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michael_lyons
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
  • Antibiotics
  • Asthma
  • Bedwetting
  • Bronchitis
  • Bug Repellents for Kids
  • Canker Sores
  • Chapped Skin
  • Child Obesity
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Acne: Every Teenagers’Worst Nightmare

Posted August 4, 2013 by admin & filed under Uncategorized.

Q: My three children are entering their teenage years. The oldest already has acne. I can remember several years as a teenager living with dreadful pimples. Is there anything I can do for my children to prevent a similar experience for them? A: Unfortunately, there is really nothing you or your children can do to prevent acne. Acne’s simply a consequence of the hormone changes that come with puberty. It’s not anyone’s fault – it’s just a part of growing up. It is true that some teenagers get acne worse than others. Usually there isn’t a good explanation for this, though heredity is a factor. If the parents had bad acne, it’s more likely that the children will as well. That’s probably not what you wanted to hear, but let me talk about acne a bit. Perhaps you’ll find some helpful hints.

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.
What does make acne worse?
  • 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 helps acne? Your best bet is to wash your face once or twice a day with mild soap and water. Over-the-counter acne creams can also help, if you buy the right product. The ingredient to look for is benzyl peroxide. There is substantial research suggesting its benefits, and for most teenagers it will help. If you don’t have success, see your doctor. If you and your regular doctor don’t have any luck, then make an appointment with a dermatologist. There are many prescription acne medications, and sooner or later you’ll find the right combination. Helpful reminders Be patient. Any treatment you try will take six to eight weeks to make a difference. When it comes to acne medication, more is not better. Apply the medication to your face sparingly, especially at first. Many acne lotions make skin dry and red if used excessively. And be consistent: Most acne medications won’t work unless used daily. Above all, remember you are not alone. Acne is a part of puberty, and everybody goes through puberty. (First published in the Upper Valley Parent’s Paper in April 2002)

Antibiotics

Posted August 4, 2013 by admin & filed under Uncategorized.

Q: Why are you doctors so stingy with antibiotics? I brought my two-year-old daughter to see the pediatrician after she had a bad cold for five days and was pulling on her ear. The doctor said that her ear was “a little red” but that it was probably all “just a cold.” Two nights later I had to take her to the ER with a fever. The doctor diagnosed an ear infection, and put her on Amoxicillin. Why not give her the medicine in the first place? A: That’s a great question. A decade or two ago the doctor would have been much more likely to prescribe the antibiotics when you first went to the office. It was common practice to prescribe antibiotics for lingering colds on the theory that it would prevent ear infections or other more serious secondary infections like pneumonia. We now know that this practice doesn’t work. Furthermore, the frequent use of antibiotics can be harmful. Remember, runny noses and coughs from the common cold are caused by viruses. Unfortunately, we don’t have medicines that kill viruses. When the cold lasts five, seven, ten days or more without improvement, the child is at increasing risk to develop a secondary infection with bacteria such as an ear infection. But it’s actually not that common. Studies show that at least 15 kids with a cold and fluid in the ear (making it a little red) need to be treated with antibiotics to prevent one ear infection. That’s a lot of unnecessary antibiotics. Especially when you consider that the antibiotic might have adverse side effects like nausea, diarrhea, rash or rarely even a severe allergic reaction. And perhaps more important, taking antibiotics that your body doesn’t really need can promote bacterial resistance. Each time your child takes antibiotics, sensitive bacteria are killed, but some resistant ones may be left to grow and multiply. Repeated use and improper use of antibiotics are some of the main causes of the increase in resistant bacteria. These resistant bacteria can also be spread to others in the family or close contacts in the community. If your child gets another ear infection, it’s more likely to be with these resistant germs, and may require more powerful and expensive antibiotics. Don’t get me wrong. Antibiotics are great medicines. In fact, as I write this, two of my children are taking Amoxicillin for scarlet fever. But we don’t want to overuse them, or they might not work so well when our children really need them. Like in the case of your little girl, the judicious use of antibiotics will sometimes mean two trips to the doctor instead of one. But in the long run I think it’s worth it. If you want to learn more about antibiotics and your child, ask your doctor or contact the Centers for Disease Control and Prevention. (First published in the Upper Valley Parent’s Paper in April of 2000).

Asthma

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: My second grader had frequent visits to the doctor’s office last winter for coughing and wheezing. The doctor diagnosed him with asthma. My son did get better with the medications that were prescribed, but the term “asthma” bothers me. He seems too healthy to have something so serious. Maybe I don’t understand what asthma really is. Does it ever get better or go away? Will he need his inhalers every winter? Are there other ways to treat asthma? A: That is a great question! I find many parents have similar questions and concerns about asthma. I’ll try to clarify.

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
  • Perfumes
  • 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.
Another approach is to figure out whether a change in lifestyle might help the body resist the commonplace triggers. Our bodies seem more resistant when we sleep better, eat nutritiously, exercise appropriately, and manage life stresses well.

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)

Bedwetting

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: My seven-year-old wets her bed. When she was six, I mentioned this to our doctor. She reassured me that bedwetting was not a big deal. But now my daughter has started to have sleepover parties, and I’m beginning to worry she might get teased. When will she stop wearing pull-ups at night? A: I can’t tell you when your daughter will stop wetting her bed at night, but I agree with your doctor that bedwetting is more common than most people think – and I assure you that your daughter is not alone.

Nocturnal Enuresis

The 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.

Cause

We 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 Theories

There 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 strategy

There 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.
In many cases, it’s just as easy to keep the pull-ups on, keep the sleepovers small, and educate the families invited over that bedwetting is just one of those things that kids grow out of at different ages. It’s like learning to read: Most children get there at their own pace, but if it looks like they are really getting behind, there are ways to help.

