Lead by Example

We’ve all heard the saying: kids will do what they’re shown, not as they’re told. Lead by example.

It’s so true. Think about all the times your kids are watching you. They are learning from you.

What can you do to help them have healthy habits?
  • Eat your vegetables.
  • Get daily exercise.
  • Wear your seatbelt.
  • Stop at stop signs.
  • Don’t use your phone while driving.
  • Wear a life vest near a lake or river.
  • Maintain your composure during times of stress.
  • No phones at the dinner table.
  • Don’t tell lies- even little ones.
  • Get enough sleep.
  • Be kind to others.
  • Call home- your parents and siblings would love to hear from you.
  • Don’t permit violence in your presence.
  • Give your time and talents to others.
  • Take care of your things.
  • Limit screen time.
  • Brush your teeth at least twice a day and floss daily.
  • Wear a helmet when on a bike.
  • Don’t mow the lawn without proper shoes.
  • Make time for family.
  • Lead by example every day!

 

helmets, exercise
Exercising together safely as a family sets great lifelong habits!

Breast is best… Unless it’s not

We’ve all heard the well-intentioned slogan “Breast Is Best” in reference to supporting breastfeeding. Breastmilk is made just for our babies, so yes, it is a great source of nutrition. But it isn’t the only option and there are many reasons mothers give formula and even with exclusive breastfeeding there comes a time that infants need additional sources of nutrition.

I decided to write on this topic because I see so many mothers struggle to feed their baby and they feel like a failure if they don’t exclusively breastfeed.

And then to top it off I saw a blog that encouraged exclusive breastfeeding without any foods or supplements until one year of age.

I knew someone had to counter that thought before it becomes popular.

It shouldn’t be a badge of honor to breastfeed to the point of potential harm to the infant, and some ultra-crunchy moms are bragging about it as if it is.

Mom Guilt Has Gotta Stop

You’re not a failure if you feed your baby, regardless of what you feed your baby as long as it’s age appropriate.

Your baby needs nutrition and hydration.

While most babies under 6 months of age can get all their nutrition from breastmilk, some need a boost, especially at the beginning of life.

If you’re not producing enough milk, you’ll need to give your baby some formula as well (or use a milk donor). Usually this is temporary – just until your own milk supply increases or until your baby starts enough solid foods that the supplement isn’t needed.

I’m not suggesting that every newborn who struggles at the breast should be supplemented, but if your doctor says the baby’s blood sugar is low or the baby is losing too much weight, it’s not only okay, but it’s necessary to supplement.

Benefits of Breast Milk

Most of us have heard by now the many benefits of breastfeeding for the baby, including:

  • Immune system benefits. (Which means fewer infections, meaning not only helping babies stay healthy, but also leading to fewer lost work days for working parents and fewer sleepless nights for all parents.)
  • Decreased risk of Sudden Infant Death Syndrome.
  • Decreased risk of asthma in a child who has breastfed.
  • Decreased risk of diabetes when the baby grows up.
  • Decreased risk of obesity as the baby grows up.
  • Decreased risk of certain cancers in the child, such as leukemia.
  • Improved cognitive development of the child.

Benefits for mothers include:

 

  • Less bleeding, both in the immediate postpartum period from contracting the uterus after birth, and fewer menstrual cycles during breastfeeding.
  • Decreased risk of getting pregnant while breastfeeding – though this is not 100% effective! If you’re not wanting to get pregnant don’t rely on breastfeeding alone.
  • Easier return to pre-pregnancy weight.
  • Decreased risk of ovarian and breast cancers.
  • Decreased risk of Type II diabetes.
  • Decreased risk of postpartum depression.
  • Decreased risk of heart disease.
  • Less missed work (see immune system benefits above).
  • Cost – breastmilk is free and formula is expensive. Breast pumps should be covered by insurance.

When Breast Milk Isn’t Enough, Isn’t Desired, or Isn’t Safe

Feeding your baby is most important, not what you feed your baby.

Despite the benefits, breastfeeding not always possible or desired.

In the US, 8 out of 10 mothers start breastfeeding during the newborn period.

Only half are still nursing at 6 months, and less than a third are still nursing at 12 months.

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months, followed by continued breastfeeding for 1 year or longer, as mutually desired by mother and child.

Some AAP sources indicate starting foods at 4-6 months.

The American Academy of Allergy, Asthma & Immunology (AAAAI) recommends introducing foods between 4 and 6 months to prevent certain allergies.


There are very few contraindications to breastfeeding:

Classic galactosemia

Classic galactosemia is a rare genetic condition in which a baby is unable to metabolize galactose.

It is one of the conditions we screen on the newborn screen.

Galactose is the sugar made from the lactose in milk. When galactose is not metabolized, it will reach high levels in the blood and become toxic, causing cataracts in the eyes, damage to the liver and kidneys, and brain damage.

The galactosemic baby will fail to thrive on breast milk or formula based on cow’s milk. The treatment for this condition is to remove all sources of lactose from the baby’s diet and give soy formula.

HIV

Mothers who have HIV and are able to feed formula made with safe water should not breastfeed according to current guidelines.

However, there is growing evidence that HIV positive mothers who take proper medications can safely breastfeed.

Untreated active tuberculosis

Treatment makes a difference, so if you’ve potentially been exposed to tuberculosis, talk to your physician and get tested.

Chemotherapy or radiation treatment

There are times that you need to take care of you.

If you require chemotherapy or radiation, do these to improve the chances your baby will have you as a mother. If that means he needs to have formula, that’s okay.

Certain drugs

Most medications are compatible with breastfeeding.

You can look on Lactmed to learn if a particular medicine is safe or what other options are recommended.

Some mothers do not want to breastfeed for various reasons.

That’s okay. It isn’t for everyone.

No one should say things that make these mothers feel guilty. They brought new life into the world. That alone is an amazing feat. As long as the baby is fed age-appropriate and formula that has been approved for use in infants, it is great.

Babies can thrive on formula.

Just be careful of the many alternate formulas and milks that are advertised online.

Discuss with your child’s pediatrician if you plan on making your own formula or giving another alternative milk. There are many concerns with these, as discussed in Please Don’t Feed Your Baby Homemade Formula!

