Dr. Lyons has been practicing with WRFP since 1995. Between 2005 and 2007 he wrote articles for a local publication on pertinent health issues affecting the family.
- Acne: Every Teenagers’Worst Nightmare
- Bug Repellents for Kids
- Canker Sores
- Chapped Skin
- Child Obesity
- Cold Sores
- Diaper Rash
- Ear Infections
- Express Feelings
- Fluoride Supplementation
- Hay Fever
- Heat Rash
- How Loud is Too Loud
- Instant Messaging
- Let’s Talk
- Language Development
- Lessons from the Cow Barn
- Lice: A Real Head Scratcher (External link)
- Lice: Cute, but She’s Scratching Her Head
- Limiting TV and Computer Time
- Tick Bites/Lyme Disease
- Ouch! Splinters!
- Pink Eye
- Pneumococcal Vaccine
- Poison Ivy
- Restless Leg Syndrome
- School Colds
- Seasonal & Novel H1N1 Flu
- Skeletal Planning
- Sleep Needs
- Some Time Alone
- Sun Protection
- Swimmer’s Ear
- Teenage Knee Pain
- The Common Cold in Kids
- The Flu Shot
- The HPV Vaccine
- Thinking ahead: Peanut Allergies on the Rise
- Vaccination Boosters
- Water Safety
- West Nile Virus
- Women, Girls and Knee Injury
What causes acne?Hormones called “androgens” surge during puberty in both girls and boys. Androgens tell glands in the skin to produce more oil. At the same time, the cells that line the oil ducts swell and may clog the ducts. It’s the clogged oil duct that appears as a whitehead on the skin surface. When the cells lining the oil duct dry out, you get blackheads. Then, if bacterial germs get trapped in the plugged ducts they multiply quickly, causing red swollen pimples that really hurt. I still remember them – not to mention my older sister teasing me about them. Common misconceptions about acne:
- Acne is caused by particular foods, such as chocolate or potato chips.
- Dirt causes acne.
- Sexual thoughts cause acne.
- Acne is contagious.
- Abrasive facial cleansers;
- Some cosmetics;
- Menstrual periods;
- Things that rub on the skin, like athletic pads or a headband;
- Emotional stress;
- Squeezing the pimples (I can remember my older sister doing that, too).
What is asthma?Asthma is a disease of the airways of the lung. In people with asthma the airways have a tendency to become easily irritated and inflamed. The inflammation causes the airways to constrict and spasm, which the child experiences as coughing, wheezing, or in more severe cases, shortness of breath.
Who gets asthma?Asthma is a very common breathing problem. In fact, probably 5% of the children in our community have it. No one can predict who will have asthma, but children are more apt to get it if someone else in the family has it.
What causes asthma?Doctors still don’t know. We do know there are common factors that may trigger an episode in a susceptible person. Here are some examples of allergens or airway irritants that may trigger an asthma attack:
- Seasonal allergens like pollen
- Animal dander
- Dust mites and molds
- Cold viruses
- Cold air
- Dry air
- Noxious fumes like paint
- Cigarette smoke
- Household cleaners
- Heavy exercise
- Air pollutants
- Weather changes
- Sensitivity to drugs, certain foods, or food preservatives.
Is asthma serious?Yes and no. In some cases asthma can be life threatening if an attack isn’t taken care of right away. However, for many children asthma is never serious unless ignored, and with one or two preventative steps may rarely even bother them. Although your son’s asthma does not sound serious, your goal, as with all asthma patients, is to find a treatment strategy for eliminating his symptoms.
What about asthma medications?The most commonly prescribed asthma medications are inhalers. These come in two main types: “preventative” inhalers, which are taken daily to prevent airway inflammation and thus asthma attacks; and “rescue” inhalers, which relieve the airway spasm once an asthma attack starts. The treatment depends on the severity of the asthma. Some children with mild asthma might use their rescue inhaler once or twice a month. Other asthmatics need to use their rescue inhaler several times a week, despite being on a preventative inhaler. The treatment should be tailored to the child. I have one patient, an 11-year-old soccer player, who has asthma that is brought on by exercise. Usually exercise-induced asthma can be managed with a rescue inhaler. However, despite using her rescue inhaler appropriately, she was frequently coughing during and after her soccer games. Like many kids, she didn’t like the idea of using an inhaler every day. I eventually persuaded her to try a preventative inhaler, and now she uses it once a day, never needs her rescue inhaler, and breathes better during her soccer games.
Are there alternative treatments?Physicians and other health care providers try various approaches to treat asthma. A good place to start is to figure out what brings on your child’s asthma and how to avoid those triggers. Here are a few ideas to consider:
- Schedule a visit to an allergy specialist.
- Learn to control dust mites at home.
- Find a new home for the family pet.
- Don’t allow smoking in the house.
- Trade in the wood stove.
- Get an annual flu shot.
- Visit with a dietary expert to determine if certain food groups or food additives make the asthma flare up.
Does asthma ever go away?Asthma is a chronic condition. Sometimes children with mild cases of asthma seem to outgrow it as adolescents, only to have it reappear later in life. The important thing to remember is that most people who care for themselves and their asthma live normal lives, including professional athletes. No parent likes to be told that a child has asthma. Children don’t like to hear it either. But by accepting that your child has asthma, educating yourself about the disease, doing the detective work to discover what triggers the asthma, and helping your child adhere to a treatment plan, you’ll minimize doctor visits and medication use, and just make your child feel better. I hope that helps. I wish your son a cough-free winter. (First published in the Upper Valley Parent’s Paper in November 2001)
Nocturnal EnuresisThe medical term for bedwetting is “nocturnal enuresis.” It’s a very common condition. It occurs in 60 percent of three-year-old children, 40 percent of four-year-olds, 20 percent of five-year-olds, 10 percent of six-year-olds, and all the way through to 1 or 2 percent of 16-year-olds.
CauseWe do not know exactly what causes enuresis. We do know, however, that enuresis tends to run in families. If a seven-year-old child is wetting at night, most likely one of his parents or an aunt or uncle did, too. At some point he or she grew out of it, and so will your daughter. One thing for sure is that it’s not your child’s fault. Kids want to be dry at night, too, but their body is not physiologically ready.
Medical TheoriesThere are several theories as to why kids have enuresis, though none has yet been consistently supported by the research. One theory is that it occurs among deep sleepers. Many parents describe their youngsters with nocturnal enuresis as heavy sleepers. This seems like it would make sense, but when kids with enuresis have sleep studies done, the sleep patterns we know how to test for don’t look consistently different in the bed-wetters. Another theory concerns hormone levels. Our bodies make a hormone called ADH (antidiuretic hormone) that controls urine production. Studies have shown that some children who wet their bed produce less ADH. Many adults can probably empathize with the child who has low ADH, since alcohol blocks the secretion of ADH – which explains the extra urge to pee after an adult beverage. Other theories have to do with bladder size and maturity. Some kids with enuresis have small bladders. A lot of researchers believe that the nerves on the bladder have not matured enough to send a strong message back to the child’s brain saying, “Wake up! Your bladder is full!”
Treatment strategyThere are options for treating nocturnal enuresis. As you decide whether to treat your child, you need to balance several important points:
- The treatment should never be a negative experience for the child. This usually means they have to be old enough to be motivated to participate in the treatment plan.
- Children don’t like to wet the bed. Punishments or teasing will only make matters worse.
- For most kids it subsides with time.
- At some point bedwetting can lead to social isolation or low self-esteem. I think we’d all agree that treatment ideally starts before that point.
- Stress may contribute to enuresis. It might be anything from a new baby in the house to a divorce to adjusting to a new school. Treatment won’t likely be successful until the child has had a chance to adapt to that stress.
- Most treatments require a time commitment from the parents. The treatment often involves changes in routine, self-awakening exercises, a bed-wetting alarm, and sometimes a nightly medication.
When to see the doctor:
- If bed-wetting occurs after several months of dry nights. (A quarter of children who are initially dry at night will develop bed-wetting, but a simple urine test can rule out most medical concerns.)
- If your child has any trouble urinating during the day.
- If your child drinks excessively.
- If you’re concerned about a urinary tract infection.
- If your child also has bad constipation.
- And finally, if you and your child think it is time to look into a treatment plan.
Why use asthma medication?Asthmatics live with a level of chronic inflammation in their lungs, so that even mild triggers can induce bronchospasm. In non-asthmatic lungs like your daughter’s, the viral germs can create enough inflammation to cause a bronchospastic, or asthma-like, cough. The inhalers contain medication that stabilizes the airways and prevents bronchospasm and cough. I agree the inhalers can seem cumbersome, but the advantage is that they deliver the medicine to where you need it – directly to the lungs. That means less chance of side effects.
Why not use antibiotics?Bronchitis is usually caused by viral germs, and antibiotics won’t kill viruses. It is true that people with bronchitis can have a secondary bacterial infection. Signs of a secondary infection include worsening symptoms after a week, such as increasing phlegm, fatigue and recurrent fever. It is sometimes hard to be sure that your child’s bronchitis isn’t bacterial, and that’s where a visit to the doctor can help. If the doctor prescribes an inhaler, you can be reassured that that is the right medicine. Studies show that when doctors diagnose viral bronchitis, patients on inhalers improve much faster than with an antibiotic. (First published in the Upper Valley Parent’s Paper in March 2001)
- Off! Skintastic for Kids
- Just for Kids
- Repel Soft – Scented
- Skeedaddle Insect Protection for Kids
- Permethrin Tick Repellent
- Outdoorsman Gear Guard
- Repel Permanone
What are canker sores?Canker sores are painful, crater-like ulcers that form in the mouth, the inner lip or on the tongue. They usually last 7-14 days. The medical name for canker sores is “apthous ulcers.” The sores occur only inside the mouth, and should not be confused with cold sores, or fever blisters, which are caused by a common herpes virus and recur on the outer lips and face. At least 20% of Americans have experienced the pain of canker sores, and the most common time to get them is during the teenage years.
What causes them?No one knows what causes canker sores. When canker sores are accompanied by diarrhea, belly pain, joint pain or rashes, then there is a small chance that the sores are a sign of a more serious illness. That’s a reason to check in with the doctor right away. But the overwhelming majority of canker sores are no more than just plain annoying. There are theories that the sores are caused by vitamin deficiencies, food sensitivities, viruses, menstruation, toothpaste, life stress, or minor cuts to the skin inside the mouth (like from braces). The only thing we really know is that they occur less often in people who are well rested, exercise, and eat a balanced diet – I’ll bet you’ve heard that before! The most likely patient is an adolescent with braces who has been staying up too late.
TreatmentThere are a range of treatments that help alleviate the pain, but nothing that cures canker sores or consistently shortens their life span. Home treatments include avoiding spicy, acidic or salty foods, gargling (Peridex or PeriGard oral solutions are worth a try), or applying an oral paste like Orabase or applying mouth salves like Cankaid. We doctors are always happy to see you in the office to review the symptoms, and we can offer a variety of things to provide relief. I polled my partners and learned that we most commonly prescribe Kenelog in Orabase, a prescription-strength anti-inflammatory (steroid) cream mixed in Orabase so help it adhere to the sores. Different topical agents or prescription mouthwashes might be favored by other doctors. If the number of ulcers is limited to one or two, doctors might apply a chemical abrasive called silver nitrate directly on the sore.
