Category: Safety

Plan for Vacation – especially if you’re going outside the US

A little planning and preparation can help everyone in your group stay healthy while traveling. Some preventative treatments take up to 6 months to complete, so talk to your doctor early!

When families are able to travel, it can be a wonderful time of exploration and bonding. Don’t let illness get in the way. Many locations have diseases that you don’t typically see in your home town. Take a little bit of time to learn what you need to do to prepare for your vacation. Insurance doesn’t usually cover travel medicine, so be sure to consider these extra costs when planning a trip.

Keep track of everything

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your travel group. Save a copy so you can easily find it on any computer in case of emergency.

  • your name, address, and phone number
  • emergency contact name(s) and phone number(s)
  • immunization record
  • your doctor’s name, address, and office and emergency phone numbers
  • the name, address, and phone number of your health insurance carrier, including your policy number
  • a list of any known health problems or recent illnesses
  • a copy of current medications and supplements you are taking and pharmacy name and phone number
  • a list of allergies to medications, food, insects, and animals
  • a prescription for glasses or contact lenses

Prepare everyone for local specs

Learn what the local healthcare options are if someone in your travel group gets sick or injured. For several tips, see this travel information from the CDC.

Find out how you can use your phone overseas. Be sure to bring a charger that will work with local electrical outlets.

If you’re traveling with young children, plan ahead for where they’ll sleep. Infants will need a safe place of their own with a firm surface. Everyone will need time to adjust to new time zones.

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page. Learn local laws prior to traveling.

If you’re going to be somewhere above 8000 feet above sea level, prepare for the change in altitude with these tips.

Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.

Remind everyone to stay in groups and to not venture out alone.

Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.

Wear sunscreen! It doesn’t matter if you’re on the beach or on the slopes, you need to wear sunscreen every time you’re outside. Don’t ruin a vacation with a sunburn. For sunscreen tips, see Sun and Water Safety.

For more safety tips, see this helpful brochure.

Prevent bug bites

When you travel be sure to protect against bug bites! #travel #prevention #vacation #questforhealthkc

Mosquitos, ticks and other bugs not only cause itchy rashes but they can carry diseases. Using insect repellant properly can help to prevent getting bit.

Use insect repellent with at least 20% DEET to protect against mosquito and tick bites. Follow package directions and reapply as directed. Do not use combination bug sprays with sunscreen. They should be applied separately.

Wear long sleeves and pants. Consider treating your clothes with permethrin and tucking your pants into your socks. Sleep in areas that are screened against bugs.

Vaccines

Extra vaccines may be needed when you travel, especially in infants who are too young to get a measles vaccine on our usual schedule and adults who have not gotten vaccines that are now on the regular schedule.

Before you travel you can look at destination-specific advice on the CDC’s Destination page.

MMR

The news routinely reports outbreaks of measles these days. Many of the US outbreaks are related to an unvaccinated person returning from abroad. The MMR protects against measles, mumps, and rubella.

While our standard vaccine schedule does not recommend the MMR until 12 months of age, the vaccine can be used in infants as young as 6 months. It is considered safe to use in infants, but we don’t know when their immunity from their mother goes down. If the maternal immunity is still active the vaccine won’t work. This immunity typically falls between 6 and 12 months. After 12 months the vaccine is more likely to be effective, so when the risk is lower, it is recommended to wait until that age for the vaccine.

Between 6 and 12 months of age the MMR is recommended for infants considered high risk for being exposed to measles. This is because if their immunity has fallen, we don’t want them to be unprotected. International travel is considered to be high risk. If your baby’s maternal immunity is still high, the vaccine won’t provide protection, but he or she is still protected until that maternal immunity falls.

Because we don’t trust that the vaccine is effective before a year of age, babies who get an early MMR will still need two after their first birthday.

Talk to your baby’s pediatrician about getting the MMR if your child is over 6 months of age. Ideally it will be given at least 2 weeks prior to travel to give the body time to develop immunity.

Hepatitis

Both hepatitis A and hepatitis B vaccines are now on the routine schedule for children in the US, but many adults did not get these vaccines as children. These vaccines are recommended for travel to many locations. Verify if your family has had both hepatitis A and hepatitis B vaccines before you travel.

It is recommended that infants start hepatitis B vaccines at birth. The series is completed at 6-9 months of age. There are catch up schedules for those who haven’t completed the series on time.

Children do not get the hepatitis A vaccine until 12 months of age. If they have not yet started the series and they are over a year, they can start at any time. The booster is given 6-12 months later.

It takes at least 6 months to complete each of these series, so plan early!

Typhoid

Typhoid is not a vaccine routinely given in the US but it is recommended for travel to many parts of the world. There are two main types of typhoid vaccine, injectable and oral.

Children 2 years and older can get an injectable typhoid vaccine, ideally at least 2 weeks prior to travel. It is only one dose and lasts 2 years.

The oral vaccine is only for people 5 years and older. It is given in 4 doses over a week’s time and should be completed at least a week prior to travel. It must be given on an empty stomach (1 hour before eating and 2 hours after eating). Antibiotic treatment can make this vaccine ineffective, so discuss any current medicine you are taking with your doctor. The oral vaccine lasts 5 years.

Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Meningitis

Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States.

In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but it can be given as young as 9 months of age. MenACWY-CRM is approved for children 2 months and older.

There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel.

Meningitis vaccines should be given at least 7-10 days prior to potential exposure.

Travelers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. Boosters for people traveling to these areas are recommended every 5 years.

Yellow Fever

Yellow fever is a mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Most physician offices do not offer this vaccine. A special license is required to be able to provide it. Check with your local health department or a travel clinic in your area. This vaccine should be given at least 10 days prior to travel.

Influenza

Remember that influenza hits various parts of the world at different times of the year. The southern hemisphere tends to finish their flu season just as ours is starting. Check to see when it’s flu season and vaccinate as needed.

Medications for your trip

Aside from bringing your routine prescription medications and over the counter medicines in their original prescription container, there are some medications that are recommended for traveling to various parts of the world.

Malaria

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be traveling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication. Review the area-specific travel recommendations with your doctor.

Anti-diarrhea medicines

I am commonly asked to prescribe antibiotics to prevent traveler’s diarrhea. This is discouraged due to growing bacterial resistance to antibiotics. It is best to prevent by avoiding local water, choosing foods wisely, using proper handwashing techniques, and considering bismuth subsalicylate or probiotic use.

Traveler’s diarrhea is often from bacteria, but it can also be from a viral source. Maintaining hydration with clean water with electrolytes is the most important treatment. Many cases of traveler’s diarrhea do not require antibiotics. See details of treatment recommendations in the Yellow Book.

After you return…

If you’ve been in an area of the world that has increased risk for tuberculosis (TB) or if you have suspected exposure to TB, testing for exposure is recommended.

Tuberculosis occurs worldwide, but travelers who go to most countries in Latin America, the Caribbean, Africa, Asia, Eastern Europe, and Russia are at greatest risk.

Travelers should avoid exposure to TB in crowded and enclosed environments. We should all avoid eating or drinking unpasteurized dairy products.

The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States. Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure.

It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body’s immune system is compromised, as with old age or another illness. Appropriately treating the TB before it causes active disease is beneficial for the long term.

Related posts

Traveling with kids

Traveling around the world

Motion sickness

7 Ways to keep kids from wandering and getting lost

Prevent Drowning

Drowning is one of the most common preventable causes of death in infants, kids, and teens. Learn how to protect against this tragedy!

Summer is on its way. We’ll soon be visiting lakes and pools to cool off from the heat. Unfortunately drowning is the leading cause of unintentional injury-related death in children between ages 1 and 4. It continues to be a top cause of unintentional death among other age groups through the early adult years. Fortunately there are many precautions we can take to help lower the risk.

I wrote about Sun and Water Safety last summer, and want to remind everyone about the risks of drowning. I also wrote about Dry Drowning previously, but it seems that it isn’t really a thing – see the addendum in that post.