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.
(First published in the Upper Valley Parent’s Paper in March 2002)

Bronchitis

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: I took my 11-year-old daughter to the doctor for a bad cough. The doctor diagnosed bronchitis, and prescribed an inhaler like the one my nephew uses for his asthma. It seems to help, but it is awkward to use. Why use an asthma medication to treat a cough? Aren’t antibiotics usually given for bronchitis? What causes the cough? A: When children or adults have a head cold or viral illness, the cough usually comes from congestion in the throat, or from post-nasal drip running down the back of the throat. This type of cough usually goes away with time, especially with the help of home remedies or over-the-counter cough suppressants. Other times, we can sense the infection settling in our chest. When the germs descend into the airways of the lungs it is called bronchitis – which means inflammation (“itis”) of the airways (“bronchi”). Bronchitis also may resolve on its own with time and rest. Remember that the body is pretty good at healing itself. However, for some children, their airways are more sensitive and respond to the inflammation by going into spasms. This airway spasm, or “bronchospasm,” results in a deeper cough, and often a wheeze may be heard on the doctor’s exam.

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)

Bug Repellents for Kids

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: I’m worried about my children getting sick from insect bites. The black fly bites swell terribly, and I certainly don’t want them to get Lyme disease from a tick. But I’m also concerned about the safety of insect repellents. What’s your advice?   A: When it’s practical, dress the children in protective clothing like long pants tucked into socks, and a turtleneck rather than a sweatshirt. One of my medical colleagues always recommends a hat. It’s certainly safe to spray the hat with insect repellent, and as my colleague says, the hat works as a good substitute for a fly swatter. For little ones in strollers or packs I suggest netting. Several local department stores carry nets that drape over a stroller. To protect against blackflies, ticks or mosquitoes, the best repellent is diethyl-meta-toluamide, more commonly known as DEET. DEET is safe as long as it’s not used excessively. There have been 13 cases of DEET toxicity in children reported in the medical literature over the past four decades, and all were associated with excessive or inappropriate use of adult strength DEET repellents. The American Academy of Pediatrics recommends that children use insect repellents with no more than 10% DEET (adult products contain up to 40% DEET). Here are a few examples of commercially available products:
  • Off! Skintastic for Kids
  • Just for Kids
  • Repel Soft – Scented
  • Skeedaddle Insect Protection for Kids
Be careful not to apply the insect repellent too close to the eyes, nose or mouth. Avoid using repellents near cuts or irritated skin. And wash the hands of little ones after they apply it. For children under two years of age, I recommend you spray it primarily on clothing, and limit the amount applied to the skin. Actually, there are other products made specifically to spray onto clothes that will last longer than DEET. They contain pyrethrum, which was originally derived from the daisy flower. Spray it on your hat or sweater, and some people say it will work even after a washing. Examples of these products are:
  • Permethrin Tick Repellent
  • Outdoorsman Gear Guard
  • Repel Permanone
Recently, someone asked me if there were any natural insect repellents. The few products I’m familiar with contain citronella, which studies show is less effective than DEET. However, I did read about a new product called, Bite Blocker, that I’ve not seen in the stores yet. The main ingredient is a 2% concentration of soybean oil, and the manufacturer claims it repels bugs as well as DEET. A challenging piece of this puzzle is slowing the kids down long enough to spray on the insect repellent or wrangle them into a turtleneck. If it’s a sunny morning at my house, I feel accomplished just to get the kids out of pajamas and fed before they’re out in the yard playing and getting preyed upon by bugs. Good Luck! (First published in the Upper Valley Parent’s Paper in July 2000)

Canker Sores

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: My poor adolescent son got canker sores several times during the last school year. Each time he had them, the sores agonized him for about ten days. He was miserable, and hardly ate. What causes canker sores, and how do we keep them away?   A: Canker sores are a drag! I can remember getting them in high school. I always seemed to get them during sports seasons when I wore a mouth guard. I feel bad for your son. But unfortunately, I don’t have any magic tricks to keep them from coming back. Here is what I can tell you about canker sores that might help:

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.

Treatment

There 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.

Prevention

The 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)

Chapped Skin

Posted August 5, 2013 by admin & filed under Uncategorized.

A:We’ve lived in the Upper Valley now for three years and each winter, our children experience a great deal of discomfort due to chapped lips,  cheeks, and dry skin. Why is it so unpleasant and what can we do to make it more comfortable for our children? Q: If your children have chapped cheeks and dry skin all winter long, then welcome to Northern New England. My kids do, too. Eczema or “atopic dermatitis” is a common skin problem that gets worse in the winter. The heated indoor environments of our homes, daycare centers or schools dry the skin and can bring out eczema. Also, the cold outside air is harsh on exposed skin like the face. Add a runny nose, a little drool, and the rub of a mitten, and you can see why your toddler’s cheeks might stay chapped until April. What’s the solution? You could move to Florida, but I wouldn’t recommend it. The Upper Valley just has too much family fun. Prevention begins by modifying those activities that dry the skin. Take less frequent baths with not-quite-so-hot water, and for shorter periods of time. Short showers are less drying than short baths. Soap only areas of the body that need it. Choose mild soaps such as Dove, Neutrogena, Basis or Aveeno. Sorry, no bubble baths. The second line of prevention is moisturizers. Pick a brand without perfumes or a lot of extra ingredients. Eucerin, Moisturel or Lubriderm are a few good examples. Put the lotion on while still damp after a towel drying. A good cheap moisturizer is petroleum jelly (Vaseline). This is especially good for the kids chapped cheeks. Apply before going outdoors and nightly to soothe those red spots. Some doctors recommend setting up a humidifier in the affected child’s room. This will help, but pay close attention to the manufacturers’ cleaning instructions, so other problems don’t get started. I hope that helps, but if you’re still red and itchy, see your doctor. (First published in the Upper Valley Parent’s Paper in January 2000)