PreventionThe only sound advice for prevention I can give is to eat well, sleep well, exercise regularly, and be happy. I appreciate that this is a lofty goal for even the most together parent, much less an adolescent child. Various vitamins and supplements have been tried to prevent canker sores, but nothing that works well enough and consistently enough to pass muster in a clinical study. However, that doesn’t mean that there isn’t something out there to decrease the frequency of canker sore outbreaks in your son. For example, it won’t hurt to try lysine, an amino acid, or zinc supplements, eat live-culture yogurt everyday, and use a soft-bristle toothbrush. If your son is not a good fruit and vegetable eater you should convince him to become one. But in the meantime it seems logical to try a daily multivitamin and B complex vitamin. When my medical training doesn’t lead me to good answers to prevent common problems like recurring canker sores, I’m always curious what the alternative medicine providers have to say. When I was writing this article my closest naturopathic medicine colleague was away on a long vacation. So, I consulted four different textbooks for advice on herbs and dietary supplements. Unfortunately, there wasn’t a common thread of advice. If you want more input you might choose to schedule an appointment with a dietician or naturopathic doctor. After all my advice, “Go to bed early” might be the best words of wisdom for your teenage son. Good luck! And I hope this school year is canker sore free! (First published in the Upper Valley Parent’s Paper in September 2006)
- America leads the world in obesity, with 62% of the nation’s population seriously overweight, compared to 40% a decade ago.
- 13% of children are obese, and the rate is steadily rising.
- A quarter of obese children and adolescents already show signs of diabetes and heart disease.
- American parents are working more and they and their children are eating fewer meals at home.
- Restaurant meal portions have increased as much as 40% over the past 15 years. Did you know that a “kid’s meal” at McDonald’s has as many calories as the standard adult meal (burger, soda, and fries) had in the 1950′s?
- Since 1985 12 medical studies have linked TV watching to childhood obesity.
- During 4 hours of Saturday morning cartoons there are more than 200 ads for junk food.
- Look into what your child’s nursery school or daycare serves for snacks.
- Bring alternatives to food – flowers, pens, balls – to reward or celebrate an event with your child’s class.
- Require more P.E. in school or at home.
- Develop government-funded programs to provide fresh fruits and vegetables to school kids (and we could help local farmers while we’re at it).
- Question whether a school milk program makes sense. Could we make it skim milk?
- Eliminate the sale of junk food in schools. Texas and California have already started; other states should make it a priority.
- Put time limits on sedentary pursuits such as television, video games, and computer use.
- Begin a public health campaign that educates children and their parents about healthy choices in eating.
- Fund the campaign by taxing the fast food industry. Have the likes of Taco Bell and Frito Lay pay for it.
- Consider class-action lawsuits. Some of the same lawyers who went after Joe Camel and the tobacco industry are setting their sights on Twinkies and Burger King.
Not due to colds at all, but they’ll give anybody a chilly feeling come picture-taking timeQ: Your article last month gave me an education on “canker sores.” Now I know my oldest daughter suffers from “cold sores” as opposed to canker sores. She clearly gets the blisters on the outside of her mouth, for all to see. So, I want to know: what can you tell me about treating my daughter’s awful cold sores? A: You are right! Cold sores come out on the face whereas the canker sores are inside the mouth. Sometimes called fever blisters, cold sores are usually on the outer edge of the lip, and they are as likely to come at an inopportune time, like right before school pictures, but no one knows exactly what brings them on. People who get them say they feel a prickly or light tickling sensation on their lip within the day before the spots appear on the skin. The sores are not necessarily accompanied by a “cold,” but they are most definitely sore. And, although there is no “fever” when they recur, the sores frequently blister for a day or two before drying up and going away, usually after 7 – 12 days. Cold sores are very common, and from the standpoint of physical health, they aren’t serious. But they are annoying to the children and adults who get them.
CauseUnlike canker sores, we do know what causes cold sores: they are caused by herpes simplex viruses. Herpes simplex is one of the most common viral infections in the world. Estimates suggest that 50 – 80% of Americans have been infected. People catch herpes by kissing a person with a cold sore, or by sharing a drinking glass or utensils. Believe it or not, most children who have herpes picked up the virus from a parent, grandparent, or another loved one who unintentionally transmitted the virus while giving the child a kiss. Some infected people get cold sore outbreaks once a month while others get outbreaks once every 5 years, or never at all. Once herpes invades the body, the viruses stay dormant in a nerve ending until something – illness, stress, sunburn, menses, or an unknown factor (maybe bad luck) – causes the virus to awaken and replicate. We really don’t know why the viruses take permanent shelter in the nerve cells in some people or why they frequently replicate and become an aggravating cold sore in others.
PreventionPrimary prevention is obvious – avoid kissing or sharing drinks, washcloths, or eating utensils with someone who has or gets cold sores. Obvious yes, but not always easy or practical. When patients ask me about prevention it is usually because they already have the herpes simplex virus, but want to “prevent” getting multiple recurrences. Over the years I’ve heard many patients report benefit from topical treatments or daily oral supplements that help. The two that come up most are Lysine supplements and a Vitamin B-complex. I can’t promise they will help, but it won’t hurt to try.
TreatmentTreatment is tailored to each individual. Some patients aren’t bothered that much, do nothing, and wait for the cold sores to go away. Others find that ice, or an over-the-counter ointment such as Campho-Phenique, Herpecin-L, Blistex, or Abreva cream, offer adequate relief. For those adolescents like your daughter who experience more severe symptoms, I recommend a visit to the doctor’s office. Although there is no cure for cold sores, antiviral medications like Zovirax, Famvir and Valtex, when taken early, can substantially shorten the course and severity of the cold sore outbreak. I hope that helps and that she’s happy with her high school picture. (First published in the Upper Valley Parent’s Paper in October 2006)
CryingAll babies cry. In fact, years ago a pediatrician studied babies to see what amount of crying was normal. He came up with 1.75 hours a day of crying for a two-week-old and 2.75 hours a day for a six-week-old baby. Why do they cry? Crying is the baby’s one means of communication. It’s how she tells us she’s hungry, wet or lonely. We need to accept that babies cry and try to meet their needs and comfort them when we can. Colicky babies, on the other hand, do more than cry. They aren’t just fussy, they’re frantic. I think most parents of a colicky baby would rate the crying as more of a screaming marathon than a crying spell.
ColicIt’s hard to define colic, but it’s easy to recognize when parents describe it. A few months ago, I met the parents of a six-week-old boy who had been crying almost every day at suppertime. Despite reporting a normal, happy baby during the day, they described him pulling his legs up and twisting while he screamed for a couple of hours each evening. Then one day, almost miraculously, the crying stopped. The mother said her son was 12 weeks and four days old. That baby boy had textbook colic. What Causes Colic? When colicky babies tense their tummies and cry like they hurt, grandmothers and parents alike usually suspect they are gassy. I think “gas” is a good guess. I often wonder if these unhappy babies aren’t having trouble adjusting to being nourished through their mouths and guts instead of through their umbilical cord. But to be truthful, no one knows what causes colic. What are the remedies? If there were an answer for colic, you’d already know about it. Still, there are several things you can try. My first recommendation is for parents to take care of themselves, and this especially goes for mom. Listening to a screaming baby is exhausting. And I suspect there is something about being a mother that makes caring for a colicky baby especially daunting: you’re the one who carried the child, with an innate instinct to nurture and protect. Parents need a break. So call in the troops – grandparents, other relatives or friends to spot you during the crying hours. Get out of the house or at least out of ear shot. Go for a walk, go out to dinner, take a nap, do whatever will make it a restful and enjoyable time. Keep in mind that the crying will stop again, and your baby will be fine. You may need to reassure yourself periodically that your baby is not hurt or sick. Check that the diaper isn’t wet or chaffing, look at the skin for a rash or a hair wrapped tightly around a finger, make sure he doesn’t have a fever. If you haven’t done so already, talk with a doctor. Your doctor can help you be certain there isn’t some other medical reason for the crying. With breast-fed babies, most moms can’t help but analyze what they have been eating and guess at what might contribute to the fussiness. The usual suspects are caffeine, chocolate, broccoli, cabbage and other cruciferous vegetables. Occasionally, mothers report a change in diet that clearly helps. In my experience, though, it is difficult for mothers to figure out which foods bother the baby. Often, before the mother really knows what might irritate her baby, the baby has matured and seems able to handle everything mom is eating. In the case of bottle-fed infants, parents desperate to find a solution usually try several different formula brands, but studies indicate that changing the formula doesn’t help the colic. Frequently, I recommend massage. This is mostly for the baby, but it also helps the mother. One of my colleagues recommends starting baby massage when the baby is two or three weeks old, whether he seems fussy or not. She believes the massage may prevent colic. Although it is hard to study the effects of massage on colic, it certainly can’t hurt. If nothing else, it is something to do that might relieve the baby’s discomfort. As stressful as it seems to parents of a newborn when their baby cries, we can take comfort in knowing that crying is something babies do – we’re not bad parents just because they cry. If your baby has colic, my heart goes out to you; it’s challenging enough simply starting parenthood. The good news is that colicky babies, like all babies, continue to grow. Their inconsolable crying stops, they mature into normal infants and toddlers, and most parents eventually forget the crying as new issues arise to remind us that raising children is never free of challenges. (First published in the Upper Valley Parent’s Paper in December 2001)
- Leave the diaper off whenever possible. Put the baby on an old towel. That may not seem like practical advice, especially if your baby is mobile and it’s cold outside (like November in the Upper Valley), but believe it or not, societies that don’t use diapers don’t have diaper rash.
- Use a hairdryer. Turn it on while you change the diaper, and it will ensure that the baby’s skin is totally dry, at least until she pees again. It also serves as a distraction to babies who don’t like cool air on their bottoms, or simply don’t like getting their diaper changed.
- Try poking holes in the waterproof outer cover of disposable diapers so they breathe better. This will remind you to change them more too.
- Don’t cover a cloth diaper with a plastic diaper wrap, because the wrap will hold in moisture.
- Prevention starts with breastfeeding. Studies show breastfed babies get fewer ear infections.
- If your baby is bottle fed, don’t allow him to fall asleep with a bottle, and wean the baby from the bottle at 12 months.
- Avoid exposing children to cigarette smoke.
- Teach your kids to blow their noses gently.
- And most important, wash their hands frequently.
WHAT IS A FEVERSimply, a fever is an elevation in body temperature. Part of the body’s natural immune response is a fever. When our bodies are insulted, usually by an infection like a sore throat or the flu, the immune system responds. The fever is not an illness in itself; it actually helps the body get rid of the infection by making it a less favorable place for bacteria or viruses to grow. Normal body temperature is often defined as 98.6°F. In truth, body temperatures can vary, so a true elevated temperature or fever is usually defined as a body temperature above 100.4°F.
FACTS ABOUT FEVER• A fever itself won’t hurt a child. In fact, it may help them get better.
• The height of the fever usually doesn’t indicate severity of the illness. For example, a child with scarlet fever may have a temperature of 101; but the child with a bad cold may have a temperature of 103. The child with the cold will get better with time and TLC. The child with scarlet fever will benefit from antibiotics. Rather than the height of the fever, it’s how sick the child acts that counts.
• An estimated 80% to 90% of all fevers in young children are related to common viral infections; the kind of infections that get better without treatment.
• Fevers of less than 105°F are not harmful and they don’t cause brain damage.