What are the risks?

About 1 in 5 people who die from drowning are children 14 and younger. Each year about 300-500 children under 5 years of age drown.

For every child who dies from drowning, another five receive emergency department care for nonfatal submersion injuries. Even though they’re not fatal, they have significant consequences.

Over half of drowning victims treated in emergency departments require hospitalization for further evaluation and treatment. These nonfatal drowning injuries can cause severe brain damage that may result in long term disabilities such as memory problems, learning disabilities, and a permanent loss of basic functioning.

What increases the risks?

  • Lack of Swimming Ability: Many adults and children report that they can’t swim. Swimming lessons can reduce the risk of drowning among children. See the link at the bottom for more on swim lessons.
  • Lack of Barriers: Barriers, such as pool fencing and alarm systems, prevent young children from gaining access to the pool area. A 4-sided fence reduces a child’s risk of drowning 83% compared to 3-sided fence with the house as the forth side. A great guide on barriers is from the US Consumer Protection Service.
  • Lack of Close Supervision: Drowning can happen quickly and quietly anywhere there is water. This includes bathtubs, swimming pools, pet water bowls, and buckets. This is why non-swimming times account for most drowning accidents.
  • Location: Most children 1-4 years of age drown in home swimming pools. More than half of the drownings among those 15 years and older occurred in natural water settings, such as lakes.
  • Failure to Wear Life Jackets: Most boating deaths are caused by drowning, with 88% of victims not wearing life jackets.
  • Alcohol Use: Among adolescents and adults alcohol use is involved in up to 70% of deaths associated with water recreation. 
  • Seizure Disorders: For persons with seizure disorders, drowning is the most common cause of unintentional injury death, with the bathtub as the site of highest drowning risk.

How can you recognize drowning?

Movies show people splashing around and yelling for help as they drown.

Don’t let that fool you. Movies are not reality.

Signs of drowning:

  • Head low in the water, mouth at water level
  • Eyes glassy and empty, unable to focus
  • Head tilted back with mouth open
  • Eyes closed
  • Hair over forehead or eyes
  • Not using legs – Vertical
  • Hyperventilating or gasping
  • Trying to swim in a particular direction but not making headway
  • Appear to be climbing an invisible ladder
  • Trying to roll over on the back

Most drowning victims are silent. They don’t splash to get your attention. Watch this video from Inside Edition that captures several drowning victims:

Assign a water watcher to keep an eye on young children in water. #drowning @pediatricskc

Teach water safety

Learn how to swim and teach your children to swim as well. If your child(ren) are good swimmers, be sure to still have rules about pool use and limit pool access. Even strong swimmers can drown. See the link in the resources below for infomation on swim lessons.

No one should swim alone. If your children are not able to follow that rule, the pool should not be accessible to them. Gates and alarm systems can be used to limit access to home pools and hot tubs.

Not all teens are safe swimmers, but they don’t often fess up to their friends. They are also at risk of making impulsive decisions to drink alcohol near water, forego their life vest on a boat, jump off a cliff into water, or other things that could put them at risk. Talk to your teens about safety – in and out of the water! Encourage teens to learn CPR.

Water safety in easy-to-see graphic form

From https://twitter.com/DrEmMontgomery/status/1109249128712810497

The @AmerAcadPeds updated their policy statement on #drowning prevention this week. #watersafety pic.twitter.com/8B57ZprmvJ— Emily Montgomery, MD (@DrEmMontgomery) March 23, 2019

Making home water safer

All pools should have a 4 foot fence around all sides. This includes below-ground pools as well as portable pools. It is much less safe to use the house as one of the borders, since young children can escape out the door and into the pool, but if you must use your home, take precautions. Install an alarm system to alert you if the door to the pool area is opened. Use a pool or spa cover when the pool or spa is not in use.

A short word on portable pools. They can include inexpensive blow up pools and larger pools. Portable pools present a real danger to young children because they are often not seen as a threat. Portable pools account for 10% of the total drowning deaths for children younger than 15 . They should be drained, covered, or fenced to protect children. Don’t leave them in the yard unattended.

Ask neighbors to put a proper barrier around their pools or hot tubs.

Ensure any pool or hot tub (spa) you use has anti-entrapment safety drain covers.

Have life saving equipment such as life rings, floats or a reaching pole available and easily accessible.

If you have a home pool, be sure that it's protected from your kids. @pediatricskc
From https://downloads.aap.org/DOPA/Drowning-Prevention/pool_safety_english.pdf

It’s not just pools that are risks…

Bowls and buckets

Keep pet water bowls out of reach of young children.

Drain any buckets of water after they’re used.

Toilet dangers

Close bathroom doors and toilet lids to keep young ones from playing in the water.

Bath time

Monitor young kids and those with seizure risks in the bath the entire time. Do not leave the room even for a few moments.

Don’t read or check your phone when you’re watching kids in the tub, just like at the pool.

Drain the bath tub before young kids even get out. This not only helps your kids not climb back in (a common reason to need stitches when kids slip trying to climb in), but it also prevents them from drowning in left over water.

For more:

Swim Lessons: When to start and what parents should know

Infant water safety: protect your new baby from drowning

Drowning Prevention for Curious Toddlers: What Parents Need to Know

Water safety: Tips for parents of young children

Water safety for teens

Teen drowning can be prevented with safety measures: Teens don’t always follow the rules. Their impulsivity and thrill seeking behaviors put them in a unique risk for dangers.

For pool barrier guidelines and suggestions, see the Safety Barrier Guidelines for Residential Pools Preventing Child Drownings from the US Consumer Product Safety Commission. This is important for all pools and hot tubs, including portable pools.

Pool Dangers and Drowning Prevention – When It’s Not Swimming Time: Remember to keep all pools, tubs, and buckets of water secure at all times.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS)

Momo. Hoax or not, scary things happen online.

It’s not just Momo… Even if she started as a hoax, we DO need to protect our kids online.

The news is full of stories about Momo and other scary things our kids are exposed to online. Many stories say this is a hoax. YouTube has said this would be against their rules. It doesn’t really matter if this started as a hoax or if it’s against the rules. The fact is that our kids are exposed to things online.

Our kids do see inappropriate things

I recently saw a preschool aged child for a well visit. During the visit it came up that the child had been exposed to Momo online. When the mother learned that the child saw scary Momo videos, she came up with a great plan. They took images of Momo and transformed her into funny faces, much like what I did for the image above.

I think this mother’s idea is great. She took a character that was scary to her child and made it funny. She used the opportunity to talk to her child. It became a great teaching moment.

Our kids can never “un-see” what they’ve seen, but we can help them to not view it as so scary. If you are unable to do this alone, talk to your pediatrician or a therapist.

We know that traumas impact a child’s development. They can develop significant anxieties and suffer if things are not quickly and adequately addressed.

When things happen we need to find ways to help our kids process them. If your child’s mood or behavior suddenly changes, it is quite possible that they have experienced a traumatic event of some sort. If they won’t talk to you, seek professional help.

What can we do to prevent online exposures?

We can’t stop all exposures, but we can do many things to help protect our kids. This includes monitoring software, anti-virus software, and teaching our kids how to behave responsibly and safely.

Increasing responsibility

Our kids will be online, whether it’s at home or at school or at a friend’s house. They are growing up with the world at their fingertips through the internet, so we must teach them to use it wisely.

Like in other benefits and responsibilities of growing up, our kids should have fewer limits and less monitoring as they show maturity. We cannot expect them to be responsible online at 18 years of age if they never practice with supervision along the way.

Give your kids age-appropriate allowances for games, videos, and other online experiences. I love to use Common Sense Media to learn about movies, games, and other media.

Set up parental controls.

Research parental control software. It’s easy to search “parental control apps” or “parental control software reviews” to find the pros and cons to various brands.

One of my favorite sites that exposes safety concerns has a great post for parents: 5 tips for setting up your child’s device for safety from a tech mom.