Child Obesity

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: I have a question about eating well and maintaining a healthy weight. Here is my story: It’s not unusual for me to be in a rush when it is time to leave work, pick up the kids at elementary school, and drive them to soccer practice. On one afternoon, though, I’d been organized, and I was proud of myself. I had packed a healthy snack the night before, I was running on time, and I didn’t forget that I’d agreed to give a ride to my daughter’s friend. In the car I offered the kids apples, water, and nuts. My daughter’s friend pulled soda and chips from her backpack to share with everyone. It was a well-intended gesture. The kids finished the big bag of chips, and I was the only one who ate an apple. When the kids went happily off to soccer practice, I was left asking myself why the soda and potato chips bothered me so much. My two kids are trim, but my daughter’s friend is clearly overweight. The kids run hard on the field. Since motherhood took over my free time, I’ve struggled with my weight a little, but I don’t think I’m obese. On the other hand, both my parents have diabetes, and I don’t want that for myself or for my kids. Should I bother worrying if my kids are so active? What kind of message would I have sent if had asked my daughter’s friend to put her chips away? Any advice?   A: Whoa! That’s probably the toughest question I’ve encountered since the start of this column. I don’t know if I dare to respond without first consulting colleagues in other medical specialties, psychotherapy, and nutrition. I assure you I have no straightforward answers. However, your questions are important ones. Could it really be harmful to eat chips and soda once in a while? No. On the other hand, isn’t junk food at the root of America’s obesity epidemic? It seems to me that a kid gorging on a bag of chips once in a while (maybe once in a great while) is “normal.” Yet the increasing rate of childhood obesity is staggering, and worrisome with regard to the health of future adults. The U.S. Surgeon General believes the nation’s obesity epidemic has gotten so bad that it may soon overtake tobacco as the leading cause of preventable deaths. This is something I think all parents should be concerned about. Here are some additional disturbing facts:
  • 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.
New forms of fast food keep showing up, such as calorie-rich coffee bars for grown-ups, or frozen-pizza burritos. Does anybody really need the crust on their pizza filled with cheese like at Pizza Hut? The American School Food Service estimates that 30% of public high schools offer some type of name-brand fast food. Fast food chains are even opening in hospitals nationwide, including pizza at DHMC. In one study more than 85% of teenage girls reported that they didn’t exercise. Excessive pounds clearly increase the risk of heart disease, diabetes, cancer, asthma, arthritis, and other illnesses. Obese children use more prescription medicines. So what can we do? I don’t think there is a simple formula to arrest childhood obesity. Although I have no pat answers, I do believe that change needs to come at different levels of society. It’s not enough to say that your daughter’s friend must learn to eat better or exercise more. Kids, parents, community leaders, legislators, and heads of industry all need to act if we’re going to have an impact on such a big problem. We all need to make an effort to promote a trimmer, healthier population of future adults. Physically active children like your soccer players will become less active as adults. But the food habits you teach them now can benefit them over their lifetime. Our beliefs and habits around food consumption are not innate; they’re man-made. So there is potential for change. Here are some ideas that can point us in the right direction:
  • 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.
How do you talk to your kids about healthy eating? This is where I could use the advice of a psychologist. We need to promote healthy eating and body habits without giving the wrong messages to our children. We want to encourage them to exercise without making non-athletic children feel left out. Children should not start “dieting” or worrying about body image. I wish I knew how to accomplish these goals. I do think the language we choose is critical. It’s about eating healthily, not about dieting. It’s about being fit, not being thin. It’s about being active, not “in shape.” It’s about eating the right balance of foods and appropriate portion sizes – it’s not about giving up chocolate cake. Sweets, like fast food, can be a small part of a child’s healthy diet. To get back to your story, I wonder whether you might diplomatically have asked your daughter’s girlfriend to save her soda for another day, share a few chips before putting them back in her backpack, and join in the family snack. And, of course, still arrive at soccer practice on time with everybody happy and feeling good about themselves. I’m not sure I could have managed it, but anyone with that skill deserves an honorable mention in my book. Sometimes the jobs of parenting and community parenting are tough. Good luck. (First published in the Upper Valley Parent’s Paper in Novemberr 2002)

Cold Sores

Posted August 5, 2013 by admin & filed under Uncategorized.

Not due to colds at all, but they’ll give anybody a chilly feeling come picture-taking time

Q: 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.

Cause

Unlike 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.

Prevention

Primary 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.

Treatment

Treatment 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)

Colic

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: My baby is two months old. Like most new parents I was so excited about the arrival of my first-born. I thought I was prepared for motherhood. However, I’m overwhelmed by my baby’s inconsolable crying. It’s been going on nightly for three weeks. My doctor says it’s colic, and reassures me that it will pass eventually, but how do I stay sane in the meantime? A: There is nothing more magical than a newborn. “Precious” is the word that always comes to my mind. A baby’s squeaks and gurgles can make a parent’s heart melt with joy. Crying, however, is another matter – especially a baby’s cry of discomfort – and it’s an awful feeling when we can’t console an infant in distress. When my oldest child was a month old, she cried for two hours every evening for almost a week. I didn’t think I’d survive another day of it. I kept wishing she could grow up for just one moment, so she could at least tell us where she hurt. I thought one week was horrible, so my sympathy goes out to you.

Crying

All 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.