• A small percentage of toddlers get seizures from fever. The first seizure needs immediate medical evaluation. The seizures are frightening to witness, but don’t cause residual problems. Subsequent fevers, even low-grade ones, will need to be treated early.
• Mild elevations of up to100.4 can be caused by exercise, excessive clothing or hot weather.
• Teething won’t cause a true fever.
WHEN YOU SUSPECT A FEVEREven if the degree of a fever doesn’t equate with seriousness of an illness, the presence or absence of a fever can tell us a lot. If you are worried enough to call the doctor’s offce, then it’s time to know your child’s temperature rather than just feeling his or her forehead. Have a thermometer in a designated place in your house, especially if your kids are little. For infants under three months, use a rectal thermometer, for older infants and toddlers, the axillary (under the arm) thermometer is best. As soon as your child is old enough to hold an oral thermometer in her mouth for the required time, you can expect an accurate reading from that method. Ear thermometers are easy, but still are not consistently reliable.
ASSESSING THE CHILDOnce you know your child has a fever, you can stop focusing on the temperature itself. Focus instead on the child’s behavior. Your child’s doctor or nurse won’t be as concerned with the exact reading of the temperature as other symptoms, such as diarrhea, a runny nose or headache. An important indicator is how your child is acting, such as his level of alertness and appetite. The further the child gets from a semblance of themselves, the more likely they need a medical evaluation.
TREATMENT OF FEVERWhether or not to treat a fever always comes down to judgment. If you have four children, you’ve accumulated a lot of experience. Trust your judgment. If the child is acting unusually sick, then an evaluation by the health care provider is warranted. Here are other suggestions:
• If your child has a fever under101, but is overall acting pretty well, there is no reason to treat the fever.
• If the fever is making your child feel miserable, giving medication to reduce the fever can help him be more comfortable. Being comfortable at night seems especially important. Fever-reducing medicine might help your child sleep so her body can fight back. A well-rested body is more likely to heal faster.
• Another reason to treat the fever is to help get a sense of how sick the child is. If your parental sense reaches the worry point, treat the fever with an appropriate dose of medication and recheck the fever in 30 to 60 minutes. A child that acts close to normal once the fever has come down is not likely to have a serious underlying illness. The common fever-reducing medicines are acetaminophen (Tylenol), and ibuprofen (Motrin, Advil). We recommend beginning with acetaminophen. If you find the ibuprofen works better, that’s okay. When the fever won’t come down to a level that allows your child to sleep comfortably on the appropriate dose of one medicine, then it’s reasonable to use a dose of both medications at bedtime. Do not use aspirin to treat a fever.
WHEN TO CALL THE DOCTORThe bottom line is that it is good to call when your informed judgment tells you to call. Have a safe and happy winter!
Guidelines from Contemporary Pediatrics for bringing your child to a doctor’s office for evaluation:
1) An infant under 3 months of age has a fever over 100.4 degrees.
2) The child is lethargic or irritable or has a fever that has lasted more than three days.
3) The child consistently complains of sore throat or ear pain.
4) The child has abdominal pain or pain when urinating.
5) The child is not drinking fluids, or is producing a decreased amount of urine.
6) The parent is worried about the child’s breathing, level of activity, intake or loss of fluids, or whether the child really has a fever.
How much fluoride is in the water?The first step is to check the fluoride content of your own water supply. If you are on town water, you can call your town’s water department. In the densely populated areas of the Upper Valley, most municipal water supplies contain fluoride. Hanover, Lebanon, West Lebanon, and Norwich all have fluorinated water. An exception is the town of Hartford. If your home is supplied by a well, then ideally the water should be tested. In Vermont, the State will test your well water for a cost of $12.00. You can schedule fluoride testing by calling (800) 660-9997. I’m not aware of a similar fluoride testing program in New Hampshire, but there are commercial labs which can serve this purpose. The ground water of the Upper Valley does not typically contain fluoride, but there have been isolated reports of wells that tested high.
How much fluoride is right for your child?Drinking water that has a fluoride level of approximately 0.6ppm (part per million) satisfies recommendations for all age groups with the idea that as kids get bigger and drink more, they automatically get the additional fluoride that they need. You can see that there’s flexibility here: experts know that some kids drink a lot more than other kids their same age, so don’t worry about going a little over on intake: it’s not an exact amount. If fluoride doesn’t come from the water source, you should supplement the equivalent amount. Currently, the recommendation is to begin supplementing at age 6 months to protect forming teeth. If your child’s daycare or school has fluorinated water, I recommend you skip the fluoride tablets on the days they attend. The recommended amount of fluoride supplement takes into account that toddlers usually swallow some of the fluoride toothpaste. As long as a child has a normal pea-sized amount of toothpaste, you don’t need to worry about the fluoride that might be swallowed while brushing. If your well water tests for some fluoride but not quite enough you can alert your doctor to adjust the supplement amount. The chart below outlines the standard recommendations for fluoride supplements.
|Schedule for Fluoride Supplementation.|
|Child’s Age||Fluoride content of drinking water (in parts per million [ppm])|
|<0.3 ppm||0.3-0.6 ppm||>0.6 ppm|
|birth to six months||0 mg||0 mg||0 mg|
|six months – 3 years||0.25 mg||0 mg||0 mg|
|3 – 6 years||0.50 mg||0.25 mg||0 mg|
|6 – 16 years||1.00 mg||0.50 mg||0 mg|
|Source: American Academy of Pediatrics, Committee on Nutrition. Fluoride supplementation for children: interim policy recommendations. Pediatrics 1995; 95: 777.|
How much fluoride is too much?Any medication or supplement has the potential for side effects, and the chance of side effects usually depends on the dosage. The one well-known side effect from fluoride is mottling or pitting of the teeth. Fortunately, it is extremely rare at the recommended fluoride doses, and you can see that there’s some flexibility in there. Stick to the fluoride doses in the chart above which are approved by the American Academy of Pediatrics and American Academy of Pediatric Dentistry, and I believe your child will be well below the dose range where there any other health concerns.
What else can be done to prevent tooth decay in the infant and toddler years?Begin brushing teeth with a soft brush, gauze, or cloth as soon as the first tooth comes out. By age 1 you can use a pea sized amount of toothpaste on a soft brush once a day. For children two years and older, I recommend brushing twice a day. Besides brushing it’s important to wean off the bottle at around twelve months of age. Also, during that first year, avoid allowing the baby to fall asleep with the bottle. Too much juice or other sugary foods in between brushings also increases risk for tooth decay. I hope that answers your fluoride questions. Keep on smiling! (First published in the Upper Valley Parent’s Paper in May 2007)
Are allergies treated best with an antihistamine or a decongestant?The answer is an antihistamine. Antihistamines block the body’s response to allergies. Common examples of antihistamines sold without a prescription are diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton) and bromphenarimine (Dimetapp Allergy). When taken regularly (usually two to three times per day) they work well. The main limitations to these antihistamines are the side effects. Drowsiness is the most frequent complaint, but it may improve as you take it. Decongestants, on the other hand, won’t block your body’s reaction to tree pollen or grasses. The decongestants help to relieve the congestion once the allergies are already bothering you, but don’t play any role in preventing the allergy symptoms. An example of a decongestant is pseudoephedrine (Sudafed). Common decongestant side effects include racing heart or insomnia. When decongestants are used to treat allergies it is most often in combination with an antihistamine (one medicine to block the allergy and one to relieve the congestion). Dimetapp Cold and Allergy and Triaminic are examples.
When is a prescription antihistamine better than an over-the-counter one?The advantage to prescription antihistamines are less frequent dosing (usually one to two times per day), and less sedation. The downside is that they are much more expensive and may have other side effects.
Are the nasal sprays better than the antihistamines?I often recommend nasal sprays. Although some kids find them awkward to use, I like the idea of putting the medicine right where the problem is (in the nose!) which means less chance of a side effect somewhere else in the body. But it also means the symptoms beyond the nose, like the itchy eyes, might not be as well controlled. There is only one allergy nasal spray I’m familiar with that’s sold over-the-counter. It’s called cromolyn (Nasalcrom). The disadvantage to this product is the dosing regimen of three to four times a day. Several prescription sprays dosed once a day are available for older children. Again they tend to be expensive and may cause nasal irritation.
Once I decide on a medicine is it important to take the medicine everyday?Yes. In fact, the nasal sprays only work if you use them before the allergy symptoms start. I usually recommend starting the nasal spray one to two weeks prior to the typical onset of the symptoms. The antihistamines I suggest starting a few days to a week ahead. For many people, however, the onset of their spring allergy symptoms is just too unpredictable. For others the idea of taking a medicine when you don’t even feel bad yet is either reproachable or just too hard to remember. However, the truth is that once your nose is itchy and running it takes even more medicine to alleviate the symptoms than if you took it ahead of time. In other words, you’ll likely get better relief and with less medicine if you take it regularly and early in the season. Perhaps you know your child well enough to assume he would never remember to take a pill if there wasn’t a runny nose to remind him. Well, I sympathize. There is one of you in my household too. If that’s the case you’re best off taking an antihistamine and a decongestant together. Once the symptoms have started the combination of the two medicines will give the fastest relief. I hope my suggestions help you find the right medicine for your son. If not, don’t hesitate to visit your family doctor or pediatrician. (First published in the Upper Valley Parent’s Paper in May 2000)
What causes heat rash?Heat rash is caused from the body overheating. The skin can’t sweat fast enough to cool the body down. Then the ducts from overactive sweat glands become clogged, and this leads to tiny red bumps forming on the surface of the skin. The bumps can get further irritated by the baby scratching or clothing rubbing up against the skin. Sometimes, well-meaning parents carefully clothe their baby to prevent sun exposure and inadvertently promote the excessive sweating and rash formation.
What is the treatment for heat rash?Heat rash will clear up completely in two-to-three days, once the weather cools down. In the absence of a change in the weather the key to treatment is to keep the baby cool. Some ideas include removing or loosening clothing, picking the shady spots when you’re outdoors, and soothing the baby with a cool bath or cool, wet washcloths. Also, let the skin air-dry instead of using towels – drying by evaporation helps us lose heat from our body. If you sense your child is itchy and irritated you can try some over the counter calamine lotion or mild over-the-counter-strength hydrocortisone cream for one or two days. I’m glad Eliza is better and that the rash didn’t take away from your fun on the beach. (First published in the Upper Valley Parent’s Paper in August 2007)
Here are some guidelines
- Listen at volumes of 1-5 (on a typical MP3 player’s scale of 1-10), and you can probably listen as long as you like. Another way to think of it–if your child cannot hear you speaking when you are nearby, the volume is too loud.
- Listen at a volume 8, and this is what some experts recommend depending on headphone style:
- earbuds: about 1 1/4 hours
- sound-isolating headphones: about 50 minutes
- over-the-ear headphones: 4 – 5 hours
- Recent research from Children’s Hospital Boston suggests more caution at the higher volume levels. They found that listeners could suffer hearing loss if they regularly listen with earbuds above level 6 for just an hour a day.
- If you experience ringing in the ears after listening, you know you are putting yourself at risk for hearing loss.
- Keep the computer in a central room where it is easy to check the screen.
- Monitor online time, and spend time with your children when they’re logged on.
- Explain your concerns. For example, do your teenagers know that a 2001 Pew Study reported 89% of sexual solicitations of youth were made either in chat rooms or through Instant Messaging?