Learn to safely monitor phones and specific apps.

Choosing the best for your family is not easy, but read several reviews to find what is best for your family’s needs.

Adult supervision and guidance

If our kids are playing outside, they will have close supervision when they’re young, less as they get older.

Online use should be no different.

Your 3-4 year old should not go to the park alone and they shouldn’t go online alone. If they are online, project the screen to the television so you can watch along or sit with them and play along with them. They should not be online when you are busy doing something else. It is not a safe babysitter.

As kids get older and can understand how to navigate the internet more safely, they can have less and less direct supervision. This does not mean they can have a free for all. Parents can still help them choose age-appropriate sites and have software to keep blocked sites from being accessible.

You can’t just avoid online use

Several parents over the years have tried to end the conversation when I bring up social media safety by saying, “we don’t allow any of that.”

It is not sufficient to simply not allow any social media. Our kids and teens will come across it, whether it’s their own account or a friends.

What things did you do as a teen that your parent didn’t know about? It’s even easier for kids to hide social media accounts than it is for them to do many of the things we used to do as kids.

As kids grow

Talk to older kids and teens about why pornography sites are harmful.

Have discussions about oversharing. Predators look for ways to identify where kids hang out. Kids shouldn’t give a team name or mention that their soccer game is tomorrow morning at 9. That innocent information can help a predator find them. Even photos with identifying information, like a school shirt or team jersey, can be risky if shared publicly.

Kids sometimes get tricked into sharing photos that are inappropriate. This includes pornographic images as well as snapshots identifying where to find them.

Talk about their digital footprint. Schools and employers will look at your child’s online history. It needs to be positive and what they post today will be there forever.

Teach kids basic right and wrong

We cannot protect our kids from everything, but we can teach them to be good decision makers.

Use real life examples and daily experiences to help your kids learn to make safe choices. Let them accept more responsibility and make more choices as they get older. Allow them to make the wrong choice sometimes. They’ll learn from these little mistakes much more than they would if you refuse to let them do that little mistake. This helps to prepare them to make the right choice with the riskier options as they grow.

For example, if your middle school child wants to stay up late to watch a movie but you know he has an early soccer game, discuss the situation with him. Let him make up his own mind in the end – without being judgmental. If he struggles getting out of bed and disappoints his teammates because he’s too tired, is that really the worst thing in the world? I bet the next week he won’t beg to stay up late so much. Just don’t play the “I told you so” game or give attitude about it. That will make him mad at you.

Let kids learn from their own mistakes without discussion or lecture. Kids learn from things like this if we let them. Trust me, there are lots of opportunities for them to learn to make safe, responsible choices as they grow.

In the end, if our kids want to find an inappropriate site or do something they’re not supposed to do, they will. If they use good judgement and make safe choices in other aspects of life, they are more likely to do so online too.

Be vigilant

It’s not just Momo… Even if she started as a hoax, we DO need to talk to our kids about risks online.

We need to keep up with online challenges and apps.

Follow your kids on their social sites. Talk about what sites they can and cannot use, but remember that it is easy for them to set up hidden accounts. That’s why it’s so important to talk to your kids and let them make their own choices as they grow. If you don’t allow options and never let them fail, they will not learn. The more you restrict them, the more they’ll hide from you.

Monitor for new apps. Learn how kids hide them. If your child has an iphone, they can be hiding them in these ways.

Keep track of the time your child spends online. Go to your app store and search “time on phone tracker” or check out these popular apps that track time:

For more:

In addition to the many links above, these articles are highly recommended:

New Car Safety Guidelines 2018

The #1 killer of our children over 4 years of age is vehicle crashes. New car safety guidelines are based on safety data to keep our kids safe.

The AAP recently released new car safety guidelines for kids. The number one killer of our children over 4 years of age is vehicle crashes. These new guidelines are based on safety data and research about how to keep our kids safe. They are not meant to keep kids happy. They will be hard to enforce at the beginning, but it’s worth it to keep our kids alive! Once kids know this is not negotiable, the fighting will decrease. Spread the word to your friends with kids so yours don’t feel like they’re the only ones who must stay in a safety seat. Plus you might save a life!

A big thank you to Molly Blair for the colorful photos!

General car safety tips

Car seat choice and maintenance

  • The best seat is not necessarily the most expensive. Choose a seat that fits your child and your car.
  • Car seats expire. Write when your seats are close to expiring on your calendar.
  • You should not buy a used car seat from anyone you don’t know. It is not possible to verify that it hasn’t been in an accident in this situation.
  • Register your car seat so you will be notified in case of recalls.
  • If you’re in an accident, your car seats may need to be replaced. Insurance may cover this cost.
  • Do not remove the stickers that provide important information, such as the height and weight limits of the seat.
  • Always review the size minimum and maximums of your car seat. Make it a habit to check the seat’s limitations after each well visit check to be sure your child’s height and weight still fit in the seat as it is being used.

Car seat use and mis-use

  • Bring your child and the car seat to a certified car seat installer with each change in seat and change in vehicle.
  • The most common mistake other than installing a seat improperly is to move a child to the next seat too quickly. Keep your child in the seat until they meet the height or weight limit. Each transition (from rear-facing to forward-facing, forward-facing to booster, and booster to lap/shoulder belt) lowers the child’s protection.
  • Do not use attachments, such as a head roll, in a seat unless it was tested and sold with your seat.
  • Keep bulky clothing and padding out of the car seat. Layer clothing if it’s cold. 
  • Rear facing allows the head and spine to be protected in case of a crash. It is the safest way to travel. The head, neck, and spine are all supported by the hard shell of the car safety seat. They all move together, with little relative movement between body parts.
  • When children ride forward-facing, their bodies are restrained by the harness straps, but their heads can be thrown forward in an accident. This can lead to more spine and head injuries.
Bulky clothes and winter coats are not for use in car seats!
Molly Blair makes a lot of great images for her mother, Dr. Kim Burlingham, and has given me permission to share. 

Potential problems with following the guidelines

Motion sickness

If your child suffers from motion sickness (car sickness) when rear facing, talk to your pediatrician.

Resistance

Kids will resist many things, including properly buckling up. It is worth it to insist that they’re safe. Try various parenting strategies.

Kids like choices, so offer choices about climbing in or getting put in the seat or if they want to help do the buckle. The choice is never whether or not to ride safely. Find acceptable choices that end with them properly buckled. There are more ideas in 5 Tricks to Get an Uncooperative Toddler Into Their Car Seat.

Older kids can learn about why they need this level of safety seat to remain safe. I know my kids are both shorter than classmates, so it was a regular discussion in my house. They always ended up agreeing that it was necessary when we looked at age-appropriate crash pictures and safety data. (Do an online search to preview sites without your kids so they aren’t exposed to more than they can handle.) I ask kids in my office all the time if I should ride a motorcycle without a helmet – it’s legal in my state. They all say “no” and then seem to comprehend that just because it’s legal doesn’t make it safe.

Summary of 2018 car safety guidelines

Infants through preschool years

Infants should always remain rear facing. Both rear-facing only seats and convertible seats can serve this purpose.

Infants should remain rear facing until they outgrow the limits of their car seat.

Rear-facing only seats

Rear-facing only seats are convenient because they can be snapped in and out of bases. This allows various drivers to have bases installed in their vehicle and the seat can be used in multiple vehicles.

Rear-facing only seats tend to have lesser weight and height allowances, but as infants become toddlers they do not need a carrying seat. Not to mention the safety issues with carrying a heavy kid in a heavy seat – we don’t need parents to hurt themselves!

Although these infant rear-facing carrying seats can be used to carry infants in and out of buildings to the vehicle, it is not recommended to use them long term outside of the vehicle. They are not approved for overnight sleeping.

Convertible seats

Convertible seats are able to be used rear facing until a child outgrows the weight or height maximum.

The minimum weight recommended to turn forward facing is now 40 pounds unless the seat has a lower maximum for rear facing.