Some mothers really want to exclusively breastfeed but they have problems.

Working with a lactation consultant and physicians (both mother’s and baby’s doctors) might help if there is a correctable condition, such as

  • insufficient breastfeeding attempts per 24 hours – not feeding frequently decreases supply
  • tongue tie treatment can improve latch and milk transfer from the breast into baby
  • jaundice, which makes baby sleepy and not feed as effectively
  • identifying and treating hormonal problems in mother
  • identifying and stopping medicines or herbs that might be inhibiting milk supply
  • stopping nipple shields as soon as possible – the use of nipple shields can decrease breast stimulation and lower supply
  • avoid unnecessary supplements – supplementing with formula can decrease supply overall because the mother’s breast makes milk based on how much is used (This does not mean you should avoid formula if it is medically necessary.)

Even when breastfeeding goes well for both Mother and Baby, it is not sufficient to be the sole source of nutrition for the entire first year of life.

There are some mom blogs that support exclusive breastfeeding for the first year of life, and that is not safe.

I’m not linking any of them here because I don’t want to promote them, but if you don’t believe me just do a quick search and you will find some.

Nutritional needs

While breast milk is fantastic for young infants, it does not have the nutritional components to exclusively feed for the second half of the first year.

Iron

Babies need a source of iron after about 4-6 months of age.

If they are not eating foods rich in iron (meats, legumes, egg yolk, leafy greens) they will need an iron supplement.

Many of the bloggers who support exclusive breastfeeding do not want any supplements at all. Just breast milk. It simply isn’t enough to support the older infant’s growing brain and body.

Vitamin D

Vitamin D is important for us all, but it is not passed through breast milk well unless a mother is taking at least 6400 IU/day.

Historically we could make vitamin D with the help of the sun, but we now know that sun damages our skin so it is safer to protect against excessive sun exposure. This puts us at risk for vitamin D deficiency.

The AAP recommends that newborns begin supplementing with 400 IU/day of vitamin D soon after birth, and increase to 600 IU/day at 6 months of age.

The supplement should continue even if they transition to Vitamin D fortified cow’s milk at 1 year of age.

Motor skills

Feeding with food from fingers or a spoon also encourages healthy development of fine motor skills.

It is important for older infants to learn to eat from a developmental standpoint.
Once they can sit fairly well, turn away from food or open their mouth in response to food, they are showing signs that they are ready to start eating.
They don’t need teeth to move foods around in their mouth and make chewing motions.

They are much less averse to new things typically when they’re younger, so if babies are delayed past a year they are much more likely to be picky eaters and not get the nutrition they need during childhood.

Allergies

Then there’s the research that shows that delaying certain foods past a year increases the risk of allergy. If you’ve ever seen a child with anaphylaxis to peanuts, you won’t want to increase this risk for your child! See the AAP’s guidance on introduction of high-risk allergenic foods.

 

Any problems feeding should be discussed with your child’s doctor

If your baby struggles with feeding, whether it’s breastfeeding, formula feeding, or eating foods, please discuss it with your child’s doctor.
There are many reasons feeding might not go well, and we need to insure that your baby is being adequately fed.
We will look at your baby’s overall growth and development in addition to discussing the specific details of the problems.

Resources

Related Blogs on Quest for Health

Over and Under Supply of Breast Milk

Breastfeeding: Easier for Working Moms with New Insurance Rules

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Car Seats for Safety

It’s been years since I’ve written about car seat safety and since September 17-23, 2017, is Child Passenger Safety Week I thought I’d take a moment to review car seat safety basics and share some of my favorite car seat safety links.

Most parents are now aware that all infants must be in a rear facing car seat, but many turn their toddlers around too early or let older kids move to the next level too soon.

I tell kids all the time that the state law is the bare minimum, but it isn’t necessarily the safest way to ride. I use the example that in my state an adult can ride a motorcycle without a helmet, but that’s not safe. They usually agree, and I think it helps them understand that just because it’s legal to do something, it doesn’t make it safe to do.

Kids learn from the behaviors they see their parents display, so all parents should buckle up for safety!

Which car seat is best?

When looking for a car seat or booster seat, don’t assume spending more money will buy a better seat.

You need to be sure it fits your vehicle and your child.

Whatever seat you buy, be sure to register it so you are notified of any recalls.

Infants and children under 2 years or 30 pounds

Infants and children under 2 years should ride rear facing unless they are bigger than the height or weight maximum for the seat.

Children over 2 years who still fit in the height and weight requirements of the rear facing car seat can still ride rear facing safely.

Another safety factor for infants and young children: don’t leave them in the car!

Young children often fall asleep in the car.

If sleep deprived (no parent is ever really well rested) and in a hurry, even the best parent can be distracted and forget about the sleeping baby.

There are many tips to follow to be sure you don’t leave your baby unattended in the car.

Children 2 years and older

Kids over 2 years (and those larger than the rear facing car seat maximum height or weight) should use a forward facing car seat with a 5 point harness.

They should continue the harness until they are mature enough and big enough. This means they must be capable of staying seated during the duration of the drive. Of course they must meet the minimum height and weight requirements for a booster seat.

Learn to use the tether properly with your forward facing car seat.

There are limits to using the LATCH system. LATCH stands for “Lower Anchors and Tethers for Children.” It was developed to help parents more easily install seats in cars and eliminate seatbelt incompatibilities. What you may not know is that the LATCH anchors are currently designed for a maximum combined weight of the child and child seat of 65 lbs.  Once the child + seat exceeds this weight, the seat must be installed using the vehicle seat belt, not LATCH. Depending on the weight of the child seat, your child may weigh quite a bit less than 65 lbs and need to stop using the LATCH.

Moving to a booster

Children should remain in a booster seat until the vehicle’s lap and shoulder seat belt fits them properly.

This is generally between 10 and 12 years of age and about 4 foot 9 inches, but varies based on the size of the vehicle’s seat.

Everyone should always use the vehicle’s seat belt (or car seat harness) when riding.

Have your kids take the 5 Step Test to see if kids can safely ride without a booster.

