys and girls look forward to participating in whether it’s running down the field or cheering on the team.

While school football doesn’t typically offer the same ferocious body beating and brain –rattling that are seen in the National Football League (NFL), a new study shows that brain development can still be affected by playing football at a young age.

The study looked at the possible connection between a greater risk of altered brain development in NFL players who started playing football before the age of twelve as opposed to those players who began playing later in life.  The study is the first to show a link between early repetitive head trauma and future structural brain variations.

The study was small but interesting. It included a review of 40 former NFL players between the ages of 40 and 65 who played over 12 years of structured football with a minimum of 2 years at the NFL level.

One half of the players took up football prior to the age of 12 and half started at age 12 or later. The number of concussions suffered was very similar between the two groups. All of these players had a minimum of six months of memory and cognitive issues.

"To examine brain development in these players, we used an advanced technique called diffusor tensor imaging (DTI), a type of magnetic resonance imaging that specifically looks at the movement of water molecules along white matter tracts, which are the super-highways within the brain for relaying commands and information," study author Dr. Inga Koerte, professor of neurobiological research at the University of Munich and visiting professor at Harvard University, said in a press release.

The researches believe their findings add to the growing amount of scientific evidence that shows the brain may be especially vulnerable to injury between the ages of 10 and 12.

"Therefore, this development process may be disrupted by repeated head impacts in childhood possibly leading to lasting changes in brain structure," said study author Julie Stamm, currently a post-doctoral fellow at the University of Wisconsin School of Medicine and Public Health.

Despite finding a link to the brain development window where kids are more likely to suffer brain injury by repeated head impacts, the small size of the study means the results may not necessarily apply to non-professionals.

"The results of this study do not confirm a cause and effect relationship, only that there is an association between younger age of first exposure to tackle football and abnormal brain imaging patterns later in life," said study author Martha Shenton, a professor of psychiatry at Harvard Medical School.

Because of the intense publicity about and the findings of many studies on the short and long-term dangers of concussions, many school sports programs are looking at changing how they allow students to play in games associated with head injuries.  Where it was once common for coaches to let players continue playing after a particularly rough tackle or head butting, they are more likely now to insist that a field medical professional examine the child. Some schools are also implementing no tackle policies to protect very young players.

While traditional football isn’t likely to become extinct, parents and coaches can educate themselves about brain injuries and learn how to best protect young players from the chances of long and short-term disabilities.

Source: Brett Smith,  http://www.redorbit.com/news/health/1113407634/pre-teen-football-linked-to-more-severe-brain-changes-in-nfl-players-081115/

 

 

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

Your Child

Your Child’s First Day at School

1:45

While I may have forgotten a lot of things in my life, I remember my first day of school. I was so excited because I actually recognized someone. Her name was Donna. We’d met in a department store a week earlier. We had both picked out the same umbrella, but there was only one – she said I could have it. We’ve been friends for life.

When my daughter began school, she experienced all the same emotions I had those many years ago; scared, excited and uncertain where to go and what to do next. She found a friend also and they wandered the halls together.

Some school districts have already begun their new school year, but for many kids - the bell will ring in the next couple of weeks.

Children aren’t the only ones that are anxious as the first day rolls around – parents can get quite nervous and have that feeling that their little one is growing up so fast- trust me I know. It’s a normal “things are about to change” emotion.

One tip I’d like to suggest before your little one starts school is to share your own first day memories with your child as well as pictures. It’s amazing how comforting it is for a child to know that their parents did the same thing at their age and lived to tell about it!

To help make the first day of school a little less scary for your child, here are some other tips from https://www.healthychildren.org:

•       Point out the positive aspects of starting school: It will be fun. She will see old friends. She will meet new friends. Refresh her memory about previous years, when she may have returned home after the first day with high spirits because she had a good time.

•       Remind your child that he is not the only student who is a bit uneasy about the first day of school. Teachers know that students are anxious and will be making an extra effort to make sure everyone feels as comfortable as possible.

•       Talk about the kinds of interesting things he will learn in the months ahead.

•       Buy him or her something (perhaps a pen or pencil) that will remind her you are thinking of them while they are at school, or put a note in their lunch-box.

•       Reassure your child that if any problems arise at school, you will help re­solve them. (If problems do occur, get involved as soon as possible.)