This means most toddlers and preschoolers should be staying rear facing.

When kids turn forward in the car, they should stay in their harness.
 When kids turn forward in the car, they should stay in their harness.

School aged kids

Convertible seats

Convertible seats will accommodate children rear facing until they are 40-90 pounds.

Keep ’em rear facing longer!

The earliest it is now recommended to turn kids forward facing is 40 pounds. I know kids will fight this, but it’s worth it based on the safety studies.

This means that kids who are school aged might still fit best rear facing.

Rear facing is the safest way to travel, and remember that the #1 killer of our kids over 4 years is automobile crashes. Let’s change that and keep kids rear facing longer.

When kids are over the rear-facing maximum of their seat, turn them around, but leave the harness on. There’s a reason race car drivers use a harness and not just a lap and shoulder belt. Harnesses are safer! Use it until your child outgrows the limits of the seat.

Race car drivers still use a harness seatbelt - your kids should use one too until they're big enough to fit without.
 Race car drivers still use a harness seatbelt – your kids should use one too until they’re big enough to fit without.

Booster seats

Booster seats help keep the lap and shoulder belt positioned properly until a child is tall enough and old enough to not require it. It is generally around 4 foot 9 inches that kids are big enough to sit in most vehicles without a booster. Most kids are not this tall until 10-12 years of age, even though many state laws allow much younger kids to sit without a booster.

Age is not the main factor in deciding when a child should move out of  a booster. Use the 5 point test to see if your child fits properly in the vehicle. I always say it’s the size of the child as well as the size of the vehicle’s seat that matters.

Don't let kids move out of the booster seat too soon! Age doesn't matter as much as fit.
 Don’t let kids move out of the booster seat too soon! Age doesn’t matter as much as fit.

Seat belt alone

When kids fit properly in the vehicle’s seat without a booster seat, they still should sit properly.

If your child cannot sit upright in the seat, a booster is still recommended to keep the belt properly positioned.

No one should slide their hips away from the back of the seat to slouch in the seat. This allows the seat belt to ride up onto the abdomen, which increases the risk of injury in a crash.

Use seat belts properly and have kids sit in the safest seat always! Only teens and adults should sit up front.
 Use seat belts properly and have kids sit in the safest seat always! Only teens and adults should sit up front.

Front seat

All children less than 13 years of age should remain in the back seat.

It’s easy to remember that only teens and adults can sit up front.

This is not based only on height or weight. Physical maturity makes a difference as well.

And remember…

Don’t rush your kids to grow up too soon!

Will Standing Hurt a Baby’s Feet or Legs?

“Will standing hurt my baby’s legs?”

I’m surprised how often I’m asked if having a baby “stand” on a parent’s lap will make them bow-legged or otherwise hurt them. Standing and jumping while being held and supported is a natural thing babies do, so why do so many parents worry if standing will cause bow legs or other problems?

Old Wives Tales are ingrained in our societies and because they are shared by people we trust, they are often never questioned.

Bowed legs from allowing babies to stand with support is one of those tales.

If an adult holds a baby under the arms and supports the trunk to allow the baby to bear weight on his legs, it will not harm the baby.

Many babies love this position and will bounce on your leg. It allows them to be upright and see the room around them.

Supported standing can help build strong trunk muscles.

Other ways to build strong muscles in infants:

Tummy time

tummy time, prevent flat heads
Supervise tummy time when Baby’s awake!

This is a simple as it sounds. Place your baby on his or her tummy. Be sure s/he’s on a flat surface that is not too soft.

I think the earlier you start this, the better it’s tolerated. You can even do it before your newborn’s umbilical cord stump falls off!

Initially babies will not lift their head well, so be sure they don’t spend too much time face down. This can cause problems with their breathing. A brief time doing this is safe though as long as they aren’t laying on fluffy stuff. This is a major reason to never leave your baby alone on his stomach.

Use this as a play time.

Move brightly colored or noisy objects in front of your baby’s head to encourage your baby to look up at it. Older siblings love to lay on the floor and play with “their” baby this way!

Many babies will look like they’re taking off trying to fly. Others will put their hands down and look like they’re doing push ups. Around  4 months they can support their upper body weight on their elbows. All of these are good for building muscles.

Parents often avoid tummy time because their babies hate it. It’s hard to hear babies cry, I know. You can progressively make it harder for your baby without being a mean drill sergeant! Increase the time on their tummy as they gain strength. Start with just a minute or two several times a day. If you never do it, they’ll never get better.

Bonus: Tummy time helps to prevent flat heads!

Chest to chest:

From day one babies held upright against a parent’s chest will start to lift their heads briefly. You will most likely go to this position to burp your baby sometimes.

The more babies hold their head up, the stronger the neck muscles get. Chest to chest isn’t as effective as floor tummy time for muscle strength development, but it’s a great cuddle activity!

The more reclined you are, the more they work. Think of yourself doing push ups. If you do push ups against the wall, it’s pretty easy. If you put your hands on a chair, they get a little harder. Then if you put hands and feet on the floor, they’re even harder. Lift your feet onto a higher surface and it’s even harder.

Chest to chest time can be an easy version of tummy time, but I don’t want it to replace tummy time completely. Make time for both each day!

Lifting gently:

When your baby is able to grasp your fingers with both hands from a laying position, gently lift baby’s head and back off the surface. This can usually start around 6 weeks of age.

Babies will get stronger neck muscles by lifting their head and strong abdominal muscles by tightening their abs even though you’re doing most of the lifting. You could call these baby sit ups!

Be careful to not make sudden jerks and to not allow the baby to fall back too fast.

Kicking:

Place your baby on his back with things to kick near his or her feet.

Things that make a noise or light up when kicked make kicking fun!

You can also give gentle resistance to baby’s kicks with your hand to build leg muscles.

Bicycling:

When you ride a bike, you get exercise, You can help your newborn stretch and strengthen leg muscles by making the bicycle motion with his or her legs.

When babies are first born they are often stiff from being in the womb. They will learn to stretch their legs, but you can help by moving them in a bicycle pattern. They usually find this to be great fun!

I also suggest doing this after they get their first few vaccines to help with muscle soreness, much like you move your arm around after getting shots. Generally by 4 months, babies kick enough that they can do this on their own.

Sitting:

Allow your baby to sit on your lap or on the floor with less and less support from you.

You can start this when your baby has enough head and trunk control to not bop around constantly when you hold him or her upright for burping. Don’t wait until 6 months to start – by this age some babies can already sit for brief periods alone if they were given the opportunity to practice when younger.

A safe easy position is with the parent on the floor with legs in a “V” and baby at the bottom of the “V” – this offers protection from falling right, left, and back.

When your baby is fairly stable, you can put pillows behind him or her and supervise independent sitting. Never leave babies unattended sitting at this stage.

Big benefits

“Will standing hurt my baby’s legs?” is the wrong question.

Parents should ask more about what you can do to help your baby develop strong muscles. Standing with proper support is not only safe, but also beneficial!

What are your favorite activities to help your baby grow and develop strong muscles?
Will standing hurt a baby's feet and legs? What about hips?

Summer Penile Syndrome

Did you know there’s a name for the super swollen male parts from bug bites? Actually two names: Summer Penile Syndrome and Lion Mane’s Penis. Doctors might even call it seasonal acute hypersensitivity reaction. If you’ve ever seen it, you know it can be quite impressive.

What is summer penile syndrome?

Summer penile syndrome is a fairly common concern during the summer months. It’s usually due to a chigger bite on the sensitive skin of the penis or scrotum. You can often find a small bug bite near the center of the swelling.

They can itch like crazy, but usually don’t interfere with urinating.

Despite the significant swelling, there isn’t usually much pain, only itching. Unless there’s a secondary infection, there won’t be any fever.

What is a chigger?