- Make a policy that passwords are shared with the parents. That way you can retrace internet activity, or read e-mails if deemed necessary.
- “Google” your teenager’s name. Websites like myspace.com are so popular they can understandably leave teens feeling complacent about posting personal information like photos, addresses, and phone numbers. Teens might be more cautious about what they post if they know that their parents, potential employers, and college admissions officers might look them up.
- Once you feel like your children’s maturity levels warrant more internet social time, make sure they use an alias.
- Educate yourself. Get to your child’s favorite teen website and explore.
- Some parents have said they have regular “use common sense” chats about internet safety, and establish a system of trust with their kids. Other parents have the same conversations but then sign a contract with their teenager. Contracts might disallow chat rooms, the giving of personal information, or the downloading or opening of enclosures.
- Use filtering technology in the home to limit access to the web.
- Employ software that monitors where your kids go online.
- Ask your Internet Service Provider how to set up a “buddy list” that allows your child to communicate only with parent-approved e-mail and IM addresses.
- Here are some websites for more ideas: www.protectkids.com, www.netmom.com, and kids.getnetwise.org.
Q.Many parents have questions about “normal” language development for infants and toddlers. Since my own children are young, I am also living this question right now: When should a parent seek help/evaluation about a possible delay in language development?
A.Infancy and toddler years are a very exciting time for parents. How wonderful it is to hear “mama” or “dada” for the first time. Learning a language is a big milestone in our development and affects other developmental stages, learning skills and abilities. Language development is unique and nuanced, but also follows some standard timelines and stages. For most children, development is marked by achievement of certain skills that happen at a particular age. Just as milestones on a road mark distance traveled, milestones in a child’s life mark normal development and progression. The table below lists some language milestones.
|4 months||Turn toward sounds. Smiles|
|6 months||Imitates speech sounds Does raspberries Coos and babbles when happy Smiles often|
|9 months||Babble and uses gestures Responds to name Says “dada”, “baba” Understands common words: mama, daddy. Bye-bye.|
|12 months||Understands “no” Follows simple gestured commands Uses mama/dada appropriately and uses 1 or more additional words Shakes head for yes and no. Wave bye-bye|
|18 months||Vocabulary of 10-25 words Makes animal sounds Uses lots of gestures with words to get needs met. Points to 2 –4 body parts|
|2 years||uses and understands at least 50 words uses at least two words together in a way that makes sense “want juice” 50% intelligible to strangers|
|3 years||Three to four-word sentences and >500 words. Uses pronouns and plurals Answers “what”, “where”, and “who” questions 75% intelligible to strangers|
|4 years||Talks about things that happened during the day. Tells stories that are real and imagined Knows first and second name 100% intelligible to strangers|
Suggestions for Raising Self-Reliant Children
By Angela Toms, MD“Where’s the manual?” asked one of the moms. She was referring to that much-sought- after parenting manual on raising children. We were in the 4-H dairy barn of a local fair while our children were making their cows beautiful with special shampoos, clippers, blow dryers and hair spray before they paraded them into the show ring. We laughed because, as we discovered long ago, there is no manual. That’s too bad, because raising kids is hard and we certainly could use some guidance.
As parents, we aspire to raise healthy and happy children. When we signed up for this job, a lot of the details were left out. Years ago, my husband and I wanted to adopt kittens before we had kids. It was only after we had completed reams of paperwork, filled out questionnaires and had a home visit that assessed our competency to raise cats that we were able to take the two furry felines home. That doesn’t happen when you have kids. They arrive whether you are qualified or prepared.
And just when you’ve figured out some things, they start changing.
The transition from dependence to independence can be tricky. On many occasions, I ask myself, “How did they grow up so fast? And how did we end up in a cow barn?” A quick look around the barn usually reveals kids of all ages, preparing their animals, helping one another, cleaning stalls, talking and giggling in the corner or snuggling up against a warm cow’s belly. Adults are present but, for the most part, not involved. These kids in the barn are figuring out how to be independent.
Many parents have shared their struggles of trying to get kids to take on responsibility, work hard and go beyond the minimum of what is asked of them. This path to independence is much easier when the child is following his own interests or passion. For some of my children, this landed us in the 4-H dairy and steer barns as they raised and showed their animals.
The opportunity for kids to explore their own interests can lead to a nice connection to their community. Often these connections will link kids with a good role model or mentor. Sometimes a message is received much better from a coach or club leader than from a parent. The American Academy of Pediatrics states that kids who are involved in their communities will do better in school, have an easier time staying out of trouble and have a more positive outlook on life.
I have friends who are trying an approach with their kids called “Duct Tape Parenting,” as described in the book by Vermont resident Vicki Hoefle. She recommends a “less is more approach to raising respectful, responsible and resilient kids.” The duct tape is for the parents to prevent themselves from interfering with their kids as they learn to solve their own problems. I’ve heard good reports so far. As we all know, making mistakes is a valuable learning tool.
Fostering our kids’ independence is hard to do at times because we want to protect them and help them succeed and be happy. Despite the common practice of “helicopter parenting” — “hovering” over one’s children so that nothing bad or unfortunate ever happens to them — allowing children the freedom to succeed and fail on their own is important. What they learn from failure can be equally valuable to the lesson of success.
As it happened, the 4-H show at this fair didn’t go so well for my son. But he found ways to improve with each subsequent fair and ended the season winning his show and earning a sense of accomplishment. Some points for parents to remember:
- Raising kids is hard.
- Start fostering independence early by letting children learn to solve their own problems.
- Encourage your child to follow his or her interests (art, music, sports, drama, etc.).
- Find ways your child can connect with the community.
- Helpful resources include your child’s pediatrician, school counselor or teacher, coach, club leader or spiritual leader.
- Explore local organizations like scouts, community theatre, 4-H, fire departments, and many more.
- Support your children’s passions – whatever they are – and make sure they always know you believe in them.
- Buy anti-lice shampoo. Nix, Rid Mousse and others can be purchased without a
- Scrub the hair and scalp for 15 minutes, by the clock, then rinse.
- Combs and brushes should be soaked for an hour in a solution
- containing anti-lice shampoo.
- Wash or dry-clean the child’s sheets, blankets, pillowcases and any clothes worn over the last 3 days in hot water. (Lice can’t live for more than 3 days off the human body.)
- Items that can’t be washed, like stuffed animals or headsets, should be placed in airtight plastic bags for 3 weeks (the longest period the nits can survive).
- Vacuum the child’s room to get rid of any lice dust or dead nits that were left behind.
- Family members with close contact may need simultaneous treatment even if they have no symptoms.
- If acceptable, a haircut makes treatment easier.
- The dead nits are removed by using a fine-toothed comb; it’s an arduous labor of love.
- To loosen the nits you may purchase a special hair rinse, use a tangle-free conditioner, or try the standby home remedy: soak the hair in vinegar before combing.
CombingWhen you go to the pharmacy to buy the Nix, pick up a metal (not plastic) pediculosis comb. Use the Nix shampoo right away, and repeat in five to seven days. Comb wet hair diligently with the metal comb every day for two weeks, removing all lice and nits. The combing is a big chore. I usually say it’s a labor of love – it takes a lot of parents’ time – probably and hour for a child with shoulder-length hair. To be thorough, you need to comb the hair in sections similar to the way a hairdresser separates clumps of hair for dying or highlights. Conditioning wet hair makes the job easier. Some parents prefer wetting the hair with old home remedies like vinegar or tea tree oil. A study recently published in England showed combing alone to be more effective than over-the-counter shampoos. I believe, though, that shampoos and thorough combing together will successfully treat almost all kids with head lice. You’ll also want to wash the linens – another crucial step in eliminating head lice. Hot water wash or dry-clean the child’s sheets, blankets, pillowcases, and any recently worn hats or clothes. Items that can’t be washed, such as stuffed animals or a headset should be placed in plastic bags for three weeks (the longest period a nit can survive) or, in an Upper Valley winter, you can just leave those items in the subfreezing temperature for several days. When all else fails, come to the doctor’s office. There are other shampoos available by prescription, which are much more expensive. One reason the prescription shampoos are not first-time treatment is because there have been concerns of toxicity and other side effects, such as skin, scalp, or airway irritation. These shampoos are controlled to avoid overuse, which could lead to resistance. Ovide, the most commonly prescribed medicine, raises fewer concerns about toxicity, but kids don’t like it – it’s stinky. Parents should be aware that Ovide is also flammable. I hope the discussion of head lice allays some of your concerns, and I hope it doesn’t leave you with an itchy scalp!
THE BAD EFFECTS:
- Obesity: There is a strong correlation between being overweight and spending a lot of time in front of a screen.
- Aggressive behavior: Multiple studies link television violence with aggressive behavior in small children.
- Risky behavior: Films viewed by preteens that includes smoking, alcohol, and sexual content influence their choices as teenagers.
- Lagging intellectual development: High television use correlates with poorer success in school.
- Commercials: Television commercials do influence our choices. One study counted 200 commercials for junk food during four hours of Saturday morning cartoons. Apparently, the advertisements work. Why else would a study of 4 year-olds show that that they like carrots better when they are wrapped in MacDonald’s packaging?
- Life skills: Laptops, video games, and TV viewing are passive, solo activities. This may inhibit social and personal skill development. Playing with other kids, listening to stories, reading books, and playing games and make-believe all teach us to be imaginative, entertain ourselves, and interact well with others. These aren’t often defined as “skills,” yet they are abilities that are vital to keeping us happy during a long life.
THE POSITIVE SIDE
- Entertainment: Some TV is fun. It makes us smile or excites us. As a friend of mine says, “My favorite TV shows are like mind candy.”
- Modern culture: Certain entertainment programs are so much a part of our culture that it’s arguable that children might feel left out socially if they’re unfamiliar with the television programs their schoolmates are discussing.
- Educational Value: A number of TV and computer programs are fabulous.
- Convenience: Televisions and laptops are at our fingertips. There’s no driving or admission fee.
Ah, Spring! Sunshine warms our days, grass greens up, leaves and flowers unfold… and ticks come out of their winter hibernation to start feeding. Time to start thinking about Lyme disease again. But that does NOT mean you and your children and pets cannot romp outside and enjoy the spring. Let’s go over some ways to deal with ticks and the concern about Lyme disease.
First, here’s some background about Lyme. Lyme is a bacterial illness transmitted by the deer tick, also known as the Black Legged Tick or Ixodes Scapularis.
These ticks range from the nymphs and larvae which can be the size of a poppy seed (see photo above, from the Centers for Disease Control website), to the adults which are sesame seed-sized and easier to find. Nymphs tend to be the main transmitters of Lyme to people and are more active in the spring and summer while adults are more active in the early spring and fall. Lyme disease initially starts with a rash at the bite site followed by fevers, aches, headaches and swollen lymph nodes. If left untreated it can cause more worrisome problems like arthritis and other conditions.
Over the last few years, Lyme has gradually worked its way into our area and now about 50% of deer ticks are infected with Lyme. Fortunately, the more common wood or dog ticks that we see do not carry Lyme, nor do mosquitoes (thank goodness!). In order for a deer tick to give you Lyme, it needs to bite and feed on you for more than 36 hours. As the tick gets engorged, it regurgitates some of its meal back into you, possibly along with Lyme bacteria. With this in mind, there are several ways to prevent getting Lyme disease during your outside adventures.