Colic

It’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)

Constipation

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: Yesterday my baby screamed off and on for an hour before she passed a rock-hard stool. Believe me, it was a miserable experience for both of us. Worse yet, she’s been constipated three or four times previously this month. What do I do?   A: Constipation is a common and uncomfortable problem for all ages, and it’s particularly stressful when an infant or toddler who can’t talk yet is the one suffering. Because your baby sounds like she’s developing a pattern of hard bowel movements, I recommend the first thing you do is see your doctor. Once constipation starts it sometimes leads to a recurring cycle of painful bowel movements: the baby fears the pain of a bowel movement, so she resists the urge to go, and then when she finally does go, it hurts, and may even tear the skin around the anus. Your doctor can recommend temporary stool softeners to use until any scratches on the baby’s bottom have healed, and she’s confident again that going to the bathroom won’t hurt. Once bowel movements are soft and regular, you will want to avoid stool-softening medication by maintaining diet and life-style habits that promote good bowel movement. Each of us has individual bowel patterns. If your child goes one to three times a day or once every three days it’s okay as long as the stool is soft and passes easily. When bowel movements aren’t soft and regular, there are three contributing factors you can modify: fluid, fiber and exercise. Breast milk, store-bought milk, juice and water are all appropriate fluids, but I especially recommend water. Babies, toddlers, and grown-ups alike can all benefit from an extra glass of water each day. Fiber is important, but it won’t help without the fluid. In fact, if you don’t drink enough, fiber can exacerbate constipation. One idea I suggest to increase dietary fiber is to make a habit of reading the nutrition labels on packaged food. For example, breakfast cereals are touted as a high-fiber food source, but some store-bought cereals have little or no fiber. In my own house, if cereal doesn’t have at least three grams of fiber per serving, we don’t buy it. Another trick I learned a few years ago, when my then 18-month-old daughter was constipated, was to sprinkle on bran. You can find unprocessed bran in the baking or cereal aisle at your grocery store, and it’s sold under common brand names like Quaker Oats. If your constipated child is a fussy fiber-food eater then you can add the bran to food kids tend to like, such as yogurt or pudding. Then there’s exercise, which is something else we all tend not to do enough. Remember that the American Academy of Family Practice and American Academy of Pediatrics recommend at least 30 minutes of vigorous exercise every weekday and one hour on weekend days for all children. What else is there to say about constipation? “Don’t hold it in!” Constipation is frequently caused by a child’s discomfort using the bathroom outside his or her own home. Teach your children to use the toilet when they feel the urge to go to the bathroom whether they are at school, a friend’s house or a restaurant. If they hold it in, the stool hardens, their rectum may distend, and the constipation cycle begins. Encourage your children to use the bathroom when they feel the need and remind them there’s nothing to be embarrassed about. (First published in the Upper Valley Parent’s Paper in December 2000)

Diaper Rash

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: My third child gets the worst diaper rash I could ever imagine. The rash never seems to completely go away, and when it’s bad her skin is so raw that she screams when I change her diaper. Help!   A: Diaper rash is very common, and usually responds well to simple measures like more frequent diaper changes and a protective cream such as Dessitin or A&D ointment. However, some skin types are quite sensitive, and parents have to be diligent about preventing and treating a rash. Unfortunately, your daughter sounds like she has much more sensitive skin than her older siblings do. I sympathize with you and your baby. It hurts just to think about wiping poop from a baby’s raw, irritated bottom. Ouch! Diaper rash is caused primarily by constant moisture against the baby’s skin. So prevention means keeping the skin dry. If changing your baby’s diaper more frequently isn’t enough, here are some tips:
  • 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.
It’s also important to keep the baby’s bottom clean. The ammonia in urine and bacteria in feces aggravate the rash. Since your baby has especially sensitive skin you should probably wash her with water, instead of using commercially purchased “wipes.” The mild soap or fragrance on the wipes may irritate sensitive skin. The best medicine for routine diaper rash is zinc oxide. (Dessitin Ointment is 40% zinc oxide.) Research shows that zinc oxide substantially reduces both the frequency and the severity of diaper rash. Treatment should begin whenever the skin starts to look red. You can also apply it preventively. In fact, you may want to buy special diapers that apply a thin layer of zinc oxide to the baby’s bottom with each diaper change. If these measures don’t improve the rash, it’s time to get in touch with your doctor. Once a diaper rash begins, the rough, damaged skin is at risk for infection. Yeast is the most common infection; it’s characterized by a rash that begins in the skin folds and creases, and spreads rapidly – despite the zinc oxide. Fortunately, it also responds quickly to prescription antifungal medications like Nystatin. Bacterial infection can also occur, but more rarely. Impetigo is the one I see the most. It appears as blisters or red spots with a brown crusty surface. We usually treat impetigo with prescription antibiotic cream. Another cause of difficult-to-treat diaper rashes is seborrheic dermatitis (Cradle cap on the bottom). This typically bothers us parents more than it bothers our babies. When it’s severe, though, your doctor might prescribe a steroid cream. Good Luck! (First published in the Upper Valley Parent’s Paper in November 2000)