Chiggers are a type of mite, which is an arachnid in the same family as spiders and ticks. They are also called harvest mites, harvest bugs, harvest lice, mower’s mites, or red bugs. Chiggers are so small they often go unnoticed until several hours after they attach to our skin. They can attach even under clothing, and the most common places that we notice chigger bites are in the areas of our pants.

Chiggers live in moist, grassy and wooded areas. They are commonly found in the warm summer months.

Adult chiggers don’t bite. It’s the larvae that cause itchy problems. The larvae are red, orange, yellow, or straw-colored, and no more than 0.3 millimeters long.

File-Chigger bite
Chigger. Source: https://commons.wikimedia.org/wiki/File:File-Chigger_bite.svg 
After crawling onto the skin, the larvae inject digestive enzymes into the skin that break down skin cells. They do not actually bite the host even though the bumps are called chigger bites. They form a hole in the skin called a stylostome. Their saliva goes into deep skin layers, which results in severe irritation and swelling.

People usually start to itch within a few hours and often scratch the feeding chiggers away. A hot shower with plenty of soap will kill chiggers and prevent them from finishing their meal, so showering after being in grassy or wooded areas can help prevent deeper reactions.

The good news is that in the US, chiggers are not known to carry diseases.

Prevention

Even though they don’t cause disease, chigger bites are something to avoid because they can cause significant itching for weeks.

Bug sprays with DEET will deter the chiggers. DEET is approved for use in children over 2 months of age.

Clothing can be treated with permethrin to avoid ticks and chiggers. Permethrin can be purchased at sporting goods stores to pre-treat your clothing. It should not be used directly on skin. Once dried into the clothing, permethrin will last for about six washings. You can also treat your shoes, which makes a lot of sense since chiggers are usually found in the grass and crawl up onto your skin.

Even untreated clothing can help a little if you don’t have time to pre-treat with permethrin. Wear long sleeves and long pants. Be sure to tuck the pant legs into your socks so they can’t enter from the bottom leg hole.

For more on bug sprays, including citronella, picaridin, oil of lemon eucalyptus and more, see the EPAs information on registered and unregistered products. You can even use this handy tool to find the right product for your needs.

How do you treat chigger bites?

Much like any bug bite, control of the itch is important. If kids scratch any itch, it can become secondarily infected from the break in the skin allowing germs in.

Antihistamines

Antihistamines are used for allergic reactions. We commonly use them for seasonal allergies, but they can help most allergy reactions.

Bug bites itch when our bodies react to the saliva injected into our skin with histamine. Histamine is our body’s allergic response and it itches. If you aren’t allergic to the bite, you won’t itch from it. This is the way we react to allergies, which is why we get itchy eyes and noses with allergies to pollen.

Diphenhydramine (Benadryl) is a short acting antihistamine that can help control allergic reactions, but tends to make kids tired or wired. It also only lasts a few hours, which can require frequent dosing.

I don’t like topical antihistamines, which are often sold to treat bug bites. I worry that kids will get too much of the medicine when it is applied to each bite. It’s a low risk, but still a risk. Just because they aren’t taking it by mouth doesn’t mean it isn’t absorbed. Children using a topical antihistamine for an extended time over large areas of the skin (especially areas with broken skin) may be at higher risk, especially if they also are using other diphenhydramine products taken by mouth or applied to the skin.

I am a fan of using an oral long-acting antihistamine, such as cetirizine or loratadine, to treat bug bites. Most kids with one bug bite have many. One dose of an oral antihistamine helps to control the overall histamine reaction, making each bite itch less.

Antibiotics

Despite the significant swelling, these usually do not require prescription antibiotics.

If your child has open areas from scratching the skin, you should keep the area clean and consider using a topical antibiotic ointment to help prevent infection.

Steroids

Over the counter topical hydrocortisone is a very low dose steroid. It can be used on insect bites to help stop the itch.

Stronger steroids that require prescriptions are occasionally used, but you will need to see your physician to discuss the risks and benefits of prescription steroids.

Oatmeal baths

Soaking in an oatmeal bath might help the itching. It works very well for dry skin conditions and sunburn relief as well.

You can buy commercially made oatmeal bath products or you can grind regular plain oats to make it fine enough that it dissolves in bath water. Test a small amount in a cup of water to see if it’s finely ground enough before putting 1 cup of oats into the bath water.

Some people have even made a paste of oats and applied it directly to the itchy skin for relief.

Baking soda

Another kitchen remedy for bug bite itch relief is baking soda. Mix a pinch of baking soda with a few drops of water to make a paste. Put this paste on the bites. Reapply as needed.

Ice or cool cloth

One more kitchen treatment is ice. Many kids won’t tolerate this one, but if they can’t tolerate an ice pack placed over clothing, you can try applying a cool wet washcloth directly to the skin.

When should you see your doctor?

If your child has any of the following symptoms, talk with your doctor.

  • Trouble urinating.
  • Pain or itch not controlled with the above measures.
  • Fever.

Fear has big eyes
By Robbie Grubbs from Houston (What????) [CC BY-SA 2.0 (https://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons
 

ASK to save a life!

June 21, the first day of summer, is National ASK (Asking Saves Kids) Day. The ASK Campaign encourages everyone to ask if there are unlocked guns in the homes where children play. Learn how to make it less awkward.

June 21, the first day of summer, is National ASK (Asking Saves Kids) Day. The ASK Campaign encourages everyone to ask if there are unlocked guns in the homes where children play. The Asking Saves Kids (ASK) Campaign encourages parents to ask a very important question before playdates: “Is there an unlocked gun in your house?” It’s a simple question, but it has the power to save a child’s life.

1 in 3 homes with children in America have guns. Ask to save a life.
Click to enlarge. Source: http://askingsaveskids.org/

Keeping a gun in the home increases the risk of injury and death, yet 1 in 3 American homes with children have at least 1 gun.

Every year thousands of kids are killed or injured by guns. When parents think of asking about guns in a playdate’s home, they often can’t imagine how to enter into that conversation.

It doesn’t have to be awkward to ask before your child visits friends. I’ll show you how.

But first let’s review why this is so very important.

Guns are common in our communities. Ask if they are in the area your children will play, and if so, be sure they're stored safely! #ASKingSavesLives
Guns are common in our communities. Ask if they are in the area your children will play, and if so, be sure they’re stored safely! #ASKingSavesKids

Gun Safety

One question could save a child's life. Ask.
Click to enlarge. Source: http://askingsaveskids.org/

Many parents buy a gun to help protect their family, but a gun in the home increases the risk of a family member being hurt or killed by a gun more than preventing a crime.

Kids have natural curiosity and if they find a gun, they are likely to play with it, even when they are taught to not touch guns.

Toy guns and real guns are so similar, it can be difficult to tell them apart.

Several studies over the years show that gun education programs fail. Diane Sawyer’s Young Guns episode showed that even soon after gun safety education, kids will play with a gun and not follow the rules they just learned.

Regardless of the reason for or type of gun, there are guns in 1 in 3 homes with children in America. Too many of those guns are not locked. A gun in the home increases the risk of homicide, suicide, and accidental injuries.

Don’t mistakenly think that your gun is needed to keep your family safe. For every time a gun in the home was used for self-defense, there were 4 unintentional shootings, 7 criminal assaults or homicides, and 11 attempted or completed suicides.

Accidental shootings

Accidental shootings occur far too often, especially in young children.

See the table below that lists the numbers of leading causes of injury deaths by age. In children under 15, there were 73 unintentional firearm deaths in 2016. That number does not include homicides and suicides.

10 Leading Causes of Death by age in 2016
Click to enlarge. Source: https://www.cdc.gov/injury/wisqars/leadingcauses.html
Homicide

Sadly there have been too many kids who have been killed by intentional gunfire, both at home and in public areas. The higher the number of guns in a community, the more gun deaths there are.

Our kids must practice active shooter drills at school because school shootings are occurring with more frequency. Many of these shootings are kids who bring their parent’s gun to school.

Suicide

Suicide attempts with guns are usually fatal. Sadly too many people consider suicide as an option when they’re down.