Preventing tick bitesPrevention is the best place to start!
- Avoid tick-infested areas if possible.
- Wear light-colored clothing, ideally long pants and shirts that cover your skin.
- Consider clothing which has Permethrin integrated into the fabric – there are several manufacturers of these clothes.
- Tuck pants into socks and spray clothing and shoes with insect repellant that contains Permethrin or 20% to 30% DEET. Consider a DEET-containing repellant on exposed skin. Read the package instructions carefully before using, particularly on young children.
- To avoid bringing ticks into the house, check over your clothes when you return and if possible shower or bathe to remove any ticks before they attach. Running your clothes through a hot dryer for an hour will likely kill any ticks present.
- If your pets go outside, treat them with a pet-safe tick repellant to help decrease the number of ticks coming back into your house.
Treating tick bitesInevitably, a tick will get through your defenses, so let’s talk about tick bites. Remember that the deer tick needs to be attached to your skin for at least 36 hours to transmit Lyme, so if you do a tick check on your kids and each other every night, you are likely to remove any of the little offenders before they can transmit the disease. Check ALL over, even in the nooks and crannies, and run your fingers through the hair on the scalp too, keeping in mind these ticks can be very small. If you find a tick, the method most successful to remove it is to grasp the bug as near to the skin as you can get with a pair of tweezers and pull straight out with firm constant traction until it comes off. If you are not sure what kind of a tick it is, save it for identification later. If its head or mouth parts break off and don’t come out easily, there is no increase in the risk of getting Lyme, but the bite may itch more and you may want to contact your doctor about removal of imbedded tick parts.
If you find a deer tick that you are pretty sure has been feeding for more than 36 hours or is engorged, you have two options for managing the bite. One option is to contact your doctor’s office to discuss Lyme prophylaxis (prevention) after you remove it. The antibiotic doxycycline in a single larger dose has been shown to significantly reduce the transmission of Lyme if given to someone within 72 hours of removing an engorged deer tick. This antibiotic is often not used in younger children. Antibiotics that are useful for treating Lyme in young children, such as Amoxicillin, have not been shown to be effective for prevention. Your other option is to not treat at the time of the bite but keep a close eye out for signs of Lyme and treat with a course of antibiotics then.
Signs of Lyme
With any tick bite, there will be redness at the bite site. A small ring of bruising or redness about the size of a dime around the bite is normal and there may be some swelling, as with any bug bite. The typical early signs of Lyme disease usually start 1 to 4 weeks after the bite and include:
- Spreading larger area of redness around the bite site, either as a red blotch or ring with the bite in the middle. The rash is present in about 80% of cases of Lyme. This may happen with or without:
- Fever, chills
- Body aches and headache
- Swollen lymph nodes
If you have these symptoms and don’t have a cold or cough, you should think about Lyme and contact your doctor to make an appointment. Treatment of Lyme at this stage is very effective.
Keeping Lyme in perspectiveWhile Lyme is certainly not a disease to be taken lightly, it should also not keep you and your family from enjoying the exceptional outdoor opportunities that the Upper Valley offers. So as you head out to enjoy your spring adventures, take some precautions to avoid tick bites and be vigilant for ticks snacking on you and for the signs and symptoms of Lyme. These measures should keep you and your family protected from the long term concerns about this disease.
For more information on Lyme disease including pictures of the Lyme rash, see the CDC website on Lyme disease at http://www.cdc.gov/lyme/Julie Davis, MD, is a family physician at White River Family Practice. She lives in Lyme, NH, where she enjoys playing outside with her husband and two kids.
- Don’t get into the habit of making something special if the children don’t eat their dinner. Skipping a meal is harmless. They’ll be fine. And it just might bring back their appetites.
- Don’t worry about the quantity. Your children will grow well with the amount their body is telling them to eat.
- Don’t worry too much, or at least don’t let the kids know you’re worrying.
- Keep mealtime fun. Try to eat together. Draw the kids into conversation.
- Serve meals with their likes in mind, as well as nutritional balance. Share recipes with friends.
- Respect strong dislikes.
- Make the food look fun to eat. It can be as simple as cutting the cucumbers with a star- shaped cookie cutter.
- Keep portions small and ask the child to try everything on the plate before offering seconds.
- Try not to get sucked into the “no dessert” threat. If you are offering dessert that night, then serve a small portion regardless of what they ate of the main dish. Most nights make desserts nutritious like fruits, fruit and Jello, fruit smoothies, applesauce or yogurt. Save the decadent sweet stuff for a Saturday night treat.
- Encourage fruits and vegetables. But if your children won’t eat the veggies, then offer more fruit. Fruits contain all the same good nutrients as vegetables. If you can’t get the fruits in them either, then provide a daily vitamin until your poor eater rediscovers her appetite.
- Be good examples for the kids. Children are naturally cautious about new foods. If you eat the vegetable, they will be more likely to try it. You may need to serve the same thing several times before they dare to like it.
- Excuse everyone from the dinner table at the end of a reasonable time.
- Watch the snacks. Snacks are the most common reason for a poor appetite. When you do serve snacks, make sure they are nutritious (nuts, dried fruit, fresh fruit).
- Watch the juice. Juice has lots of calories, but not much nutritional value. Water is a healthy alternative.
- And watch the milk. Milk can fill kids up. Two cups a day is plenty to get the calcium they need.
Why get the vaccine?The vaccine your doctor wrote to you about is most easily recognized by its brand name, Prevnar. It protects against a bacterial germ called pneumococcus. Pneumococcal infections are responsible for hundreds of cases of bacterial meningitis and thousands of cases of pneumonia and blood infections each year. These infections can be serious. In fact, 200 children a year die from pneumococcal disease in the United States. Trying to prevent infections with the vaccine is important because the disease itself is hard to treat. In the last ten years the pneumococcal germ has become resistant to some of the very antibiotics we use to treat it. The Prevnar vaccine has been available locally since November. It is recommended for children under two years of age, and the protection lasts at least three years. Since most serious cases strike children under two, the vaccine will protect them when they are apt to need it the most.
What about side effects?Side effects are always a serious concern. I’d be more comfortable recommending the vaccine if it had been in widespread use for at least a year. On the other hand, I trust the quality of the clinical studies run by the federal Centers for Disease Control and Prevention (CDC). So far only mild reactions have occurred, like redness where the shot was given or a mild fever. We all need to realize that vaccines – like antibiotics or any other medicine – carry the risk of adverse reactions. That risk needs to be weighed against the potential benefit. I’m convinced that the chance of harm from the vaccine is tiny compared the risks posed by pneumococcal infection. Immunizations can seem scary, but remember the upside. Whoever hears of children these days with tetanus, polio or even measles? Many younger doctors like me have never even seen a child with epiglottitis, a life-threatening throat infection that doctors saw regularly just a few decades ago. Vaccines clearly make a difference.
What about all those shots?This is one area where children, parents, nurses and doctors all agree: Shots are no fun. But I think we doctors each have a memory of caring for some terribly sick child that allows us to see beyond the discomfort we inflict administering the vaccines, and reminds us that we are doing the right thing. And there is ongoing research in search of finding ways of combining vaccines, so perhaps your next child won’t have to get quite so many pokes. Many parents struggle with the decision to vaccinate their children. I sympathize. I have a friend, a nurse, who decided to limit the number of vaccines she gives her three children. Although in her scientific mind she knows the immunizations prevent illness, she is overwhelmed by the fear that she is consenting to a shot that might in some remote way hurt her child. That feeling is powerful, and something we all wrestle with. All a doctor can do is offer advice, talk with you about the risks and benefits, and then respect your choice. Good luck with your decision. If you or other readers want more information on the Prevnar vaccine ask your doctor, call the CDC at 1-800-232-2522, or look it up online. (First published in the Upper Valley Parent’s Paper in February 2001)
- Learn to recognize poison ivy plants. They tend to grow near riverbanks where you might be fishing or launching your canoe. Wear long pants and socks if you find plants at your campsite.
- If there is any chance your child has had contact with poison ivy, wash all exposed skin with any available soap several times. Do this as soon as possible because after one hour, it is of little value in preventing absorption of the poison ivy oil.
- Wash everything that may have been in contact with the poison ivy leaves. That includes clothes, camping equipment and even the dog. Anything that has poison ivy oil on it is contagious for several weeks!
- Don’t believe anyone who tells you that the rash spreads. The poison ivy leaf emits an oil. Any skin that erupts into a rash was in contact with the oil. Typically people get the oil on their hands, and then touch their face or some other place that never contacted the plant. That’s how the rash gets to unlikely places on the body.
- Don’t trust someone who says there is no poison ivy in the woods just because they have not gotten it yet. Some people (about one in four) are less sensitive to poison ivy, and may not react until they have multiple exposures.
- Don’t inhale the smoke from burning poison ivy leaves. This can be dangerous and can result in serious respiratory dysfunction. In fact, it’s illegal to burn poison ivy in several states.
- Don’t hesitate to see a doctor if the rash is severe, involves the eyes or lips, or if you think it’s become infected. Prescription medications can really help.
- Soak in cool water or take an oatmeal bath (Aveeno).
- Apply over-the-counter anti-itch creams that contain zinc acetate (Benadryl Itch Relief Stick, Caladryl Clear Lotion) or hydrocortisone (Cortaid), or drying agents like Domeboro solution or calamine (Caladryl Cream).
- Take an antihistamine like Benadryl at bedtime.
Growing Pains“Growing pains” are a recognized condition in childhood and are not a sign of a serious health condition. Classically, they affect children between 3 and 10 years old, who may wake up at night crying or complain of leg pains at bedtime – usually in the calf, knee or thigh. The discomfort usually lasts 5 to 15 minutes, and massage or a heating pad often can help. Although labeled growing pains, they probably have to do more with tired muscles than anything else. Most parents can correlate an active day of play with a night of leg-cramp complaints.
TreatmentI don’t recommend any restrictions on activity or special treatment for the pains. I think your loving massage and reassurance are probably the best medicine. In fact, making too big a deal of the pains sometimes encourages children to complain more often, as a way to seek out parental attention. This is especially true among three- to five-year-olds.
When to see the doctorYou do need to seek out medical attention if the leg pains become a nightly occurrence; if your children’s sleep is interrupted enough to leave them tired during the day; if they have daytime pain, pain in just one leg, or a limp; or if you have any sense that the pain is slowing your child down. Basically, the right time to see a doctor is anytime you are not sure your child’s discomfort is not serious. Doctors call growing pains a “diagnosis of exclusion.” That means we contemplate more serious conditions before deciding on a diagnosis of growing pains. Restless leg syndrome is one of many things doctors might consider when a child complains of nighttime leg cramps. However, restless leg syndrome is actually quite different. It is very rare in children, especially if one parent does not also have it. Restless leg syndrome significantly disturbs sleep, so the discomfort wouldn’t go away after 10-15 minutes and a massage. I hope that clarifies things for you. All the best to you and your daughters. (First published in the Upper Valley Parent’s Paper in February 2002)
- First, make sure you and your kids eat right.
- Also make sure they get to bed early. The late nights of summer need to end with the lazy days of summer. School and sport activities are demanding, and kids need their sleep.
- Keep them well hydrated.
- Make sure they don’t share cups or water bottles.
- And everybody: WASH YOUR HANDS!