Sitting up front

Only teens and adults should sit in the front seat. It’s always safer in the back seat.

If you look at the sticker on the passenger side visor, it will say something to the effect that children 12 and under are safer in the back seat. That means wait until 13 years of age to sit up front.

Airbags can be dangerous if a passenger is too short for it to hit properly in the chest. The force of the airbag can cause significant injury to the face or neck. If the airbag is turned off, the passenger is at risk of hitting the dashboard or being ejected from the car.

Even big kids don’t have the muscle or bone strength to be safe up front. They aren’t mini-adults.

Winter safety

In the winter months it’s important to avoid over bundling infants and children in car seats.

The added layers and padding of clothing can increase the amount a child can move in the force of a crash or sudden stop. The Car Seat Lady has great tips to keep kids warm and safe in the cold weather.

Car seat additions and accessories

Don’t use car seat attachments and accessories that were not sold with the seat. They may look cute or seem to make your child more comfortable, but if they haven’t been tested with the seat they may not be safe.

This includes neck rolls, shoulder pads, winter covers that go between the child and the seat, dangling toys, and more.

If you’re in an accident and have these additions they might void the warranty of the seat.

What if kids try to escape the car seat?

Do you have a Houdini? If your toddler or preschooler is able to weasel out of the car seat harness, try this button down shirt trick.

How can you be sure your kids are buckled correctly?

Take your kids to a certified car seat installer to see if they’re buckled in properly. Car Seats for the Littles has information about how to find an installer near you.

Register your car seats so you can be alerted if they are recalled.

Identification Stickers

Car Seat Stickers are a great way to notify first responders who to call if you’ve been in an accident and aren’t able to communicate.

I recommend putting them under the cloth part of infant seats so they aren’t visible when you’re carrying the seat in public. You can put a small sticker on the handle to let emergency personnel know to look under the padding for emergency contact information.

Once kids are out of the infant seat you can put the sticker on the outside of the seat, just not over any important information. Never cover the height/weight max information or other things you’ll want to see later.

My office gives stickers from the W.H.A.L.E. Program to patients, but you can print your own at home and attach them to your seat with wide clear tape. Information to include would be:

  • Child’s name, birth date, address, allergies, important health history, medications
  • Parent’s names and phone numbers (cell and work)
  • One emergency contact name and phone number (not a parent)
  • Doctor’s name and number
  • Childcare provider name and number if applicable

After an accident

Remember that if you’re in an accident, your car seats might need to be replaced. Talk to your insurance company.

Used car seats

Used and borrowed seats cautions

  • Be sure to know when your seats expire. The seats typically expire about 6 years after manufacturing. This is due to unseen breakdown in the materials used to make the seat.
  • Never buy a used seat from someone you do not know. A friend should verify that it hasn’t been in an accident and it’s not expired before you use it.
  • Don’t just throw your old car seat away. Someone might try to use it past its expiration date. You can break it down into pieces to make it unusable or you can see if you can recycle it.

Just for fun…

The model in the top photo is my daughter at a car seat check many years ago. She now is (hopefully) a safe driver herself.

The original car seat safety blog was on by old blogspot site. 
Talk to teens about safe driving.
Teen Safe Driving Tips will be covered in another blog… coming June 2018!

 

 

 

 

 

 

 

 

Teen safe driving tips will be covered in a June 2018 blog. Watch for it if you have new drivers!

For more information:

 

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Vaccines Don’t Have to Hurt As Much As Some Fear

Many kids are scared of shots. Some even fight parents and nurses when it’s time to get shots. The more they fight and worry, the worse it gets. But it doesn’t have to be that way.

Increasing the fear

In general there are some things that increase anxiety about shots or just make them seem bad.

Lying

Do not tell kids it won’t hurt. Shots can hurt. Lying doesn’t help. It just minimizes their fear and makes things worse. It might hurt, but how much is variable. Pain is a very individualized feeling. You can describe it as a pinch. Some kids do better with advance warning.

No promises

Never tell kids they won’t get a shot at the doctor’s office. They might be due for one (or more) and if they were specifically told they won’t get one, they are usually more upset.

Threats

Don’t threaten kids with shots if they misbehave. This makes kids see shots as a negative.

Siblings

Siblings can increase anxiety with their teasing. Don’t share the need for shots with siblings and if it’s possible to leave siblings at home when one child will need shots, that might work best.

Your fears

Some kids worry more because parents are worried or presume the child will be worried. When the parent starts talking about shots in a worrisome manner it feeds into the fear. Try to be factual. Don’t start telling them it’s okay and not to worry. That tells them there’s something to worry about.

Building anticipation

Some kids do best if they don’t know shots are coming. If they ask if they’ll get shots at an upcoming visit, you can say you don’t know. If you think your child will lose sleep for days worrying about the shots, this is often the best way to handle it. Then the doctor and nurse at the office can deliver the news and it isn’t your fault.

How to prepare

If you want to prepare your kids before bringing them in for shots or if you just need some help when you’re at the office, follow these tips:

Risks and Benefits

I often ask kids if they’ve ever gotten hurt playing outside. They usually say yes. Then I ask if they still wanted to play outside again. They usually say yes. I might sound surprised that even though they know that they can get hurt, they still want to play, but then I “realize” that it was because the benefit (playing) outweighs the risk (getting hurt). Then we talk about the benefits of the shot are so much more than the quick poke and a little pinch feeling. This works really well for the middle school shots because they’re old enough to get the connection.

Medicine?

Don’t pre-treat with an oral pain reliever. Studies have shown that acetaminophen and ibuprofen decrease the immune response, which might make the vaccines less effective.

Crying’s okay

Don’t tell kids to not cry. It’s okay to be scared and to feel pain. Let them know what is and is not okay. If they cry it’s okay. It is not okay to kick, hit, run, or do anything that can harm others or themselves.

Education

Educate kids about how vaccines help us. There are many resources available. When they understand why the shots are good for them, it helps them to accept them.

Practice

Practice what happens when we get shots.

Have them practice sitting still and making their arms loose.