Having a gun in the home when a teen is depressed increases the risk of death by suicide. Over 80% of teen suicide by firearm is done with a family member’s gun.

Keeping guns locked with the ammunition locked separately is important even when you don’t have young children. It can deter teens from accessing guns in a time of despair.

Hiding guns

Parental perception of what kids know about guns is lacking.
Child knowledge of handling of guns in the home. Source: https://www.bradycampaign.org/sites/default/files/Kids-and-Guns-Report%202016_final.pdf

Hiding guns is not a safe plan. Nearly 80% of kids know where the family gun is hidden. Parents usually don’t realize the kids know.

I’ve seen more than a couple surprised parents when they learn that their child knows where the family gun is stored in a drawer or closet. They presumed the child had no idea about the gun, but kids know things. It’s bad enough if they know your secret hiding place for birthday gifts, but if they know where the unlocked gun is, natural curiosities can take over.

It’s not political

I don’t care if you’re a Republican, Democrat, Liberal, or other political affiliation. This isn’t about politics. It’s about keeping kids safe.

This is not about the Second Amendment. Americans have a right to bear arms. But with rights comes responsibilities.

This is about the responsibilities that come with the right to bear arms. Adults have a responsibility to keep children safe.

When having the discussion, keep it about safety. Don’t make it about politics. That turns people off and gets them on the defensive. Don’t judge whether it’s okay to own a gun. Focus on the issue of making sure all guns are safely stored unloaded and locked.

Make it less awkward

Parents must have awkward conversations. Don't let that stop you from keeping kids safe.
Click to enlarge. Source: http://askingsaveskids.org/

As parents there are many awkward things we must deal with. Being awkward or difficult doesn’t make it okay to just ignore it if safety is involved.

By introducing safety concerns that are not judgement issues, it can be more natural to then talk about more sensitive topics.

Use these non-controversial openers to start the conversation before playdates.

Pets

Allowing a dog who is not friendly and patient around kids to be with the kids is a red flag. Ask if there are pets and how they respond to kids, especially kids they don’t know. If you’re not comfortable with that pet, ask if the parent can keep the kids and pet separate.

When kids are afraid of animals, the other parent needs to be aware.

If there are any pet concerns, see if they can keep the pet in another room while your child is there. If not, have their child to your home instead.

Allergies

If your child has allergies to animals or foods, the other parent needs to be aware. Talk about the allergy and what can be done to help your child not suffer.

When the parent is not able to keep your child safe from allergens in their home, ask if their child can come to yours instead.

Other safety risks

There are numerous other safety risks that could be used as introductory concerns. You can’t ask everything, but pick the things that are most important to you.

Will the kids be riding bikes or scooters? Are there enough helmets for everyone or should your child bring his own?

Is there a wooded area that will require bug sprays or tick checks after the play date?

If they play outside, how closely are they supervised? Do you need to send along sunscreen?

Does your child need to wear sneakers or will they be staying indoors and the flip flops are okay?

If a parent will be responsible for driving your child, do they have an appropriate car seat or booster seat?

Do they have a trampoline or pool? If so, what are their rules and safety measures?

Be first

Be the first to ask a child to your home. With the invitation, list everything you think another parent might be interested in knowing. Hopefully they will reciprocate by giving similar information when they invite your kids over, but if not, ask.

“We’d love to have Johnny over. We have a German Shepard, but he’s really good with kids. If Johnny needs him to be put in the master bedroom, just let me know. We also have a trampoline, but if the kids get on it, a parent is always outside. If that’s not okay, let me know. And we have a rifle, but it’s in the gun safe and the ammunition is locked separately. Is there anything we need to know about Johnny?”

My Pocket Pediatrician

Take a look at Dr. Lili’s comprehensive video on gun safety for more information! Here’s the full version:

And here’s a shorter version with the most important information:

Take the ASK Pledge

Pledge to ASK if there are unlocked guns where your child visits. Encourage friends and family to do the same!

Pledge to ASK if there are unlocked guns where your child visits: http://www.bradycampaign.org/take-action/pledge-to-ask
Pledge to ASK: http://www.bradycampaign.org/take-action/pledge-to-ask

Resources

The Truth About Kids and Guns from The Brady Campaign

CDC’s WISQARS™ (Web-based Injury Statistics Query and Reporting System)

WISQARS Interactive Visualization

jose-alonso-589704-unsplash

photo credit:Jose Alonso

Is Miralax Safe?

Constipation is one of the most common problems that affects kids. Sometimes it’s mild and changes to diet and routines can help sufficiently. Those are of course the ideal treatments. But if it’s more severe or if kids are resistant to change, Miralax is my go-to treatment. Several parents have asked me about its safety due to what they’ve seen online. I know many more are probably worried but just haven’t asked. With all the concern, I thought I’d share some of the concerns and reasons that I still recommend it.

What is Miralax?

Miralax has been used since 2000, and since I finished my pediatric residency prior to that, I can remember the alternatives we used previously. Many of them were difficult to get kids to take due to poor taste or grittiness. When Miralax was first available, treatment of constipation improved significantly due to the tolerance and acceptance by kids. It was initially available by prescription only and expensive – thankfully both of those hurdles have been removed.

Miralax is the brand name for polyethylene glycol 3350 or PEG 3350. It is now available as an over the counter medication, so no prescription is needed. Generic versions are available. It has been used by many kids over many years, often for long periods of time, to treat constipation.

Is it a laxative?

PEG3350 is a stool softener, not a laxative (despite the name).The molecule binds to water, but is too large to be absorbed through the gut so it passes through the gut and carries the water with it. It works by increasing the water content of the stool. The more PEG taken, the softer the stool.

PEG is not a laxative and should not cause cramps. It is not habit forming. As mentioned above, it is not absorbed into the body it just goes through the GI tract and leaves with the stool.

How is it used?

PEG 3350 is a tasteless powder that dissolves in liquids. It often needs to sit for a few minutes and re-stirred to fully dissolve.

It may be dissolved in water, with a slight change to its taste, but is palatable. Be careful of adding it to drinks high in sugar (even juice), since your child may be on it for a long time, and they don’t need the added sugar. Consider making flavored water with your child’s favorite fruit. Simply put cut up fruit in water in the refrigerator for a couple hours. Infused water tastes great and is a healthy base for your Miralax mixture – or anytime your kids need a drink and don’t like plain water.

I don’t recommend adding it to carbonated beverages.

I recommend mixing a capful of powder in 8 ounces of water and titrating the amount given based on need. My office website discusses this in detail.

Why do we need medicine?

Constipation is common.

Very common. It causes pain, poor eating habits, fear of toileting, and sometimes even leads to ER trips and CT scans. It can last months to years in some kids, so it is not a minor issue when kids suffer from it.

Diet changes are hard – especially in kids!

Kids are often constipated because they have a diet that is poor in water and fiber. They need to eat more fruits, vegetable and whole grains. Many kids drink too much milk and eat too much cheese.

Changing habits is very difficult in strong willed kids. When it comes to food, they’re all strong willed! Dietary changes of course should be done so they are healthier on many levels, but if their stomach hurts all the time, they are unlikely to get out of their comfort zone with foods. Habits change too slowly to help the constipation if used alone.

I encourage first changing the diet to help constipation, but if that fails, or if it is too significant of a problem, PEG 3350 is my first choice. I have recommended it for years without any known side effects or complications, other than the kids who have frequent watery stools on it. This usually responds to continuing the medicine to release the large stool mass that has built up. Some kids just need to decrease the dose a bit.

What’s the concern?

I was quite surprised in 2015 to see that researchers were starting a study on the drug. It surprised me not only because I’ve never heard valid concerns about the safety or efficacy of the medicine (I have seen some really weird stuff online, but nothing that is valid), but also because I’ve never seen headlines that a study is starting. Usually headlines report results of studies. Why did it hit the press before the study was even done? I have no idea.