•       Find another child in the neighborhood with whom your youngster can walk to school or ride with on the bus. If your child is not going to ride a school bus and you feel it is appropriate, drive your child (or walk with her) to school and pick her up the first day.

•       Encourage him to look for new students in his classroom or in the play­ground, invite them to join the group for a game, and ask them about their interests.

•       After school, show your child some special attention and affection. Give him or her a hug and ask what happened at school. Did she have fun? Did he make any new friends? Does she need any additional school supplies (notebooks, rulers, erasers) that you can shop for together?

In addition to the suggestions listed above, your child may need some extra support if he or she is starting school in a new location. Here are some suggestions to make the transition easier.

•       Talk with your child about his or her feelings, both their excitement and their con­cerns, about the new school.

•       Visit the school with your child in advance of the first day. Teachers and staff are usually at school a few days before the children start. Peek into your child's classroom, and if possible, meet the teacher and principal. You might be able to address some of your child's concerns at that time. She may have no questions until she actually sees the building and can vi­sualize what it will be like. (When you formally register your child in the new school, bring her immunization record and birth certificate; usually school records can be sent directly from school to school once you sign a "release of information" form.)

•       Try to have your child meet a classmate before the first day so they can get acquainted and play together, and so your child will have a friendly face to look for when school begins.

•       Do not build up unrealistic expectations about how wonderful the new school will be, but convey a general sense of optimism about how things will go for your child at the new school. Remind him that teachers and other students will be making an extra effort to make him feel welcome.

•       If your child sees another student or a group engaged in an activity she is interested in, encourage her to ask if she can participate.

•       As soon as you can, find out what activities are available for your child in addition to those that occur during school itself. Is there a back-to-school picnic or party planned? Can he or she join a soccer team? (For community sports programs, sign-ups often begin weeks or even months before the start of the season.)

It’s been many years since my first day at school but I remember it well. Your child’s life is about to change forever, but that’s a good thing-another milestone in life’s progression. Give him or her a hug, wipe away the tears and smile a big smile. Let them know you trust them and are proud of them. Then go ahead and shed a few tears of your own when you’re back in the car. Yes, they are growing up fast. 

Story source: https://www.healthychildren.org/English/ages-stages/gradeschool/school/Pages/Making-the-First-Day-of-School-Easier.aspx

 

Daily Dose

Digital Technology & Your Children

1:30 to read

I somehow stumbled upon a recent article in the UK Mirror in which Bill Gates was being interviewed. It caught my eye as it began with “As you wrestle the tablets from your square-eyed kids for the 10th time today, it might be reassuring to hear the king of Silicon Valley shares your worries”.

 

The discussion surrounding our children and the use of cell phones and the appropriate age to give a child a phone always brings up various opinions. Some parents feel that their 6 -8 year old elementary school child “needs a cell phone for safety reasons”. Other parents think that their child “doesn’t need a phone until they drive.” Lastly, there are parents who think their child gets a cell phone when “they can pay for it”.  These are only a few of the various responses I have heard from my own patient’s parents….I am sure there are a million more. 

 

Well, it seems Bill Gates, one of the greatest technology innovators of all time, “banned his kids from having mobile phones until they were 14 years old”.  During the interview he also stated that he “forbids cell phones at the dinner table”.  It sounds like Bill Gates runs a pretty tight ship in his own home..with some well founded rules,  while weighing the pros and cons of the use of electronics with his children.

 

Many parents tell me that all of these electronics are necessary for homework and social media also allows their child to stay in touch with their friends…which again is quite true. At the same time Bill Gates commented that he and his wife “often set a time after which there is no screen time…which also helps his children (now ages, 20, 17 and 14) get to sleep at a reasonable hour”. It sounds as if Bill Gates has been reading the studies about screen time and sleep…and how the two may actually affect one another and is a believer!

 

So I now think that I will quote Bill Gates and “suggest” to parents that they not rush to buy their child a cell phone until they are around 14. It also makes a great deal of sense to monitor their usage and to continue to make sure that family time, including dinner time is a “cell free zone”. He emphasizes that using it to an excess, for any reason, is just not a good idea.

 

He is also a big believer in vaccines!!! Go Bill Go!