Wipe the arm with a tissue as you explain the person giving the shot will clean the area with a very cold wet tissue to clean the area. (I avoid the term alcohol swab because the term alcohol confuses younger kids who learn about drug prevention in school.)

Pinch the arm to show them there will be a small pinching feeling.

Put a bandaid on the area if they like or just explain that they can get a bandaid when it’s over. (If your child hates bandaids, tell the person giving shots that they prefer to not have them.)

Let them practice giving you a “shot” too.

Show that the poke will be fast and they can move their arms up and down afterwards to make the sting go away.

Lovies

Bring a comfort item from home, such as a stuffed animal or blankie.

Blowing

There is evidence that blowing out or coughing during the injection helps decrease the pain. We often recommend this for kids old enough to blow or cough.

Sometimes we’ll entice preschoolers with bubbles or pinwheels. It really helps!

Distraction

Other forms of distraction can help too. Telling stories, reading books, or watching a video on a smart phone or tablet are great distractions.

Sit vs Lay Down

Studies have shown that allowing kids to sit (rather than force laying down) during shots is perceived as less painful. The less restraining the child needs, the better. It makes sense that if they need to be held down they will be more scared and it will be perceived as more painful.

I have seen tweens and teens prefer to lay down if they have a history of getting light headed with needles or they’re worried about fainting.

Order of vaccines

Ask the person giving the vaccines to save the most painful vaccine for last, if applicable. (Our nurses do this routinely.)

Pain DISTRACTOR devices

Our office sometimes uses Buzzy when kids are especially afraid of shot pain. As long as the child isn’t overly worked up and they aren’t opposed to the coldness of the ice, Buzzy works fantastically! If kids have worked themselves into a frenzy it isn’t sufficient to distract in this way.

Bribery

I used to think bribery was not a good parenting technique… until I had kids. It can be very effective. If you can promise a reward for being brave, such as stopping for a smoothie or getting a favorite treat, that can work wonders.

Just do it

I like this Dr. Mom’s take on getting shots. Dr. Corriel knows that her son will just need to do it. Fear and all.

Help with anxieties in general

(great for life worries, not just shots!)

Build up bravery

After kids do things that they were afraid of, congratulate them for the attempt. Remind them that even though they were scared they did it. This helps set the pattern that they can be brave when faced with any fear.

Kids can even keep a list of things that they did despite being scared to try. Make a “Bravery Book.”

They can use the list whenever a new fear pops up to see how many things they’ve already done and how brave they really are.

video to future self

I’ve started recommending that parents take a video of kids to show their future self if they can say it didn’t hurt as much as they worried it would.

We all tend to remember the anxious phase of excessive worry, but forget that it wasn’t that bad.

Show the video the next time shots are due. Their own self stating it wasn’t bad can be reassuring!

Meditation

Use a meditation app, such as Stop, Breathe & Think. It’s free and helps with general anxieties as well as mindfulness. Download it and use it at home several times to let them get comfortable using it.

Some great articles:

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HPV Vaccine Concerns

The large majority of the parents who bring their children to my office want their children to be vaccinated against any disease we can protect them against. The HPV vaccine is one exception. While most of my patients are given the Gardasil at their 11 or 12 year check up, some parents still “want to do their research” or “have heard things” so they decline to protect their kids at those visits. Sadly they often return year after year and say that they still haven’t done their research, so their child remains unprotected. Sometimes they’ll say that they will let their child decide at 18 years of age. Sadly, by that age many will have already been infected.

I recently had a parent share HPV Vaccine: Panacea or Pandora’s Box? The Costs and Deceptiveness of the New Technology with me. She had concerns based on the information in this article. The first thing I noted was that it is from 2011. This is outdated, since we have learned so much in the six years since it was published, yet like many anti-vax articles, it continues to circulate online.

 The first argument is that it won’t last long enough.

It is therefore possible that the protective effects of the vaccination will wane at the time when women are most susceptible to the oncogenic effects of the virus (those over 30), providing protection to those who do not need it (adolescents) and failing to provide protection to those who do (women over 30).

Studies show protection lasts 10 years and hasn’t dropped by that time. If future studies show a booster is needed, we can add that. That in no way should mean to not give protection for the years it is really needed – adolescence and young adult life. I cannot agree with the statement that providing protection “to those who do not need it (adolescents)” at all. Yes teens need protection. I’ll get more into their risks below. And the fact that women over 30 are more likely to develop the cancer does not mean that is when they come into contact with the virus. It’s kind of like saying that kids don’t need to brush their teeth because they don’t have cavities. If you wait for the cavities to develop, it’s too late!

The second argument is based on old version of the vaccine.

We now use the 9 valent variety, which covers the large majority of cancer causing strains. Again, even if there are other strains, why not protect against what we have?

Natural immunity lasting longer than vaccine immunity?

The argument that natural immunity will last longer than the vaccine immunity is not a valid argument. Natural immunity can wane with some diseases too, and if we can protect against the disease, it is preferable. Boosters for many vaccines are needed when we know immunity wanes. That’s okay. Some parents advocate to not vaccinate and get the real disease. When their kids get whooping cough they’re miserable. Many are hospitalized. Some even die. I’d rather do boosters! (This may be a bad example because I don’t think our booster for whooping cough lasts long enough and there are complications with giving boosters more often, but ongoing surveillance and research will continue and hopefully improve the situation.)

The cost issue is interesting.

If it was not cost effective in the long run, insurance companies wouldn’t pay for it. It’s that simple. They’ve done the math. Australia is a great example. Their cancer rates are down because HPV is a mandatory vaccine.

Debunking Risks

The risks listed have all been shown to not be as risky as once shown.

Abstinence as prevention?

The article also alludes to this being a sexually transmitted disease so we can just teach abstinence until marriage.

There are so many things wrong with this.

First, this virus can spread through non-intercourse activities, which can be part of a normal and healthy teen relationship.

Second, even if your child is a virgin at marriage, their spouse might not be. Or the spouse could die and they remarry.

Or there could be infidelity in marriage.

There may not be signs of this virus during an infection. Testing for HPV is recommended for women over 30 years of age, but is not available for men at any age, so teens and young adults will not know if they have the virus or not.