Even more interesting… it seems the study hasn’t started yet. Three years later. Not a high priority, apparently. Which fits with the low level of concern I find among general pediatricians and pediatric gastrointestinal specialists.

Yet parents still ask about the risks.

What was the proposed study?

Initial reports stated that they were going to look at the safety of other molecules in the PEG 3350.

PEG 3350 itself is a very large molecule that isn’t absorbed by the gut, but there are concerns that smaller compounds could be found as impurities in the manufacturing process of PEG 3350 or formed when PEG 3350 is broken down within the body.

The question is if these smaller compounds are absorbed by the gut and accumulated in the bodies of children taking PEG 3350.

Some families have reported concerns to the FDA that some neurologic or behavioral symptoms in children may be related to taking PEG 3350. It is unclear whether these side-effects are due to PEG 3350 since neurologic and behavioral symptoms can lead to constipation.

What are the recommendations?

The 2014 guidelines for constipation diagnosis and management from the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition support the use of PEG 3350: Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN.

These guidelines basically state that not many studies are required to diagnose functional constipation after a thorough history and exam. This means that we don’t need to do expensive tests to make the diagnosis.

The common things we recommend (fiber, water, probiotics) don’t have any proof that they work. There is evidence that PEG 3350 works.

Why does the label say it’s for adults?

As a pediatrician I know that many (if not most) of the medicines we use in children are not tested in children before they come to market.

Historically once something is approved in adults, physicians start to use them in children. Companies generally don’t invest money in studies to expand uses after approval because they know that the products will be used in broader ways without the specific indication. They don’t want to spend money they don’t need to spend, which makes sense from a business perspective. It’s also more difficult to do studies in minors.

New rules encourage pediatric testing, but all the drugs previously used in children will not need to undergo this testing. Because they’ve been used for years, we rely on post-market safety data.

Are there studies in children?

Many of the news articles say that studies have not been done in children, but this isn’t true.

This 2014 research article reviews the history of PEG 3350 and compares to other medicines used in pediatric constipation. It also shows safe blood electrolyte levels while on PEG 3350 long term.

In 2001 a study was published showing safe and effective pediatric dosing.

A 2003 studyshowed safety and better tolerance than previously used medications for constipation.

A study specifically looking in children under 18 months of age showed safety.

A 2009 Canadian study shows its safety in children.

If you look at the references of any of these studies, you will find more. The only side effects noted are related to diarrhea, cramping, bloating — all things that would be expected with a large stool mass blocking the new, softer, water filled stools from coming out. Once the large stool mass is out, these symptoms resolve.

For what is PEG approved?

PEG is used in many products, not just stool softeners. It is found in ointments and pills to allow them to be more easily dissolved in water. PEG can also be found in common household products such as certain brands of skin creams and tooth paste.

PEG 3350 is approved for treatment of constipation in adults for up to 7 days. Approval is based on studies available at the time a medicine is approved. Many commonly used medications are not specifically FDA approved for use in children less than 16 years due to difficulties and expense in testing drugs on minors.

How do we know it works?

There have been several studies in children and the collective experience of pediatricians around the world showing improved tolerability over other treatments for constipation because PEG 3350 has no taste, odor, or texture.

It has been shown to be either as effective or more effective than other constipation treatments. See the links to these studies above. Until children can keep stools soft with adequate amounts of water, fruits, vegetables, and fiber, long term use of PEG is well tolerated.

How long can PEG be used in children?

This is a very difficult thing to study because the longer a study follows their subjects, the more subjects are lost to follow up.

There have been studies of up to 30 months that showed safe use. Blood electrolytes, liver and kidney tests were all reassuring that PEG is safe during the study.

Pediatric gastroenterologists and general pediatricians have often recommended even longer periods of time without any known side effects.

If my child has taken PEG 3350, should I worry?

Is miralax safe?
Is MiraLAX safe?

I cannot stress enough that the studies that have been done all support the safety and efficacy of PEG 3350.

After years of experience using PEG 3350 with many children, I have not seen any neurologic or behavioral problems caused by PEG 3350. I do see many kids with baseline neurologic and behavioral problems become constipated, so they often end up on PEG 3350, but if the issue is carefully assessed, the problems start prior to the treatment.

Generally if the stools are softer, you can more easily work with the behavioral issues that cause the constipation, such as loss of appetite/poor diet and failure to sit on the toilet long enough to empty the stool from the rectum.

If you decide it is time to stop the medicine, be sure to discuss this with your child’s doctor to keep them in the loop about how things are going!

Should your child have an Athletic Heart Screen?

In recent years I’ve been getting more and more reports of athletic heart screenings. Local schools and sports clubs are offering to have athletes get a heart work up for a relatively small fee. Of course most are perfectly normal, which is a peace of mind to parents. Some have found minor things that aren’t of much consequence, but a few have found important heart issues. So why is there even a question of whether or not to do an athletic heart screen if it discovers important heart issues?

Why worry about healthy athlete hearts?

Sudden cardiac death in athletes has been in the news a lot over the years. We all want to minimize the risk that our child has an undiagnosed heart condition that may cause sudden death when exercising. We want to prevent sudden death by identifying those at risk and keeping them from the activities that increase risk.

Communities and schools now are more likely to have defibrillators on hand in case of problems, but some children might benefit from an implantable defibrillator.

If you’ve not taken a CPR class in the past few years, a lot has changed, including teaching people how to use defibrillators. And you no longer follow “A B C” so it is very different. CPR is recommended for all teens and adults.

Is the cost of a heart screen worth it?

Assessment of the 12-Lead ECG as a Screening Test for Detection of Cardiovascular Disease in Healthy General Populations of Young People (12–25 Years of Age): A Scientific Statement From the American Heart Association and the American College of Cardiology is a review of whether or not electrocardiograms (ECGs) are beneficial for all athletes prior to sport participation. It is endorsed by the Pediatric and Congenital Electrophysiology Society and American College of Sports Medicine.

There has been a lot of controversy over the years whether or not routine ECG screening of athletes is a cost-effective means to find at risk young people. Northeastern Italy has done a comprehensive screening program of competitive athletes and has lowered their sudden cardiac death rate, which is evidence for the ECG screening. Despite this shown benefit, there are many problems with the feasibility of testing a broad range of athletes to evaluate for risk of sudden death (SD).

Complex issues from the Statement linked above:
  1. the low prevalence of cardiovascular diseases responsible for SD in the young population
  2. the low risk of SD among those with these diseases
  3. the large sizes of the populations proposed for screening
  4. the imperfection of the 12-lead ECG as a diagnostic test in this venue

It is generally agreed upon that screening to detect cardiovascular abnormalities in otherwise healthy young competitive athletes is justifiable in principle on ethical, legal, and medical grounds. Reliable exclusion of cardiovascular disease by such screening may provide reassurance to athletes and their families.

In short: 

To do an ECG screening on all athletes is not inherently unwarranted nor discouraged, but it isn’t recommended either.

What is recommended?

Although an ECG is not recommended, it is recommended to do a 14 point questionnaire for all athletes at their pre-participation sports exam. This is listed below.

Why isn’t an ECG (commonly called EKG) recommended?

Positive findings on the history (questionnaire) or physical exam may require further testing, but using an ECG as the initial screen for underlying problems in the 12- to 25-year age group hasn’t been found to save lives.

Changes in the heart in growing teenagers can make it difficult to tell if an ECG is abnormal or a variation for age (unless read by a pediatric cardiologist, which is often not possible for these mass screenings).

False negative and positive results can lead to missed diagnoses (normal ECG but real underlying condition) or unneeded testing (abnormal ECG with a normal heart).

Mass ECG screening of athletes would be very expensive and has not been proven to save lives.

If your family can bear the cost and wants to do the screening, it should be done. But if the screen is abnormal, do not jump to the conclusion that your athlete will be banned from sports forever. A more complete exam by a pediatric cardiologist will sort that out.

Know that hearts can change over time. One normal screen does not guarantee there will never be a cardiac event in your child.