 

 

 

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Your Teen

FDA to Regulate E-cigarettes, Raise Age for Purchasing

2:00

Cigarette smoking among teens and young adults has been on a slight decline in the past few years, but e-cigarette use has been rapidly increasing.

Because there are no regulations and scant information on the products used to fuel e-cigarettes, many leading health organizations, including the American Academy of Pediatrics have been urging the Federal Drug Administration (FDA) to bring e-cigarettes and liquid nicotine under its authority.

The U.S. government has responded and taken action. The FDA issued a tough set of rules for the e-cigarette industry that included banning sales to anyone under 18, requiring package warning labels, and making all products—even those currently on the market—subject to government approval.

For many teen and health organizations, the ruling has been long overdue.

Though the product-approval process will be phased in during three years, that will be little solace to the fledgling but fast-growing $3.5 billion industry that has, until Aug. 8 when the rules take effect, largely been unregulated and dominated by small manufacturers and vape shops.

Many of the vape shops, device manufacturers and liquid nicotine producers are not happy with the change.

“This is going to be a grim day in the history of tobacco-harm reduction,” said Greg Conley, president of the American Vaping Association, an industry-funded advocacy group. “It will be a day where thousands of small businesses will be contemplating whether they will continue to stay in business and employ people.”

In June, the FDA proposed requiring warning labels and childproof packaging because of an increase in nicotine exposure and poisoning incidents. The agency could move to regulate advertising or flavors such as cotton candy and watermelon that also might appeal to youth.

“We’re looking at the flavor issue with e-cigarettes,” said FDA Tobacco Center Director Mitch Zeller during a news conference. Later, he said, that while the agency was aware of “anecdotal reports” that e-cigarettes have helped smokers kick their habit; those benefits were outweighed by concerns about youth using the devices.

E-cigarettes are not the only tobacco related products that will come under the control of the FDA. Unregulated tobacco items, including pipe tobacco and water-pipe tobacco, will also fall under the supervision of the FDA.

The FDA has been regulating cigarettes since Congress granted it oversight of traditional smokes with the 2009 Family Smoking Prevention and Tobacco Control Act.

“Today’s announcement is an important step in the fight for a tobacco-free generation—it will help us catch up with changes in the marketplace, put into place rules that protect our kids and give adults information they need to make informed decisions,” Department of Health and Human Services Secretary Sylvia Mathews Burwell said in a statement.

Most researchers agree e-cigarettes are less harmful than cigarettes because, unlike cigarettes, they don’t combust. Studies have shown that when traditional cigarettes combust they release more than 60 carcinogens. But the long-term effects of using the electronic devices remain largely unknown, and many anti-tobacco groups and public health officials are concerned they could become a gateway to traditional smoking.

Anti-tobacco groups have been frustrated with FDA, saying the agency has taken far too long to finalize its rules.

Concerns escalated when a study published in August by the Journal of the American Medical Association found ninth-graders who used e-cigarettes were 2½ times as likely as peers to have smoked traditional cigarettes a year later.

The Centers for Disease Control and Prevention reported in April that e-cigarette use tripled among U.S. teenagers in 2014.

The AAP issued its recommendations on tobacco and e-cigarettes in late 2015.

In a press release, the organization said it strongly recommends the minimum age to purchase tobacco products, including e-cigarettes, should be increased to age 21 nationwide.

"Tobacco use continues to be a major health threat to children, adolescents and adults," said Karen M. Wilson, MD, MPH, FAAP, chair of the AAP Section on Tobacco Control and section head of Pediatric Hospital Medicine at Children's Hospital Colorado. "The developing brains of children and teens are particularly vulnerable to nicotine, which is why the growing popularity of e-cigarettes among adolescents is so alarming and dangerous to their long-term health."

Under the new rules, e-cigarette manufacturers would have up to two years to continue to sell their products while they submit an application to the FDA.

Story sources: Tripp Mickle, Tom Burton, http://www.wsj.com/articles/fda-to-regulate-e-cigarettes-ban-sales-to-minors-1462455060

https://www.aap.org

 

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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DR SUE'S DAILY DOSE

New report says not enough babies are getting much needed tummy time!

DR SUE'S DAILY DOSE

New report says not enough babies are getting much needed tummy time!

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