Ear Infections

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: Why does my two-year-old son get so many ear infections? A: Ouch! It hurts just to think about a crying toddler with an ear infection. If I guess correctly that you are a parent who has experienced sleepless nights and missed workdays due to a child with an ear infection, then I probably can’t give you a very satisfying answer. I can, at least, let you know that you are not alone. By the age of 3, over 80% of children have had at least one ear infection. In fact, it is the most common reason for a visit to the pediatrician. The main cause of ear infections or “otitis media” is dysfunction of the Eustachian tube. The Eustachian tube drains or ventilates the middle ear into the throat. Anything that congests the Eustachian tube leaves fluid built up behind the eardrum. Unfortunately, bacteria love to grow in the fluid. We adults often experience this trapped fluid as a “fullness” or “popping” sensation in our ears. Lucky for the grown-ups, our ears usually clear the fluid before bacteria get in. Common cold viruses are the main reason the Eustachian tube gets blocked. Unlike adults, kids have short, more horizontal Eustachian tubes that don’t drain the fluid well. In addition, children get more colds than adults do. When the bacterial germs grow faster than the child’s ability to rid the fluid, the ear infection begins. That’s when you have a fussy, feverish child with ear pain on your hands, and hopefully it’s not two o’clock in the morning. The reason your son has frequent ear infections is hard to know. It may just be bad luck. If he gets frequent colds, he is more apt to get an ear infection. Another reason might be his ear anatomy; a floppy Eustachian tube means poor drainage, and therefore the greater chance of a bacterial infection. What can you do? Well, maybe not much, but these are the general guidelines:
  • 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.
You can try to limit your child’s contact with other sick children with colds. But that is tough when our kids are in daycare or school, so at the least, practice good hand washing habits. If my suggestions don’t help, talk to your doctor. Some pediatricians believe that allergies or food sensitivities (especially to milk) play a role in ear infections. Daily medications are sometimes appropriate, and at times referral to the otolaryngologist (ear, nose & throat doctor) is needed. (First published in the Upper Valley Parent’s Paper in February 2000)

Express Feelings

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: The ordinariness of our lives has been interrupted by the events of the past few weeks. We are all touched in some way by the tragedy that has hit our nation. Many of us go through each day vaguely unsettled, harboring quiet fears about the future. As adults we can express ourselves maturely, through conversation, prayer and warm touch. But how do our kids express their feelings? What should we say to them about the tragedy, or about how we feel? How much do we shelter them? How do we be honest, yet let them feel safe?   A: As parents, these are the questions we’ve been asking ourselves. We know by now that there is no easy recipe of answers. Yet even if there is no way we ourselves can make sense of this kind of tragedy, we still have to help our children cope and understand. First, and for months ahead, we must talk to them. That is absolutely the right thing to do. How we talk to them will depend on their age, personality and degree of sensitivity, not to mention our own style and level of comfort. We should be honest, but use simple concepts that a child can understand. We can ask friends and family, teachers and health care professionals for ideas on ways to explain and what language to use, but we should also trust our own intuition, because it will probably guide us well. Talking to children demands a delicate balance. We don’t want to dig, but we want to make sure we understand their fears and uncertainties. We want to answer their questions, but don’t want to overwhelm them with information. We want to repeat our message for as long as it takes them to comprehend, but don’t want to cause them to worry. In the end, we want most importantly for them to know they can come to us with their concerns. Inevitably our children will be exposed to media they were not ready for, pick up pieces of adult conversation they don’t fully grasp, hear rumors at school that require explaining. We want them to come to us to sort it all out. And hard as it may be for us in the uncertain times ahead, we need to provide reassurance to our children, to let them know their world is secure. We need to create a sense of normalcy in their daily lives: keep up routine, leave the TV off until after bedtime (those television images are scary and disturbing even for adults to view), and hug them – though this is as much for our sake as theirs. It wouldn’t hurt to schedule extra family time either. Talking to our children about these events isn’t straightforward. But then, for most of us parenting is filled with demands we’ve had no experience meeting. We may not be experts, but simply because these are our children, we who know them best are the ones who have to do the job. (First published in the Upper Valley Parent’s Paper in October 2001)

Family Safety Tips

Posted August 5, 2013 by admin & filed under Uncategorized.

During November 2020 through February 2021 White River Family Practice is featuring fire safety tips for families. Check out the American Red Cross website for information about preparing your family for a fire by installing smoke detectors, planning exit routes from your house, doing fire drills, teaching kids how to dial 911 in an emergency, and other helpful tips. www.redcross.org

When (and how) to treat a child’s fever

Posted October 1, 2014 by admin & filed under Uncategorized.

By Michael Lyons, MD
When is your child’s fever something to worry about? When is it NOT okay to watch and wait at home? This question perplexes just about all parents (often in the middle of the night) and these guidelines can help your decision-making during a stressful time. While there is not a black and white answer, here are some things to consider.

WHAT IS A FEVER

Simply, 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 FEVER

Even 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 CHILD

Once 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 FEVER

Whether 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 DOCTOR

The bottom line is that it is good to call when your informed judgment tells you to call. Have a safe and happy winter!

(Sidebar)

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.

Fluoride Supplementation

Posted August 5, 2013 by admin & filed under Uncategorized.

How exact does it have to be? Q: We’ve been prescribed a fluoride supplement because we drink our own well water. My daughter’s preschool does have fluorinated water, and she also swallows her toothpaste. Things are different for my nine-month-old son, who only goes to daycare twice a week. I know they need fluoride, but I’ve also heard that too much is dangerous. Can you offer advice on how I can keep track? A: I hope that by my addressing fluoride supplementation in general that you’ll find your questions answered. First, keep in mind the purpose for fluoride. Fluoride supplements are recommended to prevent tooth decay. Tooth decay or “dental caries” very common: by preschool, 18% of children have at least one tooth with decay.  Fluoride is a naturally occurring mineral that combines with tooth enamel to strengthen teeth. The right amount of fluoride can reduce your child’s risk of tooth decay anywhere from 20 to 40 percent, so the goal is to make sure that all children get the right amount of fluoride, through fluorinated water, fluoride supplements, or a natural presence in your home well water.

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.[44]

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)

Hay Fever

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: Last spring my ten year old had the worst hay fever in years. I didn’t know what to give him. The local pharmacy stocked so many allergy medicines that I was overwhelmed by the choices. And what about the prescription medicine advertised on TV? Are they really better? Help! A: Yes, there are several options for treating seasonal allergies. Finding the right medicine for your son might mean trying a few different ones. But let me pose a few typical questions that I hope will help tailor your selection.