And we know that abstinence only teaching fails. Some people raised in strict Christian households have sex outside of marriage.

Teaching kids to protect themselves is much more effective to prevent many sexually transmitted infections, but condoms don’t always protect against HPV transmission.

And there’s always rape. One out of four women has been sexually assaulted. One in four! What a horrible thing to be raped. Then to find out you get cancer from that…

What about males?

They argue it hasn’t been tested in males.

It has.

And it cuts cancer rates in men too. They’re not just vectors as stated in the article.

We keep learning

This article is several years old.

It didn’t yet know that the cancer rates in Australia would fall like we now know.

We’ve learned much more information than they knew in 2011 when it was written.

We know the HPV vaccine is safe.

It is best given before the teen years to induce the best immune response and to get kids protected before the risk of catching the virus becomes more likely.

It isn’t a lifestyle choice to get this virus, as it seems the author claims. People have sex. This virus and other infections can spread through sex. But this virus is also spread without intercourse (such as through oral sex or skin to skin contact without sex), which is why 80% of the adult population has had the virus at some point.

If you don’t think the risk is real

Someone You Love is a documentary that follows several women with HPV related cancer. If you still think the vaccine isn’t worth it for your child, watch it. I am not paid in any way to recommend this. It simply is a powerful documentary that shows the devastation of HPV disease and you should see that before saying your child doesn’t need protection.

Do I recommend the vaccine?

I strongly feel this is a safe and effective vaccine. So much so that my own teens received three doses of the original Gardasil and one dose of Gardasil 9 despite no official recommendations for this booster. I want to protect them in any way that I can.

If I had any concerns about its safety I would not have given it to my own children.

I don’t think I can list any study or give any argument stronger than that.

Many people raise concerns about the HPV vaccine, but the studies show it's safe and effective to prevent cancer in both men and women.

Tamiflu status downgraded!

Those of you who follow my blog or are my patients know that I’ve never been a fan of Tamiflu. I’ve written To Tamiflu or Not To Tamiflu and I’ve posted Tamiflu from guest blogger, Dr. Mark Helm. Despite the CDC’s recommendation to use Tamiflu frequently, I rarely prescribe it. And when I do, I often find that the whole course isn’t completed because the kids don’t tolerate it well – usually vomiting, but occasionally they’ve had scary hallucinations. I haven’t seen very much benefit, especially given the cost (and often the difficulty of finding it during peak flu season).

WHO Downgrades Tamiflu

The World Health Organization (WHO) has recently downgraded the status of Tamiflu. The CDC and FDA will have to chime in for the US recommendations, but the WHO is a respected source of medical guidelines and I look forward to a response from the CDC.

Risks vs benefits

As I’ve said before, Tamiflu doesn’t seem to work as well as needed and it has significant side effects. Not all studies done on Tamiflu were published. Only studies showing a little benefit and minimal side effects were considered in making the recommendations to use it. If many studies show no benefit but aren’t published, it makes it seem better than it is. Most studies are done in adults, but studies in children for prevention of flu and treatment of flu also fail to show much benefit.

2013 review of all the studies done in adults found only a 20.7 hour reduction in symptoms (yes, less than one day). In the elderly and those with chronic diseases (among the highest risk adults) no reduction was found. They also found no evidence of decreasing the risks of pneumonia, hospital admission, or complications requiring an antibiotic. This same review also showed more side effects than commonly reported. Nausea, vomiting, and psychiatric side effects are common.

Will the CDC join in?

I hope that the CDC reviews its recommendations for antiviral use before the influenza season hits this year. Until then, plan on getting your family protected with the flu vaccine. It isn’t perfect, but it does help keep us from getting sick and it can help save lives!

 

tamiflu
Tamiflu is an antiviral used against influenza, but there are many questions of safety and efficacy.

It’s Back to School Time, Time to Think Safety!

Walking to school is wonderful for kids because they get exercise, which can help with focus at school and their overall health. It can be also be a time to talk with friends or family and build community bonds. As kids are heading back to school after the summer break, we must think about their safety.

Walking to school can pose dangers, especially if drivers are distracted talking to their own children or texting. Please stop texting and driving. Don’t touch your phone at all while driving. Calls and texts can wait. If they can’t, pull over and check the message while parked.

Really.

Talk to your kids about safety:

walking to school with others

Kids should walk with an adult until they show the maturity to walk safely without direct supervision. The specific age will depend on the area as well as the child’s maturity.

Are there safe sidewalks? Are there busy roads to cross? Are there other kids walking the same route? Are there homes along the way they can go to in case of emergency? How long is the walk?

When kids have mastered the route and are competent to walk the distance alone, find walking partners. Have kids stay in groups or with a walking buddy as much as possible.

See if your school can help arrange walking buses, where kids all walk the same route to school with adult walk leaders.

Find the safest route

Choose sidewalks wherever possible, even if that means the trip will be longer. If there are no sidewalks, walk as far from vehicles as possible, on the side of the street facing traffic.

If possible, avoid areas near high schools, where there are more teen drivers.

Cross streets safely

If there are crossing guards, use those intersections. If there are street lights, wait until the “walk” symbol appears.

Never cross in the middle of a block, use intersections.

Look both ways twice before crossing.

Do not text or play games when in the street.

Remind kids that if they are crossing a street, they should make eye contact with a stopped driver before crossing, even if there’s a “walk” symbol. Drivers turning right might turn on red and not notice small pedestrians.

Know the route

Teach kids to use the same route every day or discuss which route they will take each day if they use different routes.

If they don’t arrive to school or home as planned, you know the route to search.

Walk the routes with them until they know how to safely navigate each.

Avoid distractions

Listening to music (especially with earbuds), playing video games, watching videos, and texting all keep kids from paying attention to their surroundings.

Even talking on the phone is distracting, so don’t assume they are safer if they talk to you all the way home when you’re at work. They are more likely to trip and fall, step into a street without looking first, or not notice that they’re being followed if they’re distracted.

They should be aware of their surroundings at all times.