What is the flu?The flu (influenza) is an infection of the nose, throat, and lungs caused by influenza viruses. Flu viruses cause illness, hospital stays and deaths in the United States each year. There are many different flu viruses and sometimes a new flu virus emerges to make people sick.
What is novel H1N1 flu?Novel H1N1 flu is a new and very different influenza virus that is spreading worldwide among people. This new virus was called “swine flu” at first because it has pieces of flu viruses found in pigs in the past. However, novel H1N1 virus has not been detected in U.S. pigs. Influenza is unpredictable, but scientists believe that the new H1N1 virus will cause illness, hospital stays and deaths in the United States over the coming months.This flu season, the new virus may cause a lot more people to get sick than during a regular flu season. It also may cause more hospital stays and deaths than seasonal flu.
How serious is the flu?The flu can be very serious, especially for younger children and children of any age who have one or more chronic medical conditions. These conditions include asthma or other lung problems, diabetes, weakened immune systems, kidney disease, heart problems and neurological and neuromuscular disorders. These conditions can result in more severe illness from influenza, including the new H1N1 virus.
How does flu spread?Both novel H1N1 flu and seasonal flu are thought to spread mostly from person to person through the coughs and sneezes of people who are sick with influenza. People also may get sick by touching something with flu viruses on it and then touching their mouth or nose.
What are the symptoms of the flu?Symptoms of seasonal flu and novel H1N1 flu include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Some people also may have vomiting and diarrhea.
How long can a sick person spread the flu to others?People infected with seasonal and novel H1N1 flu shed virus and may be able to infect others from 1 day before getting sick to 5 to 7 days after. This can be longer in some people, especially children and people with weakened immune systems and in people infected with novel H1N1 flu.
How can I protect my child against flu?Get a seasonal flu vaccine for yourself and your child to protect against seasonal flu viruses. Take everyday steps to prevent the spread of all flu viruses. This includes:
- Cover your nose and mouth with a tissue when you cough or sneeze.
- Throw the tissue in the trash after you use it. Wash your hands often with soap and water, especially after you cough or sneeze.
- If soap and water are not available, alcohol-based hand cleaners are also effective. *
- Avoid touching your eyes, nose and mouth. Germs spread this way.
- Teach your child to take these action too.
- Try to keep your child from having close contact (about 6 feet) with sick people, including anyone in the household who is sick.
- Keep surfaces like bedside tables, surfaces in the bathroom, kitchen counters and toys for children clean by wiping them down with a household disinfectant according to directions on the product label.
- Throw away tissues and other disposable items used by sick persons in your household in the trash.
Is there a vaccine to protect my child from H1N1 flu?A vaccine against novel H1N1 flu is being produced and will be available in the coming months as an option for the prevention of the new H1N1 flu. A vaccine against seasonal flu is available each fall and winter. More information about the new H1N1 flu vaccine and the seasonal flu vaccine is available on the CDC Web site.
Is there medicine to treat the flu?Antiviral drugs can treat both seasonal flu and the new H1N1 flu. These drugs can make people feel better and get better sooner. But they need to be prescribed by a doctor and they work best when started during the first 2 days of illness. These drugs can be given to children. The priority use for these drugs is to treat people who are seriously ill or who have a medical condition that puts them at high risk of serious flu complications.
W hat should I use for hand cleaning?Washing hands with soap and running water (for as long as it takes to sing the “Happy Birthday” song twice) will help protect against many germs. When soap and running water are not available, wipes or gels with alcohol in them can be used (the gels should be rubbed into your hands until they are dry).
What can I do if my child gets sick?If your child is 5 years or older and otherwise healthy and gets flu-like symptoms, including a fever and/or cough, consult your doctor as needed and make sure your child gets plenty of rest and drinks enough fluids. If your child is younger than 5, or of any age and has a medical condition like asthma, diabetes, or a neurologic problem and develops flu-like symptoms, including a fever and/or cough, call your doctor or get medical attention. This is because younger children and children who have chronic medical conditions (like asthma or diabetes) may be at higher risk of serious complications from influenza infection, including the new H1N1. Talk to your doctor early if you are worried about your child’s illness.
What if my child seems very sick?Even children who have always been healthy before or had the flu before can get a severe case of flu. Call or take your child to a doctor right away if your child of any age has:
- Fast breathing or trouble breathing
- Bluish or gray skin color
- Not drinking enough fluids
- Severe or persistent vomiting
- Not waking up or not interacting
- Being so irritable that the child does not want to be held
- Flu-like symptoms improve but then return with fever and worse cough
- Has other conditions (like heart or lung disease, diabetes, or asthma) and develops flu-like symptoms, including a fever and/or cough.
Can my child go to school, day care or camp if he or she is sick?No. Your child should stay home to rest and to avoid giving the flu to other children.
When can my child go back to school after having the flu?Keep your child home from school, day care or camp for at least 24 hours after their fever is gone. (Their fever should be gone without them having taken a fever-reducing medicine.) A fever is defined as 100°F or 37.8°C. For more information, visit www.cdc.gov or www.flu.gov or call 1-800-CDC-INFO
Should Teenagers worry about Osteoporosis?Most teenagers aren’t too worried about osteoporosis. They might know somebody’s grandmother who walks hunched over from thin or collapsed bones in the spine, or they may have heard about an elder person who slipped and broke a hip. But the grandparent age seems pretty far off to the average teenager. The paradox is that preteens and teens are at the age when their diet has the most impact on their osteoporosis prevention. If teens are not taking in enough calcium during the years when their body needs it the most, they have lost the opportunity to build a strong bone base. The best bone-building years are between 9 and 18. The body’s bone building ends completely by around age 30. That’s right! Our bones reach their peak bone density around age 30, and it’s downhill after that. The calcium we consume as adults can slow the rate of bone thinning, but it won’t make our bones denser again. To start middle-age with thick, strong bones we need to build them up with calcium when we are teenagers. If your kids don’t buy into the benefits of calcium for osteoporosis prevention, you could tell them that some young people, especially women, say they feel better when they get adequate calcium intake. A significant number of women report fewer mood swings, and less fatigue during menses while eating high-calcium diets.
When milk is not on the menuIn my mind, soda (or diet soda) is never a good alternative to milk. Not only does soda take the place of calcuim-rich drinks, there is an ingredient in the soda (maybe the phosphorous) that makes it difficult for the body to absorb the calcium you do eat. Milk offers a plentiful supply of calcium, and a good source of protein as an added bonus. And, if you pick skim or 1% dairy products (so there is less fat), it is an all-around healthy food. Milk, however, is not for everybody. For some children, milk just doesn’t agree with their body. It may be an obvious symptom of lactose intolerance like a belly cramps and diarrhea. Or it might be subtle things like eczema, lingering runny nose, or more frequent ear infections. Some milk-sensitive people can handle yogurt or aged cheese because the lactose is already broken down. Fortunately, the food industry provides options. Calcium-enriched rice and soy milks are easy to find. Also, there are calcium-fortified juices too. I’ll be the first to admit—if you are not in the habit of eating milk products several times a day, or you just can’t tolerate the milk, it can be challenging to get the recommended amount of calcium in your diet.
Recommended Daily Calcium
Sources of Calcium
|milk 1 cup||
|yogurt 1 cup||
|cheeses 1.5 oz||
|broccoli 1 cup||
|spinach 1 cup||
|raw medium-size carrot||
Calcium SupplementsI’ve always been concerned that calcium pills, like any vitamin or mineral supplement, won’t be absorbed as well as calcium coming from real food. However, if you know the calcium isn’t enough in the food you eat, taking a supplement is the next best thing. Good luck. If you still can’t convince your teenagers of the importance of calcium to change their eating habits, consider talking to their school. I’ve been advocating removing all the soda and high fructose corn syrup-sweetened drinks that are made all too available to our children in school vending machines and replacing them with 100% fruit juice or low-fat milk products. Perhaps, the limited drink choices will encourage our teenagers to try calcium fortified orange juice, or yogurt smoothies, and they’ll realize they like it.
So that gets back to your question of how much sleep is enough sleep. Although we clearly know that getting “enough” sleep is critical, there is no magic number of hours that is right for all children. As you try to assess what is adequate sleep for your child, you can use the table below as a rule of thumb. The majority of children won’t fall far from these guidelines.
How Much Sleep Do You Really Need? From the National Sleep Foundation
|Newborns (1 – 2 mo)||10 ½ – 18 hours|
|Infants (3 – 11 mo)||9 – 12 hours at night and ½ – 2 hour naps 1 – 4 times daily|
|Toddlers (1 – 3 yr)||12 – 14 hours|
|Preschoolers (3 – 5 yr)||11 – 13 hours|
|School age (5 – 12 yr)||10 – 11 hours|
|Teens (12 – 17 yr)||8 ½ – 9 ¼ hours|
|Adults||7 – 9 hours|
Sleep and TeenagersYou brought up sleep and teenagers. Well, that is also a topic worth addressing. One thing fore sure; don’t let your first-grader adopt the teenage sleep habits of his sisters. I must admit I think teenagers have it rough when it comes to sleep. Research shows that normal teenage circadian rhythms are geared to staying up later in the evening and waking up later in the morning. That tends to make early morning classes a challenge. Get your son on his own early bedtime schedule so he isn’t plagued by the sleep debt that becomes common for many teenagers.
Tips for Good Sleep
- Make a consistent sleep schedule.
- Bedtime routines are good: use them as consistently as possible.
- Go to bed in the same sleeping environment every night.
- It helps to be in a cool, quiet and dark room (without TV or computers).
- For more ideas check out the website of the National Sleep Foundation.
Protecting your Family from the Sun
If you have not heard the Sun Screen song (an essay written by Mary Schmich and made into a song by Baz Luhrmann from Australia), it is worth a listen. This song started out as a commencement address and begins,
“If I could offer you only one tip for the future, sunscreen would be it.
The long-term benefits of sunscreen have been proved by scientists
Whereas the rest of my advice has no basis more reliable
Than my own meandering experience.”
While the song goes on to give advice about how to live more happily, let’s stop with this opening line and discuss the risks of sun exposure and the long-term benefits of sunscreens. Most important, let’s figure out ways to protect the whole family.
Facts about skin cancer
Skin cancers are common. The American Academy of Dermatology reports that 3.5 million skin cancers are diagnosed in 2 million individuals each year. Many of these would have been prevented by sun protective measures. There are three main types of skin cancers – basal cell carcinomas, squamous cell carcinomas and melanoma. The first two types can disruptive and disfiguring to the skin. Melanoma can be deadly. The UV rays from the sun also can cause sunburns, discoloration of the skin and premature wrinkling.
There is strong evidence that sunscreen prevents the development of precancerous skin lesions, squamous cell carcinomas and melanomas.
Sun protection for everyone!
It is recommended that everyone over the age of 6 months, regardless of skin type, wear sunscreen year round to prevent the harmful effects of the sun. Infants under 6 months old also need protection but due to their more sensitive skin, this is best accomplished by seeking shade, wearing sun hats and protective clothing. If necessary a minimal amount of sunscreen can be applied to areas of the face and back of hands. Over 6 months of age, an infant’s skin has become less sensitive and more tolerant of sunscreen use. This is fortunate as many 6 month olds can crawl or scoot out of shady areas and the battle to keep a hat in place begins!
But which one should I choose?
There is a lot of information on sunscreen bottles like SPF, broad spectrum and water resistant.