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)

Heat Rash

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: This summer was the first year for our eight-month-old baby, Eliza, to join my husband and me on the annual beach vacation with his family. During the middle of a hot and humid week on Cape Cod, Eliza broke out in a rash and seemed more fussy than normal. I was considering calling our doctor for advice when my mother-in-law reassured me that Eliza had “heat rash.” Sure enough when the weather cooled down the rash went away. I found myself wondering how my mother-in-law knew Eliza had heat rash. How did she know it wasn’t something more serious? A: Heat rash, like most rashes, has a characteristic appearance that becomes recognizable once you see it a few times. So, I suspect your mother-in-law had seen the rash more than once. It goes to show that experience adds a lot to parenting (and doctoring!). Now that you have first-hand experience, let me tell you a bit more about the heat rash, so you might also recognize it next time. Heat rash consists of little red dots or tiny pimples mainly on the neck or upper back. It is common during the hot humid weather, especially in babies. I see it most often on beautifully pudgy babies where their double chins rub on their clothing. Another name for heat rash is “prickly heat” because older children describe a prickly feeling or mild stinging sensation accompanied by the rash. I suspect that’s why Eliza seemed fussy when she got the rash. Although your mother-in-law was confident that her granddaughter had heat rash, there will always be some babies that don’t have a textbook-looking rash. So it may helpful to know what symptoms are not associated with heat rash. For example, it’s not a rash that causes a lot of pain, has any blisters, pus, or drainage. It is not accompanied by a fever or swollen lymph nodes or other signs that the child is ill. When a child has a rash and shows more symptoms than simple fussing, it’s best to see a doctor.

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)

How Loud is Too Loud

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: I was recently accompanied by a medical student to a follow-up visit with a 13 year-old boy. When we entered the exam room, the patient was listening to his  MP3 player, but he politely took it off and handed the player to his mother as I introduced the medical student. The visit was short and reassuring since the teenager was much improved. As the formal aspect of the meeting came to an end, the boy asked for his  MP3 player back. While he dialed into his favorite songs his mother asked “What’s that thing going to do to his hearing?” A: A lot of 13 year-olds have MP3 players, and few of them are ever worried about hearing loss. The truth is that hearing loss is a real concern, but it also can be avoided with a little thinking ahead. The main message is not to listen too long with the volume cranked up. Portable music players have been around for a long time. The Sony Walkman came out when many of us parents were teenagers. The difference with  MP3 players is that you can listen for long time, some headphones (or “earbuds”) can be inserted right into the ear, and kids are listening longer. Hearing loss results from both the volume of the music and the length of the listening session. We know loud noise causes hearing loss by damaging the delicate hair cells in the inner ear that transmit sound impulses to the brain. Exposure to noise of 85 decibels (about the equivalent noise level emitted by a typical lawn mower) for 8 hours will cause hearing loss. Any slight increase in the decibel level dramatically reduces the safe listening time. For instance, a person can only tolerate 100 decibels of noise for 10 – 15 minutes before there is potential damage to the hair cells in their ears. Many MP3 players can reach 100 decibels. Another factor is the type of headphones you choose. MP3 players usually come with earbud style headphones. Earbuds put out more decibels than headphones that sit on top of the ears (which is the style you’d have gotten with your 1980′s Walkman). Some people buy sound isolating headphones capable of even higher outputs. The potential advantage to sound isolating headphones is that they are better at blocking out background noise so the listener won’t need to crank the volume to drown out distracting noise (such as the lawn mower or their parents’ voices). It’s not just teenagers who need to be aware: after I said goodbye to the teenager and his mother, the medical student piped up: “I never knew I was putting my hearing at risk. I use my iPod all the time.”
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.
The American Academy of Pediatrics estimates that 16 percent of kids ages 6 -19 already have noise-induced hearing loss. Educating your children on the potential hazards of headphones will help keep them off this list. Don’t get me wrong: I love music. I frequently borrow my wife’s or daughter’s iPod especially when I go the gym (sometimes without asking first). To ensure you can enjoy music all your life, watch the volume carefully. Don’t become like my wonderful elderly neighbor Fred. He can’t hear conversation much less music after working around load noise as a young man in the Navy. Enjoy your music … safely! (First published in the Upper Valley Parent’s Paper in February 2007)