Getting a ride rules

Remind kids to never accept a ride from anyone unless you pre-plan it. Rain, snow, and cold weather make it tempting to hop in a car, so have kids dress appropriately for the weather and arrange safe rides as needed.

Contact information

Have kids keep important contact information in their backpacks in case of emergency. At least two people should be on this list. People on the list could include a parent, grandparent, or trusted adult friend/neighbor. Names and phone numbers should be included.

Going on wheels

If they are riding a bike, scooter, or skateboard to school, they should follow the rules of the road and proper safety.

Suggestions for adults:

Be alert

Be extra cautious when driving in the before and after school times, especially near schools and in neighborhoods.

Make your sidewalk walkable

Be nice and don’t use your sprinklers in the before and after school times so kids can stay on the sidewalks and not wander into the street to avoid getting wet.

In the winter, clear snow and ice as needed.

Never text and drive

Put your phone on silent and in a place you can’t reach it while driving.

Texts can wait.

Buckle up for safety!

If kids are in your car, make sure they are properly buckled.

Only teens and adults should be in the front seat.

Use an appropriate car seat or booster seat.

Kids shouldn’t wear their backpack in the car, nor should they unbuckle while in a drop off line to get their backpack on before the car is stopped.

Carpools

If your kids will carpool with other families, be sure they are in proper seats at all times.

It’s tempting to not use boosters for short drives, but it’s never safe to have kids improperly restrained. Find boosters that are easy to move between cars.

 

Talk to kids about safety when walking to school.

Dry Drowning – What Parents Need to Know

I thought about calling this one “We’re drowning in dry drowning phone calls” because we are getting many worried calls about dry drowning, but that’s overly dramatic and I hate headlines that make things seem like the sky is falling…

I had never heard of dry drowning until social media picked it up a couple of summers ago. Maybe I did as a resident, but since I’ve never seen it, I’d forgotten the term. Either way, it isn’t very common at all, but it is an emergency when it happens, so it’s good that we all know that it can happen. People also use the term secondary drowning and some experts differentiate the two by whether or not water actually gets into the lungs, causing swelling of the lung tissue, or if water irritates the vocal cords, causing them to spasm and close off. Either situation is potentially life threatening and they have similar symptoms. Note: Please see the addendum at the bottom. Several articles have emerged since the original writing of this post that clearly indicate there is no such thing as dry drowning.

One of the reasons I think so many parents are worried is that it is common for kids to go under water: in the tub and in the pool. Many get water in their mouth or complain that it went up their nose. Few actually get any into their lungs, which is where it can cause problems. How can you know when you need to worry?

Most of us recall a time we coughed briefly after inhaling liquid, and we were fine. So when is it worrisome? It’s when the water that gets into the lungs causes inflammation within the next day or two. This inflammation makes it hard for the lungs to work – the air tubes are swollen, so air can’t get through. Treatment is giving oxygen, sometimes with a ventilator (breathing tube and machine) until the inflammation goes down.

Symptoms you need to recognize and act upon by taking your child to an ER:
  • Cough: If your child has coughing for a minute or more after being in water, he’s at risk. This indicates that the child is trying to clear the airways. If water got down there and they cough most up, some can remain behind and lead to inflammation over time. Watching your child carefully for the next 3-4 days is important. This can be hard to recognize initially, so a complete evaluation is important if any other symptoms develop.
  • Difficulty breathing: Anyone who is struggling to breathe needs further evaluation. Signs can be rapid breathing, sucking in the ribs or the stomach, difficulty talking, or even a look of fear from difficult breathing.
  • Near drowning: If your child had to be pulled out of the water, he should be evaluated in an ER. Even if he seems fine afterwards. The reaction is delayed, so they can seem to be 100% better and then go downhill.
  • Behavior changes or confusion: If a child is confused, lethargic** or has a change in ability to recognize people, he should go to the ER. Serious illnesses can present with a change in mental status, including significant infections, concussion, heat exhaustion, brain tumors, and drowning. The ER doctor will ask what else has been going on to help identify the cause of confusion.  **Many people misuse the term lethargic. Lethargic isn’t the same thing as being tired after a long day. The medical definition is “Relatively mild impairment of consciousness resulting in reduced alertness and awareness; this condition has many causes but is ultimately due to generalized brain dysfunction.”
  • Vomiting: Vomiting after a day at the pool can be due to infection (from swallowing contaminated pool water), food poisoning (from food left in the heat too long) or dry drowning. It’s best to check it out in the ER.
What will happen in the ER?

Many parents don’t want to go to the ER because of high co-pays. We try to keep kids out of the ER as much as possible. But some issues are better taken care of in an ER. Most offices don’t have the equipment or staff to manage these issues well. Dry drowning can be life threatening, and the evaluation and treatment should start in the ER. I cannot say exactly what the doctor will do, since that will depend on your child’s symptoms and exam. There is no specific treatment for this, only supporting your child’s airway and breathing as the swelling goes down.

  • If the doctor thinks your child may have swelling of the airways, he might order a chest x-ray to look for pulmonary edema (lung tissue swelling).
  • An iv might be started to be able to give adequate fluids, since your child might not be up to drinking well.
  • Oxygen levels will be monitored and extra oxygen might be given.
  • Since the swelling worsens before it gets better, if there is a strong suspicion of dry drowning your child will be admitted for further observation.
  • Some kids need help breathing and are put on a ventilator (breathing machine) until the swelling goes down.
Prevention is important!
swimming
Watch your kids when around water!

As with many things, we should do all we can to be sure our kids are safe around water. This includes the bathtub and toilet as well as swimming pools, lakes, and ponds.

  • Childproof your home when you have little ones who might play in a pet water bowl or the toilet.
  • Teach your kids water safety. Swimming lessons can help them learn skills. Tell them to never try to dunk each other. They shouldn’t pretend they’re drowning because it might distract a lifeguard from a true emergency.
  • Learn infant and child CPR.
  • If you have a pool or pond at home, be sure there is a fence limiting access from your house.
  • Watch your kids closely and keep them within reach when they’re in water until they are strong swimmers. When they are strong swimmers you can let them swim outside your reach as long as lifeguards are present.
  • Learn what distress in the water looks like. The movie depiction of drowning with a lot of yelling and thrashing around is not what usually happens. If someone can verbalize that they’re okay, they probably are. Drowning victims can’t ask for help. There is a video linked to this page of what to look for with drowning that shows an actual rescue.
From this site, signs of drowning:
  • Head low in the water, mouth at water level
  • Head tilted back with mouth open
  • Eyes glassy and empty, unable to focus
  • 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
  • Trying to roll over on the back

Addendum:

    • I just read a post that gives references regarding drowning definitions. It appears I didn’t forget learning about dry drowning in medical school.