- SPF means Sun Protection Factor and refers to the protection offered by sunscreens to UVB rays. SPF of 15 means that a person can stay in the sun 15 times longer with the sunscreen than without. To work, SPF 15 needs to be applied in large amounts and frequently. SPF of 30 is valuable if your family, like many, simply does not apply the globs of sunscreen necessary for good protection.
- UVA protection is not rated in the same way by the US Food and Drug Administration. However, under recent regulations, only sun screens that pass the FDA’s test for both UVA and UVB rays will be labeled “broad spectrum”.
- Water resistant means that the SPF protection is maintained after 40 minutes in the water. Very water-resistant means that the SPF protection is maintained after 80 minutes in the water.
- Infants older than six months and toddlers may benefit from using infant formulations which tend to use titanium dioxide or zinc oxide in the product and have less risk of irritation or skin penetration.
If you are like me, you will find a variety of old sunscreens in medicine cabinets and closets, suitcases and bags that have not been used for a while. It is worth checking to see if they are listed as broad spectrum. You can also check for an expiration date. Generally, sunscreens will last for several years but they should rarely need to. If sunscreen is applied as directed, bottles should be easily depleted only months after purchase.
Lots of sunscreen and often!
Older children and adults can use whatever sunscreen is easiest for them to apply as the key is to apply every two hours to exposed skin.
A lot of sunscreen should be used often. Sunscreen should be applied liberally with one ounce (a large palm full of cream) used to cover the whole body. Apply 30 minutes prior to going outside to allow it to fully penetrate and reapply at least every two hours or after swimming or sweating.
Applying sunscreen takes time and this is a frequent complaint in our household. Perhaps the same amount of time it takes to do other dreaded activities like brushing and flossing teeth. You can bore your family with other statistics like the average person will spend a total of 1.5 years out of their lifetime in the bathroom while you help them slather more sunscreen from head to toe.
Vitamin D and the Sun
Our bodies make an inactive form of vitamin D that is converted to its active form in our skin with exposure to UV light. Vitamin D is important for healthy bones. In experimental settings, vitamin D production is greatly reduced when sunscreens are used. However, there is no evidence from studies done in real-life scenarios that vitamin D production is significantly affected.
For those who burn easily or have a personal or family history of skin cancer, strict measures to protect against sun exposure should be followed and vitamin D can be taken as an oral supplement. For others, brief exposure to the sun’s rays without sunscreen is all that is needed for healthy vitamin D levels. The American Journal of Clinical Nutrition notes that 5 to 10 minutes of exposure of arms and legs or hands, arms and face, 2 to 3 times per week in conjunction with a good diet and some vitamin D supplementation is sufficient to ensure adequate vitamin D levels.
Sunscreens are safe
Some individuals will have mild skin reactions to sunscreens. This risk is considered minimal compared to the overall benefit of protection from sunburns and skin cancers. The FDA is also currently looking into inhalation risk related to spray sun screens. If you choose to use these sunscreens, do not spray them into the wind or around the face. A recent National Institute of Health study looked at benzophenones (an organic filter in many sunscreens) and questioned the link between this sunscreen and male infertility, but the researchers were not able to establish that sunscreen was the cause. While sunscreens continue to be scrutinized, the data thus far show excellent safety profiles.
Sunscreen is just part of the protection
All clothing offers some protection from the sun, based on factors such as the tightness of the weave, color (dark is better), and composition of the yarns, but some clothing offers more protection than others. Standard summer clothing offers an ultraviolet protection factor (UPF) of around 6. This means that 1/6 of the sun’s rays will pass through the clothing. Sun-protective clothing offers UPF around 30 (1/30th of sun’s rays will pass through). To learn more about sun-protective clothing, visit the Skin Cancer Foundation website at www.skincancer.org.
Sun glasses that provide 99% to 100% blockage from damaging UV light will greatly reduce the risk of eye problems.
Tanning beds, uggh!
There is not enough room in this article to fully describe the dangers of indoor tanning. Let’s just say indoor tanning is more dangerous than exposure to the sun and base tanning is a lousy idea. Indoor tanning is a poor way to get vitamin D and there is no safe level of indoor tanning. Research agencies place the cancer risk from indoor tanning on par with cigarettes and asbestos.
Sadly, many high school students (predominantly Caucasian girls) will seek out this form of tanning as do many college students. A recent study found that nearly 50% of the top colleges have tanning beds on or nearby college campuses.
Some may be marketed as new “safer” tanning beds. But, don’t be persuaded, recent studies show these are not safer than the older tanning beds. Please make sure that the young adults in your life understand that indoor tanning is not a path to wellness or beauty but a path to age spots, wrinkles and greatly increased risk of the deadliest skin cancer, melanoma.
Final words of wisdom
Let’s end where we began, with words of wisdom emerging from Australia. In addition to the Sun Screen song, Australia is also internationally recognized for its sun protection campaign, “Slip, Slop, Slap, Seek, Slide.” Your kids may not be ready to hear much of the meandering advice accumulated by your years of experience, but you can assure them that there is firm evidence for them to Slip on a shirt, Slop on large amounts of 15+ SPF sunscreen, Slap on a hat, Seek shade or shelter and Slide on sunglasses. And, as with all advice we dole out as adults, remember to serve as a role model!
Jill Blumberg is a family physician at White River Family Practice and lives in the Upper Valley with her husband and two daughters. She tries her best to everyone protected from the sun during family hikes, bikes and swims.
How does the sun hurt our eyes?Exposure to the ultraviolet or UV – radiation in sunlight causes cumulative damage to the eyes over a lifetime.
What are some of the potential eye problems?
- Cataracts: I have a 42-year-old adult patient in my practice, a California native, who has already had cataract surgery! You can bet he wishes he wore sunglasses as a kid.
- Macular Degeneration: This condition is a major cause of blindness in older adults. Sun damage to the retina is a contributing factor to the disease.
- Pterygium: This is a common, non-cancerous growth on the white part of the eye. It appears rough with a yellow hue. (In fact, I’m already starting to get one.)
How can you protect your child’s eyes from the sun?
- Keep children under six months out of direct sunlight.
- To help ensure that your children wear their sunglasses, let them select a style they like.
- To help ensure they don’t lose the sunglasses, buy a strap that lets the glasses hang around the neck when they want to take them off.
- Make sure your child wears a hat if she won’t tolerate sunglasses.
- Teach your children not to look directly into the sun.
- Wear sunglasses or a hat outside yourself. Children will often follow their parents’ example.
- Shake the water out of your ear after swimming. I should tell you, however, that although all the advice books recommend this, I’ve never really felt I could get the hang of it.
- Don’t use Q-tips. Cotton swaps inevitably push as much water and wax farther into the ear as they get out. If you can’t resist the temptation to put something in the ear, try twirling a tissue and dab the pointed end inside the ear canal. It may get a little water out, and it won’t push anything back in.
- If your child seems prone to swimmer’s ear, you can put a few drops of rubbing alcohol in the ear after swimming. This will allow the excess water in the ear canal to evaporate. Over-the-counter products that contain rubbing alcohol, like Swim-Ear, are sold for this purpose.
- Earplugs are controversial. They may trap leaked water, which is worse than lots of water flushing through the ear. Or they may cause wax build-up.
TreatmentOnce the ear has started to hurt:
- Stay out of the water!
- Cover the ear with a Vaseline-moistened cotton ball when showering and hair washing.
- Gently rinse the ear using a bulb syringe and a 50:50 mixture of acetic acid (white vinegar) and warm water two to three times a day.
- Take Tylenol or Advil as needed.
When to see the doctor
- When the home treatment hasn’t worked after two to three days.
- If your child is too uncomfortable to wait.
- Fever develops.
- Pus starts to drain from the ear.
What is a peanut allergy?In certain children the body’s immune system mistakenly identifies peanuts as a harmful. The allergic reaction is really an immune system overreaction to the peanut, and it can range from mild to life-threatening. A reaction may be as slight as a runny nose, skin rash, or tingling on the lips, or it may be very serious, causing breathing or swallowing difficulty, and might even progress to anaphylactic shock. Unfortunately, we don’t have a good method for predicting which kids will develop a peanut allergy. The best we can do is to say that kids who have eczema or asthma or relatives with food allergies are slightly more apt to have peanut allergies. On the bright side, about 20 percent of children will grow out the peanut allergy after several years of peanut avoidance. Fortunately, the initial symptoms of a peanut allergy are almost always mild. Parents may notice that the child avoids peanut-containing foods, gets a short-lived rash. When parents are suspicious of a peanut or other food allergy, I recommend starting a food diary. It’s amazing how much better we parents are at figuring out a food allergy if we start writing down our observations. This will also help your doctor with the diagnosis. Confirmation of the diagnosis includes a referral to a pediatric allergist where skin-prick and blood tests are usually performed.
PreventionI’m afraid I don’t have a satisfactory answer to the question of prevention. Certainly, I would recommend breastfeeding your baby the first three to six months of life, and ideally for the first year. Breastfeeding is the one recommendation I can give that has some scientific backing. I get lots of questions as to whether manipulating the pregnant or breastfeeding mother’s diet or an infant’s diet will prevent food allergies. The honest answer is that there is no conclusive evidence that diet manipulation will prevent a peanut allergy. On the other hand, many experts feel that avoiding peanuts makes sense, and is worth a try despite the lack of definitive evidence. So, the standard recommendation for all babies is to avoid peanuts until they are one year old. If severe asthma or eczema run in your family, or if you have a family history of peanut allergy, the current recommendation is for breastfeeding mothers to avoid peanuts, and to postpone peanuts in the child’s diet until the age of three.
TreatmentAlthough there are medications in the research pipeline to treat peanut allergies, the treatment today is still total peanut avoidance. Parents of peanut-allergic children become vigilant readers of food labels, educators of teachers, friends, and neighbors. They begin each day prepared to deal with a severe allergic reaction and keep Benadryl and an Epi-Pen immediately available. Most parents are overwhelmed at first, but then settle into daily routines that become habits. The child learns quickly too. Parents tell me that they are amazed how well their child screens offerings of snacks-even as young as age three. As a family doctor I’ve counseled parents about living with peanut allergy, but I think we have to be careful of more than just peanuts. Foremost in our hearts, we want the child to be safe. But we don’t want the child to be fearful. Studies have suggested that some children with a peanut allergy grow up terribly anxious, affecting their quality of life. Somehow we need to be vigilant about their safety without inducing fear or unnecessarily limiting the child’s freedom. Ideally, the child grows up with ingrained habits that keep him safe, but don’t leave him feeling anxious or restricted. For many it’s helpful to talk with other parents who have a peanut-allergic child. There is a support group in the Upper Valley that’s meets at the Dartmouth Hitchcock Medical Center. For more information contact jane.soderquist@valley,net or firstname.lastname@example.org. As awareness about peanut allergy grows our culture has begun to change. Many classrooms, daycares, and even entire schools have gone “peanut free.” For the kids in your expectant-child’s generation peanut butter may no longer be a staple food. Imagine, a child not knowing what “PB&J” stands for! I wish you a happy pregnancy. (First published in the Upper Valley Parent’s Paper in April 2007)
PertussisPertussis is commonly known as whooping cough, and is caused by a bacterial infection. You probably remember the outbreak of pertussis that started last year at Dartmouth Hitchcock Medical Center, and got loads of coverage in Upper Valley newspapers. Even before the outbreak brought pertussis to the forefront of community minds, we health care providers had been seeing smaller outbreaks of pertussis at local middle schools and high schools for several years. Although all small children are immunized for pertussis, the immunity wanes by adolescence. This new pertussis booster at age 11 will hopefully prevent pertussis outbreaks in schools, which are even more likely than hospitals to be the site of potential outbreaks. Why to we care about pertussis? Pertussis causes bad coughing spells that may make it hard to breathe. Most 11 year-olds would probably not get seriously sick. If your son got pertussis, he would probably miss school for several days, cough a lot, and feel crummy for a few weeks. Only 2 in 100 adolescents with pertussis are hospitalized or have complications. The age group we really want to protect is infants, in whom a Pertussis infection can be severe and even fatal. Protecting infants means keeping school-age kids healthy too.