Instant Messaging

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: Can you recommend any rules for home internet or Instant Messaging use by teenagers? I have an uneasy feeling that IMing and web surfing is too much, too soon in the daily lives of my teenage children. A: Wow, that is one tough issue for us parents of teens and preteens. Your question comes up regularly at medical meetings and social gatherings. I’ve heard lots of discussion on the topic, and I don’t think there are any one-size-fits-all answers. On the other hand, I do think each family should think hard about how to address teen and preteen internet use in their home. A couple of stories that other parents have told me in just the last two weeks illustrate my concern. In one household, the dad decided to look back at which websites his 10 and 12 year-old children had viewed recently (a reasonable and simple monitoring technique). He was alarmed that one of them had gone to a pornography site. When he confronted his children, his 10 year-old daughter began to cry, and then explained she got to the “awful” site by accident. She had looked up “American Girl” in a search engine, clicked on an adjacent web address, and linked on the disturbing porn site. In another household, the mom admitted to her girlfriends that she hadn’t monitored her 13 year-old daughter’s computer travels. She knew she spent a lot of time IMing her friends, but figured that it seemed harmless and maybe even better than gabbing on the telephone. After her friends prompting, she investigated. In her search she found out that her daughter had downloaded a program to create her own web page. Her daughter had posted her own photo, address, and personal information, and also stated that she was 19 years old. Imagine your newly teen-aged daughter attempting to pass herself off to anyone who comes across her site as being old enough to offer legal consent! These stories suggest to me that we all need to sit down, think about the issues, and make a plan for our households. I can brainstorm with you and share ideas that have been tried in other homes, but the implementation must be custom-tailored to your own house and level of comfort. Here are a few ideas I’ve heard:
  1. Keep the computer in a central room where it is easy to check the screen.
  2. Monitor online time, and spend time with your children when they’re logged on.
  3. 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?
  4. Make a policy that passwords are shared with the parents. That way you can retrace internet activity, or read e-mails if deemed necessary.
  5. “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.
  6. Once you feel like your children’s maturity levels warrant more internet social time, make sure they use an alias.
  7. Educate yourself. Get to your child’s favorite teen website and explore.
  8. 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.
  9. Use filtering technology in the home to limit access to the web.
  10. Employ software that monitors where your kids go online.
  11. 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.
  12. Here are some websites for more ideas: www.protectkids.com, www.netmom.com, and kids.getnetwise.org.
On a personal note, I confess that the whole topic of internet safety makes me feel old. When I became a new father almost twelve years ago, I remember thinking I would make a hip dad to my future teenager. At that time I couldn’t think of anything too unfamiliar for me to handle. Well… I’m learning! (First published in the Upper Valley Parent’s Paper in April 2006)

Language Development

Posted August 5, 2013 by admin & filed under Uncategorized.

By Joanne Hayes, first published in the Upper Valley Parent’s Paper, 2007

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.
Age 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
Problems that can lead to language delay are numerous and have various causes. There are certain red flags that should prompt a parent or primary care clinician to seek further evaluation. Any concern on the part of a parent or care provider is the first of these red flags. Other criteria include not meeting general language milestones; difficulty sucking, chewing, or swallowing; difficulty with movement of lips, tongue, and jaw; no babbling by nine months; no first words by 15 months; no consistent words by 18 months; no word combinations by 24 months; difficulty in parents understanding speech at 24 months or strangers understanding at 36 months. More indications can be stuttering; frustration of the child in communication; teasing of child by peers for “talking funny”; avoidance of talking situations; problems with using language appropriately; difficulty in expressing ideas; problems in following instructions; and/or loss of milestones already achieved. Some children are “late talkers” and may not reach each milestone at the expected time. “Late talkers” eventually catch up and are not affected by the earlier delay. However, it is difficult to differentiate between “late talkers” and other language and developmental problems without an evaluation. Many parents (and clinicians) want to wait and see if the language improves on its own. Often the language will develop, but if there is a problem, early intervention is important. Research shows that delays are not the result of laziness, older siblings doing all the talking, bilingual environments, or because of being a twin. At 24–30 months, bilingual children may intermix vocabulary and syntax from both languages while language milestones are still being met. Research also shows that language impairments persisting beyond five years may continue on into adulthood. Studies looking at late talkers (with no other delays) showed that early intervention decreased parental stress and assisted the child in increasing vocabulary and intelligibility. However, without intervention, the late talkers did not have persistent problems into adulthood. Whether a child is a “late talker” or has other language problems, early intervention may help the child’s self esteem and decrease frustration for all. In the Upper Valley, there are two agencies that evaluate for developmental delay. Their number one reason for referral is delayed language. Most children are referred by their primary care clinician, but parents can call the agencies directly. For New Hampshire residents, Pathways of the River Valley performs evaluations for children age 0-3. They can be reached at (603) 448-2077. In Vermont, The Family Place evaluates children ages 0-3. They can be reached at (802)649-3268. Each agency does thorough evaluations that address several areas of development including language. Vermont and New Hampshire differ in assessing eligibility for services, but both agencies work with families to create an individualized plan for each child and assess what services are needed. The agencies will also help the families with ways they can assist their child. After age three, evaluations of language or other delays are done by the local school district. In Vermont, if a plan is in place before age three, the individualized plan will continue. In New Hampshire, a new evaluation and assessment will be done at age three by the school district. Language development in children is incredibly exciting to watch and participate in. This development continues far beyond the toddler years. Frequent reading and conversing with your children will encourage positive development of language and literacy.

Lessons from the Cow Barn

Posted November 6, 2014 by admin & filed under Uncategorized.

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.
Angela Toms is a family physician at White River Family Practice. She lives on a small farm with her husband and four children as well as cows, pigs, sheep, chickens and dogs. She truly enjoys following her kids’ passions with them and has spent countless hours in the cow barns, on the trails with the bird dog, on the soccer and lacrosse sidelines, in the window of the dance studio and in many hockey rinks.

Lice

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: My daughter was scheduled for a playdate at her friend’s house last week. The friend’s mother called the night before to inform me that her child had head lice. Although the girl had used the anti-lice shampoo two days earlier, I panicked at the mention of “lice” and politely canceled the playdate. Was I overreacting? Is it true that sometimes head lice can’t be cured with routine medications? How long is a child contagious after shampooing? A: I don’t think you were overreacting. Sometimes lice (pediculosis) are hard to get rid of. Although one shampooing is usually adequate, I recommend following the “no-nits” policy. For example, most school nurses will not allow children to return to school until all the nits are gone from the hair. I think that’s good advice for deciding on a playdate as well. The lice are tiny creatures (about the size of a sesame seed) and are commonly never seen. The white “nits,” which are easily spotted on the shafts of the hair, are the lice eggs. Since the lice themselves are difficult to see, the no-nits policy is the best way to ensure all the lice are dead. The nits, however, aren’t easy to wash out. Unlike sand or dandruff, the nits seem to stick to hair, and need to be combed out. This might take several days. You mentioned medication resistance. The Centers for Disease Control and Prevention in Washington DC has reported strains of lice that are resistant to our commonly prescribed medications. But that is still rare, and fortunately has not been an issue in the Upper Valley. I believe treatment failure most often occurs when parents are not thorough enough. Proper application of the shampoo is a frequent problem. The lice anchor themselves on the scalp. If the scalp isn’t massaged well with the shampoo, they may survive the hairwashing. Imagine how easy it would be miss a spot (one louse) on a long, curly-haired 3-year-old who doesn’t like to take baths. Another reason the lice are difficult to eliminate is reinfestaion. Children can pick up a louse from household contacts like a favorite stuffed animal, hat, or a sibling. That’s why treatment needs to be so thorough.