It isn’t really a thing.

The symptoms listed above that I recommend getting evaluated are still concerning symptoms, but they might be from another cause.

Check these out:

On “Dry Drowning”

Drowning in a Sea of Misinformation: Dry Drowning and Secondary Drowning

 

New Juice Guidelines!

Juice that comes from fruit is not the same thing as eating fruit. It’s missing the fiber and even the feeling of fullness that comes from eating foods rather than drinking. Too many kids drink excessive juice, which fills them with empty calories and can contribute to obesity and tooth decay. The American Academy of Pediatrics has updated their juice guidelines to help families limit juice intake to more appropriate amounts.

How much juice should kids have?

  • Juice is not recommended at all under 1 year of age in the new guidelines.
  • Toddlers from 1-3 years can have up to 4 ounces of 100% juice a day.
  • Children ages 4-6 years can have 4-6 ounces (half to three-quarters of a cup).
  • Children ages 7-18 years can have up to 8 ounces (1 cup) of 100% fruit juice as part of the recommended 2 to 2 ½ cups of fruit servings per day.

General tips and tricks:

100% juice

Offer only 100% juice if you’re giving juice at all. Fruit flavored drinks are not the same thing as juice.

Water

Water is always healthy!

If your kids want it flavored, cut up fruit and put it in the water.

There are many recipes online to get ideas, but kids don’t need anything fancy – just put cut up pieces of their favorite fruit with water in a glass container. Put the container in the refrigerator for 2-4 hours and then pour the infused water into their cup without the fruit (which could pose a choking risk). The infused water will stay fresh in the refrigerator for up to 2 days.

Water bottles

Some kids like to start the day with a frozen water bottle. Simply put a 1/2 to 3/4 full water bottle in the freezer overnight – don’t fill it too much because ice expands! Add a bit of water in the morning to help it start melting so it’s drinkable when they want a sip. Adjust the amount of water to freeze as needed depending on how insulated your water bottle is.

water it down

If your kids demand more than the recommended amount of juice for their age per day, water it down. By mixing water (or sparkling water for a bit of zip) with juice, you decrease the amount of sugar in every serving. You can give 1/2 the recommended daily maximum amount of juice with water twice and still stay within the daily limit.

Never let kids drink juice out of a bottle

Kids tend to drink more volume when it’s in a bottle. Infants who take bottles are too young for juice anyway. As they get into the toddler years, transition onto cups.

Bedtime!

Never put kids to bed with juice. They should brush teeth before bed and be allowed only water until morning.

Pasteurization

Offer only pasteurized juice. Unpasteurized juice can cause severe illness.

Real fruit

Give kids real fruits and/or vegetables with every meal and snack.

Make smoothies!

Putting fruits and vegetables in a blender to make a smoothie is a great way to give the full fruit or vegetable instead of juice.

Consider adding plain yogurt**, chia, flax, oats, nuts, and other healthy additions to increase the nutritional components of the smoothie! **Flavored yogurts often have added sugars. Look for just milk and cultures in your yogurt.

Juice box: not recommended!

Most juice boxes have more than a day’s supply of juice. Don’t use juice boxes. Offer juice in cups so you can limit to the age appropriate amount.

What about organic?

Organic juice is not healthier than other juice. Many parents presume it has less sugar or more nutrients, but it doesn’t.

Vegetable juice

Vegetable juices may have less sugar and fewer calories than in the fruit juice, but are often mixed with fruit juices so you must read ingredients. They also lack the fiber of the actual vegetable, so eating the vegetable (or pureeing veggies into a smoothie) is healthier.

Read labels

Beware of labels that look like juice but aren’t 100% juice.

The label might say “juice cocktail,” “juice-flavored beverage” or “juice drink.”

Most of these have only small amounts of real juice. Their main ingredients are usually water, small amounts of juice, and some type of sweetener, such as high-fructose corn syrup.

Nutritionally, these drinks are similar to most soft drinks: rich in sugar and calories, but low in nutrients. Avoid them.

Sports drinks?

Sports drinks are not healthy substitutes for water.

They are sugar-sweetened beverages that contain sodium and other electrolytes. Unless one is doing high intensity exercise for over an hour (such as running a marathon, not playing in a baseball tournament), water and a regular healthy diet provide all the calories and electrolytes we need.

water (again)

Water’s the best drink for our bodies.

Buy fun reusable water bottles and challenge your kids to empty them throughout the day.

The old rule of “8 cups a day” is outdated, but we should get enough water (from the water content in foods + drinks) to keep our urine pale.

We need more water when it’s hot, when we exercise, when we’re sick and when the air’s really dry.

Once we feel thirsty we’re already mildly dehydrated, so drink water to prevent dehydration.

juice guidelines
The AAP’s 2017 Juice Guidelines

 

Itchy, sneezy, puffy… what can you do about allergies?

It’s allergy season! Prevention and treatment is important if you have seasonal allergies so you can enjoy the great outdoors. This is an update to a previous blog I wrote on the subject, since there are many more medicines now available over the counter.

Symptoms of Allergies: 

allergies

Allergies are more than just sneezing.

They can impair sleep (leading to all the problems associated with not enough sleep) and can lead to the annoying symptoms of itching, coughing, sneezing, runny nose, and watery eyes.

Some kids get a crease across their nose from wiping.

Others get purple circles under their eyes called allergic shiners.

These symptoms last longer than the typical cold, which usually resolves after 1-3 weeks. Fever is a sign of infection, not allergies. Other than fever, it is very difficult sometimes to decide if it is a virus or allergies until a seasonal pattern really develops. Even then it is possible to get colds during allergy season some years!