DiphtheriaLike pertussis, diphtheria is also a bacterial infection. It causes a thick covering in the back of the throat and can lead to a swollen (bull) neck and serious breathing problems. I have never seen a patient with Diphtheria – routine immunization has almost eradicated Diphtheria in America, where there were only about 50 cases between 1980 and 2000. The main reason to immunize is to maintain the eradication and protect your child in the event of future travel to parts of the world where Diphtheria outbreaks still occur. When my oldest daughter was in 4th grade she visited an old Vermont graveyard from the early 20th century. She asked me about the gravestones of children (siblings) that were engraved “died of diphtheria.” That is why we immunize.
Tetanus (T)Tetanus is lockjaw - a muscle spasm and loss of muscle control that can be fatal.. It is another bacterial infection. The tetanus bacteria are found in soil, so the threat of infection can not be eradicated. Because of the success of tetanus immunization, most people will never see or hear of someone getting tetanus. While working in inner city Oakland, California during my medical training, I met a small child who contracted tetanus. He had never been immunized. Although he lived to return home, his life was forever changed. In my mind, I can still see the rigidity of his face, and I am reminded of the importance preventing tetanus through immunizations. A discussion about immunizations would not be complete without mentioning side effects. Vaccines, like any medicine (or the decision to not take a medicine or vaccinate) carry a risk. Overall, I believe the risk of serious harm is extremely small – certainly smaller than the global risk of not vaccinating. The risks are greatly varied and I believe are realized rarely enough that I won’t go into them here. Having said that, I encourage parents to read about vaccines, and to bring questions they have about side effects to their doctors. I think there are compelling reasons to give the pertussis booster at age 11. Theoretically, it would be okay to wait for the tetanus and diptheria parts of the vaccine till age 15 (ten years is a normal interval for tetanus and diphtheria). Yet we parents know it isn’t always easy to get 15 year-olds into the doctors office. So, if we booster them at 11 or 12, we know they will be covered during all the teenage years. Good luck to your son at his doctors appointment. I sympathize with his fear of needles. On the other hand, vaccinations have had a huge influence on pediatric health. And there are more adolescent vaccines on the horizon. (First published in the Upper Valley Parent’s Paper in November 2006)
- The supplement you choose should be appropriate for the child’s age. Too many vitamins and minerals can be dangerous.
- Use drops instead of chewables until your toddler’s molars are in.
- Be careful to safely store the vitamins out of the reach of children. Unfortunately there are tens of thousands of vitamin overdoses each year.
- Don’t forget to give out the vitamins before toothbrushing.
PreventionThe wart virus is all around us. There is no practical way to guard against it.
Treatment optionsThere are several over-the-counter and prescription medications for warts. The over-the-counter products I usually recommend contain salicylic acid, and must be applied several times a week for about three months. I think that’s the hard part about the treatment; every night for three months is a tall task. At my house, just getting all the children’s teeth brushed before bed can seem like a chore. A typical doctor’s office will use one or two procedures to destroy the warts. The most common is cryotherapy, with liquid nitrogen. The liquid nitrogen freezes the wart. When the skin is frozen (as with frostbite), the skin – or in this case the wart – acts like it’s been burned. The wart usually flakes off and healthy skin grows back in its place. The downside to liquid nitrogen is that it stings. Most kids under six don’t tolerate it well.
Do the treatments work?For plantar warts (on the sole of the foot) the treatments work roughly half of the time. For hand warts, one course of treatment gets rid of the warts eighty percent of the time. Serial treatments improve the success rate. In my experience, we can improve the chances of eliminating warts by paring away all dead skin and callouses from on and around the wart before applying medication or liquid nitrogen.
What if my kids don’t want treatment?No treatment is certainly an option. A quarter of all warts disappear in six months. Sixty-five percent will disappear without therapy within two years. All will go away on their own, eventually. Trimming, paring, or filing the warts will usually keep them from being sore or catching on things. A pumice stone works well on the feet. If warts are not cosmetically bothersome, it’s okay not to treat them.
Home RemediesThere are all kinds of home remedies for warts. In fact, I can remember my dad operating on my warts at our kitchen table when I was a youngster. He would nick the wart around the base with a razor just deep enough to tie on a thread in an attempt to strangulate it. I got a new and tighter thread every few days until it fell off. You know what? It worked. However, now that I’m a doctor, I don’t think I’d recommend it. Over the years I’ve heard many other stories about home remedies. There are so many that it is hard for me to comment on all of them. However, I’m convinced that there is healing power in believing that a treatment will work. So, by all means, try your own family remedy. It may do the trick. Good Luck! (First published in the Upper Valley Parent’s Paper in September 2002)
Safety RecommendationsThink water safety. Drowning is the second most common cause of death by injury for children under 15. It happens. Ages 1-4:
- Never, for even a moment, leave a child unattended near any open water. Toddlers can drown in a five-gallon bucket of water, in a shallow bathtub, even in a toilet.
- Pools are the most common sites of drowning. The only proven tactic for prevention is a good fence: tall and secure enough to keep out the most rambunctious four-year-old.
- There is a peak in the incidence of drowning at age three (which is the age when they start to seem old enough to play without us watching every minute). Remember, supervising a young child near the water is a full-time job.
- Children this age always need a life jacket when boating or playing beside water, regardless of swimming ability.
- Don’t let your “good swimmer” lull you into a false sense of security. Children under five don’t have sound judgment and are never safe near the water without adult supervision.
- Swimming lessons are a must: Children learn skills like swimming or riding a bike at different ages, but if your five-year-old hasn’t started lessons yet, it’s time to begin.
- Your children should learn to swim well.
- They should wear a life jacket while boating or playing near any fast-moving water. Nine out of ten drownings occur within in a few feet of safety.
- Teach your children never to swim alone or without adult supervision.
- Teach your children about drowning risks: thawing ice, cold water, current, tides, waves and undertow. Children need to understand how jumping or diving can lead to injury.
- Teenagers need reminders about drowning risks and injury prevention.
- Counsel them about the risks of alcohol and drug use while swimming, boating or diving.
- Encourage the buddy system.
- This is a good time for them to learn life-saving techniques.
- They should also learn CPR.
What is West Nile virus?West Nile virus is a flu-like germ. Where influenza is spread by person-to-person contact, however, infected mosquitoes spread West Nile virus. Outbreaks have occurred before in other parts of the world, but the cases near New York City in 1999 marked the first outbreak of the virus in North America. Although West Nile can infect anyone, healthy children and young adults are unlikely to get sick from it. Most people who got sick in the New York City area were over 70.
What are the symptoms?The symptoms vary widely, from a vague sense of not feeling quite right, to mild body aches and low-grade fever, to a severe headache from encephalitis (inflammation of the brain), which in rare circumstances can lead to death. So far, only the elderly have become seriously ill in the U.S., though theoretically infants or anyone with a compromised immune system could be at risk of serious illness if infected.
How common is West Nile encephalitis?As of last December, the Centers for Disease Control and Prevention had reported a total of 52 human cases of West Nile virus encephalitis in the United States. Five people have died. There have been no known human cases of West Nile virus infection or encephalitis in Vermont or New Hampshire.
How do people get the virus?West Nile virus normally lives in birds. A mosquito becomes a carrier of the virus after biting an infected bird, and then may pass it on to a human with a subsequent bite. People cannot get the virus from an infected bird or another infected human.
What can I do to keep mosquitoes away?If your backyard is really a mosquito haven, it’s worth thinking about how to change it. Getting rid of persistently wet areas is the one thing most likely to help, since mosquitoes breed in standing pools of water. (Mosquitoes only need four days of still water to breed.) Another strategy is to use bug repellent. The bug repellents that contain DEET are the most effective, but to be safe, we don’t recommend DEET for babies under one year, and the strength of DEET in the repellent should be under 10 percent until the teenage years.
What should I do if my child gets a lot of mosquito bites?Don’t panic! Remember, most mosquitoes don’t carry the virus. If your child gets ill with a fever and seems sicker than you are comfortable seeing, take him to your doctor. But also remember that it is important for kids to play outside. If they are playing in an area with lots of mosquitoes, black flies or ticks, it makes sense to use bug repellent and dress with protective clothing like socks, long sleeves and long pants whenever it’s practical. You may prevent an infection, and you will certainly keep your children more comfortable. The West Nile virus is still uncommon. With what we know about the outbreak so far, I’m not worried about our kids in the Upper Valley. I’m more worried about the future extent of the outbreak, and that is worth keeping informed about. For up-to-date information, see the Vermont and New Hampshire public health department Web sites: www.dhhs.state.nh.us/commpublichealth and www.state.vt.us/health. And have a fun, playful summer! (First published in the Upper Valley Parent’s Paper in May 2002)
CauseFemale athletes suffer many different knee injuries, but I am going to focus on the dreaded and serious anterior cruciate ligament (ACL) tear. Over 70% of ACL tears come from non-contact injuries. In sports like basketball or soccer, ACL tears occur most frequently from 3 types of movements:
- stopping suddenly
- sudden change of direction
- landing after jumping with knee extended
- Females are smaller and have smaller ACLs, which tear more easily.
- The notch in the knee that the ACL passes through (intercondylar notch) is narrower and sharper in females, and it can shear off the ACL with hard cutting and pivoting.
- The “Q angle” (the angle at which the thigh bone enters the knee joint) in women is not as suited to running and jumping.
- Women in general are more flexible, with looser ligaments, tendons and muscles. While this prevents certain injuries, it increases the risk of ACL rupture.
- Monthly hormonal fluctuation may relax ligaments at certain times, increasing risk of ACL tear.
- Muscles are important stabilizers of all joints, and females in general have smaller and less developed muscles, increasing ACL tear risk.
- Females in general do not grow up playing as many sports as males, and therefore lack the same level of coordination and balance that can help prevent injury.
- Females, when tested, consistently have weaker hamstring muscles (back of thigh) relative to their quadriceps (front of thigh) as compared with males, and this imbalance increases risk of ACL tear.
- Women generally play sports in a more upright position than men. The less flexed the knee is, the greater the risk of ACL tear, especially when stopping suddenly.
PreventionA 1995 ACL protection study in Cincinnati put a group of 1,263 female high school athletes through a comprehensive six-week strengthening, balance and stretching program which decreased the incidence of ACL injuries 3.7 fold. This means that strength and conditioning are far more important variables than anatomic conditions that can not be altered. The specific training program that was instituted in the study mentioned above included the following components:
- jump training, plyometrics and stretching
- weight training
- balance training