If you do not feel that the screening is something you want to pay for or if you feel that it is not necessary for your child who has a negative 14 point screening, you should not be required to do so.

The evidence does not support mass required screenings.

If your child has identified risks based on the questionnaire, a more thorough testing should be done.

What are the 14 points?

These 14 points are listed in Table 1 of the above linked statement: The 14-Element AHA Recommendations for Preparticipation Cardiovascular Screening of Competitive Athletes

Medical history*
Personal history 

1. Chest pain/discomfort/tightness/pressure related to exertion
2. Unexplained syncope/near-syncope†
3. Excessive and unexplained dyspnea/fatigue or palpitations, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation in sports
7. Prior testing for the heart, ordered by a physician

Family history

8. Premature death (sudden and unexpected, or otherwise) before 50 y
of age attributable to heart disease in ≥1 relative
9. Disability from heart disease in close relative <50 y of age
10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of genetic cardiac conditions in family members

Physical examination

11. Heart murmur‡
12. Femoral pulses to exclude aortic coarctation
13. Physical stigmata of Marfan syndrome
14. Brachial artery blood pressure (sitting position)§

  • AHA indicates American Heart Association.
  • *Parental verification is recommended for high school and middle school athletes.
  • †Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or after physical exertion.
  • ‡Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be performed with the patient in both the supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
  • §Preferably taken in both arms.

What do I recommend?

I think that if you can afford the screen and any potential follow up recommended if it is abnormal, it is a great tool. It can be reassuring, though nothing can guarantee that no problem will develop.

In a perfect world cost wouldn’t matter, but I know it does, so if people can’t afford the screening, they should not feel like they are not doing the right thing if they skip it.

The 14 point question is all that is recommended to be done and can catch the majority of problems if done with a thorough physical exam.

A plug for an annual well visit in your medical home.

I think all kids and teens should have annual physicals in their medical home. The medical home is where their primary care physician is.

I know this is difficult due to the requirement of all athletes have a physical in a specified time frame before a season starts, but there are benefits to doing a physical in the medical home. At your usual physician’s office there should be record of growth over the years, a complete personal and family medical history, and previous vital sign measurements. Not to mention that your regular clinic should be able to update your vaccines if needed so there are no surprises when your school nurse looks at your record in the fall. Seeing your physician yearly also helps to build a relationship, so there is a better comfort level to talk if problems develop.

At this time insurance generally covers one well visit per year. Most physicians will fill out the sports physical form at this annual visit. When you go elsewhere, you usually must pay cash. You might as well get a comprehensive physical using your insurance. You pay a monthly fee for the privilege of having it – use it! Just be sure to schedule well in advance – everyone needs physicals at the same time due to state or club requirements, so slots fill up quickly.

Schedule your physical when you schedule a sport or camp.

When you sign your kids up for any new school, sport or camp, look to see what forms are needed. Call your doctor’s office at the same time you sign up for the sport or camp to schedule the annual physical. Just be sure the date you schedule is in the time frame that is needed  to get the forms completed.

Pay attention to your insurance rules for how often physicals can be done. Don’t necessarily schedule near your child’s birthday if it is outside the range that is needed to fulfill form requirements so you can avoid a second physical when only one per year is allowed.

If in doubt, call your pediatrician’s office and ask!

Should your child have an Athletic Heart Screen?
Should your child have an Athletic Heart Screen?

Is your teen driver a safe driver?

Summertime is a common time that teens learn to drive, but also the most dangerous time. Teens have more free time during the summer, so have more opportunity to drive than during the school year. Car crashes are the #1 cause of death in teens. We are now entering the “100 Deadliest Days,” the time between Memorial Day and Labor Day. This is when the average number of deadly teen driver crashes climbs 15% compared to the rest of the year. Make sure your teen is a safe driver before you let him or her hit the road alone.

Teens tend to be impulsive risk takers. Even cautious new drivers are inexperienced, so they are at risk of not knowing how to handle a situation. In addition to riding along with your teen as they learn the rules of the road, you should talk to them about expectations and safety. Continue the talks as they gain confidence because the risk of accident actually increases in the late teen years.

May is Global Youth Traffic Safety Month to educate about safe driving.

Driving Contract

After talking to your teen, get your thoughts down in writing. There are many driving contracts available online.

This contract from the CDC has areas to write in your specific details.

The idrivesafely contract allows you to enter details for each point covered.

The AAA Driving Agreement has a nice chart depicting privileges that vary based on circumstance.

NOYS Global Youth Traffic Safety Month
From https://noys.org/global-youth-traffic-safety-month/

Special Situations

Overconfidence of the teen driver

Research has shown that after the first few driving years, teens risk of having an accident actually increases. This may be due to teens gaining confidence and taking more risks.

According to the 2017 study, 75 percent of high school seniors “feel confident” in their driving abilities, and 71 percent use a phone behind the wheel. Driving while drowsy, speeding, having multiple passengers and browsing music become more prevalent as new drivers gain confidence.

Distraction

Distractions are a common cause of accidents. Younger drivers have the highest proportion of distraction related fatal crashes.

Over 70% of teens admit to using their cell phone while driving despite recognizing the dangers of this distraction.

Parents need to model safe behavior and stay off their phone while driving. Texts can wait. If it’s that important, pull over to check your phone. Have your teens agree to no cell phone use in a driving contract.

One of my favorite ads shows just how quickly accidents can happen.

Other passengers are another source of distraction. Teens easily distract one another. Limit the number of passengers your teen is allowed to chauffeur.

Even changing the radio station can be a significant distraction. Ask teens to set the station and leave it – or to make a soundtrack and play it for the road.

Speeding

Speeding is a contributing factor to many crashes. Speed limits are set for safety and going faster makes it harder to maintain control of the vehicle.

Talk to teens about the importance of not only following speed limits, but also about adjusting speeds to road and weather conditions.

It is better to arrive alive but late rather than to speed to attempt to get there faster. Talk to your teen about calling if they plan to be late rather than just trying to speed home to make curfew.

ADHD

The symptoms of ADHD, such as an inability to pay attention and impulsivity, can make driving even more dangerous than it is for a typical teen. There are more car accidents among teens with ADHD than the general population, but newer studies show ADHD drivers on medication are at a significantly lower risk than those not taking medicine. Talk to your teen about medication management if he or she has ADHD.

Safety tips for safe driving

  • Buckle up – it’s the law but even more important, it’s the safest way to travel. Make sure any passengers are properly buckled before you drive.
  • Avoid carpooling to reduce the distraction of others in the car. The more kids in the car, the higher the risk.
  • Avoid eating while driving.
  • Ignore your cell phone. (Parents be forgiving if your kids don’t answer your call or text right away.)
  • Know where you are going and how to get there before you get on the road. If you aren’t sure you’ll remember, set a GPS before hitting the road and turn the sound on to minimize the need to look at the screen.
  • Don’t drive when you’re tired. Drowsy driving is equated to drunk driving. If you have trouble staying in your lane or keeping your eyes open, you’re too tired to safely drive.
  • Adjust seats, mirrors and climate controls before driving.
  • Set your music for the road before you start driving.
  • Watch for pedestrians and bicyclists. Five percent of teen deaths in crashes are pedestrians and 10% are bicyclists.
  • Don’t drive under the influence of alcohol or any drug that affects your ability to focus behind the wheel. Car crashes are the leading cause of teen death and about 25% involve an underage drinking driver.

Follow the law and parental expectations

It goes without saying that teens must follow the law when driving. They must respect the rules of the road for their own safety and the safety of others.

In addition to the laws, household rules about passengers, nighttime driving and cell phone use can be individualized to your teen’s abilities and weaknesses. Even if a teen can legally drive alone, if he or she hasn’t demonstrated the ability to do it safely, parents should not allow it. More supervised hours can make a difference in their experience and if they in general do not show the ability to make safe choices, they should not have the ability to drive a vehicle unsupervised.