Treatments: 

It is best to treat before the symptoms get bad. It is easy to monitor pollen counts online to know what’s out there and start treatment before symptoms make you (or your child) miserable. Treatments include medicines and limiting exposure.

Medications:

I don’t want kids with outdoor allergies to be afraid to go outside, so taking medicines to keep the symptoms at bay while out can help.

Antihistamines

Antihistamines work to block histamine in the body. Histamine causes the symptoms of allergies, so an antihistamine can help stop the symptoms. Some people respond well to one antihistamine but not others.

In general I prefer the 24 hour antihistamines simply because it is impossible to cover the full day with a medicine that only lasts 4-6 hours. Different antihistamines work better for some than others. Personally loratadine does nothing for me, fexofenadine is okay, but cetirizine is best. I have seen many patients with opposite benefits.

You will have to do a trial period of a medicine to see which works best. If they make your child sleepy, giving at bedtime instead of the morning might help.

Prescription antihistamines are available, but usually an over the counter type works just as well and is less expensive. Insurance companies rarely cover the cost of antihistamines these days.

Antihistamine and decongestant combinations

Antihistamine and decongestant combinations are available but are not usually recommended by me. Once control of the mucus is achieved, a decongestant isn’t needed.

If you need a decongestant initially, you can use one with your usual antihistamine. Most decongestants on the market are ineffective. If you ask the pharmacist for pseudoephedrine, it is available behind the counter. It was replaced by phenylephrine years ago due to concerns of methamphetamine production, but works a little better than phenylephrine.

Decongestants do NOT fix a cold, they only dry up some of the mucus. Decongestants can cause dizziness, heart flutters, dry mouth, and sleep problems, so use them sparingly and only in children over 4 years of age.

Nasal Spray steroid and antihistamine

Nasal spray steroids and antihistamines are available over the counter or as a prescription. An office visit to discuss the value of these for your child and proper use is recommended.

Nasal steroids are often the preferred treatment based on effectiveness and tolerability.

Eye drops

Eye drops can help alleviate eye symptoms. They are available both as over the counter allergy drops and prescription allergy eye drops. If over the counter drops fail, make an appointment to discuss if a prescription might help better.

Most insurance companies don’t cover prescription allergy eye drops well, so you might want to check your formulary before asking for a prescription. This is usually available on your insurance website after you log in.

Tips to administer eye drops include washing hands before using eye drops, put the drop on the corner of the closed eye (nose side) and then have the child open his eyes to allow the drop to enter the eye.

Montelukast

Montelukast (commonly known as Singulair) works to stop histamine from being released into the body. It helps control both allergies and asthma and is best taken in the evening. Once a person has been on montelukast for a couple of weeks, they usually don’t need an antihistamine any longer. It is available only by prescription, so make an appointment to discuss this if your child might benefit.

Steroids

Steroids decrease allergic inflammation well. These can include both oral steroids for severe reactions (such as poison ivy on the face or an asthma attack) and inhaled corticosteroids for the nose (or lungs in asthma). These require a prescription, so a visit to your provider is recommended to discuss proper use.

Limiting Exposure:  

The longer your airway is exposed to the allergen (pollen, grass, mold, etc) the more inflammation you will have.

Wash off pollen

Wash hair, eyelashes, and nose after exposures — especially before sleep. They all trap allergens and increase the time your body reacts to them.

I have found the information and videos on Nasopure.com very helpful to teach kids as young as 2 years to wash their noses.

keep pollen out of the house

Remove clothing and shoes that have pollen on them when entering the house to keep pollen off the couch, beds, and carpet.

Wash towels and sheets weekly in hot water.

Vacuum and dust weekly. Consider cleaning home vents. Consider hard flooring in bedrooms instead of carpeting.

Wash stuffed animals and other toys regularly and discourage allergic children from sleeping with them.

There are many types of air filters that have varying benefits and costs. For information on air filters see this pdf from the Environmental Protection Agency: Aircleaners.

Keep the windows closed. Sorry to those who love the “fresh air” in the house. For those who suffer from allergies, this is just too much exposure!

Think about pets

Keep pets out of bedrooms. If you know a family member is allergic to an animal, don’t get a new pet of this type! If you already have a loved pet someone in the home is allergic to, consider allergy shots against this type of animal.

Contact lens wearers

If itchy eyes are a problem for contact lens wearers, a break from the contacts may help. Talk with your eye doctor if eye symptoms cause problems with your contacts.

Smoke is an added irritant

Keep smoke away. Smoke is an airway irritant and can exacerbate allergy symptoms. Remember that the smoke dust remaining on hair, clothing, upholstery, and other surfaces can cause problems too, so kids can be affected even if you don’t smoke near them.

What if all of the above isn’t helping?

Maybe it’s really not allergies.

Allergies to things other than foods are rare before 2 years of age.

Viruses can cause very similar symptoms to allergies.

Allergy testing is possible by blood or skin prick testing, but can be costly. In most cases I don’t find it very helpful for environmental allergens because you can’t avoid them entirely and you can always limit exposures as above. I think that tracking seasonal patterns over a few years can identify many of the allergens. You can still treat as needed during this time. Reports of pollen and mold counts are found on Pollen.com. Note also animal exposures and household conditions. Write symptoms and exposures weekly (or daily). It often doesn’t take long to see patterns. Testing is important if allergy shots are being considered.

Need help tracking allergy symptoms?

There’s an app for that! Here’s one review I found of allergy apps. I don’t have any personal experience of any, so please put your favorite in the comments below to help others!

Wrong medicine or wrong dose.

Some people have more severe allergies and need more than one treatment. Allergies tend to worsen as kids get older. Switching types of medication or adding another type of medicine might help. If you need help deciding which medicine(s) are best for your child, an office visit for an exam and discussion of symptoms is advised.

Some kids outgrow a dose and simply need a higher dose of medicine as they grow.

Is Nothing working?

Consider allergy shots (immunotherapy) to desensitize against allergens if symptoms persist despite your best efforts as above. Schedule an appointment with your pediatrician to discuss if this is an option for your allergy sufferer.