Treatment Recommendations:

  • Buy anti-lice shampoo. Nix, Rid Mousse and others can be purchased without a
  • prescription.
  • 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.

Removing Nits:

  • 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.
(First published in the Upper Valley Parent’s Paper in September 2000)

Lice: Cute, but She’s Scratching Her Head

Posted August 5, 2013 by admin & filed under Uncategorized.

Could be… wasn’t there a report of head lice going around? Q: Recently, we visited my brother’s family for the weekend.  Afterwards, my brother called to warn me that the cousins had head lice.  Most disturbing was his story about shampooing both girls with anti-lice shampoo, but the shampoo didn’t get rid of the lice.  Luckily, there has been no sign of lice on my kids, I’d like to know now what the story is with head lice.  How do you get ride of head lice if the shampoos don’t work? A: It’s true that head lice are developing resistance to common medicated shampoos.  But usually the shampoos still help, even if they are not the whole answer on treating lice.  Treatment for head lice has always included careful combing.  With the development of resistance, we still recommend the shampoos, but combing (and more combing) has become a more important piece in the treatment of head lice. Head lice, or pediculosis, are sesame seed-sized creatures that live in human hair.  They give most kids and parents the heebie-jeebies, but otherwise are harmless to our children’s health.  The lice are not always easy to find.  They tend to hide at the base of the scalp and behind the ears.  On the other hand, the lice eggs or “nits” are easy to see, and look like specks of dried sugar attached to the hair shafts.  If you see nits, you can be sure the lice are there somewhere.  All it takes is missing one louse or nit and the head lice will repopulate on the scalp every couple of weeks.  That’s why shampooing and combing must be so thorough. The common shampoos available over-the-counter contain pyrethrins and permethrins.  The permethrins (like Nix) seem the most effective.  A study in 2002 showed that Nix shampoo effectively treated head lice about 80% of the time.  I know a few parents (perhaps your brother is one of them) who don’t believe that it works that well.  Yet despite some parents’ personal experience, I still recommend it.  The key is not to expect the shampoo alone to be the cure.  Daily careful combing is equally important as the shampoo.
Combing
When 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!

Limiting TV and Computer Time

Posted August 5, 2013 by admin & filed under Uncategorized.

Turning it on is so easy, but the side effects can last a lifetime Q: I saw you in the office a couple times this fall for my children’s check-ups. You recommended no more than an hour a day in front of the screen for my kids, and that we should include computers, videos, and TV in this figuring. Do you think that’s realistic? I watched a lot more TV as a kid than one hour a day and I grew up perfectly healthy. A: If I had to declare TV bad or good, I would have to call it “bad.”  Like many things in life, though, the answer is not quite so clear cut. There are good things about television as well as computer games and even some video games. Too much time in front of screens, however, is clearly bad. It is important to limit monitor time and pay close attention to the content you allow children to watch. The statistics compiled on the ills of TV viewing are startling and may give you insight as to how bad television can be. The average American child watches television three hours per day. By the end of high school, that translates on average into 15,000 hours of witnessing 18,000 violent deaths and 350,000 commercials. So, how does all this affect children?

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.
Domestic tranquility: This was my own favorite excuse for turning on the TV. Here is a scene from when my kids were little: it’s just before dinner: the kids are tired, hungry, and melting down; Mom is at work and I’m still standing over the stove. I start losing my cool. On goes the TV and presto! The kids are quiet (thank goodness for Arthur at 5:30 P.M. on weekdays. Is that still on Public TV?). I finish making dinner without disruption, and there is peace in the household… for awhile. Family togetherness: It’s pleasant to sit together as a family in one room. Sports is popular in my family-everyone is happy watching the World Cup soccer, although the few times we all watch together I wish that I’d purchased Tivo so we could skip the commercials! I write mostly about television because there’s decades of compiled research on TV viewing. The health effects of computer and video time aren’t as well proven. However, most healthcare professionals have the same concerns about overuse of computers and videos. That’s why I recommend limiting “monitor time” to less than one hour. I realize life is full of balancing acts and compromises, and that the circumstances in every home are unique. I respect that the rules limiting use of the TV, computer and video games will vary within each household. I guess my biggest fear is that we will let life get busy, not set up any restrictions, and then let monitors influence the lives of our children at the expense of their development and in a way that reduces the quality and quantity of family time. Best of luck with the challenges and fun of parenting! (First published in the Upper Valley Parent’s Paper in November 2007)

Spring is here and so is Lyme disease

Posted August 5, 2013 by admin & filed under Uncategorized.

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 bites

Prevention 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 bites

Inevitably, 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
  • Fatigue
  • 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 perspective

While 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 https://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.

Massage

Posted August 5, 2013 by admin & filed under Uncategorized.

Sanctuary Wellness Massage Center in Norwich Vermont 802-356-1156 Jenny Gelfan

Nutrition

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: Good nutrition has been important to me all of my adult life. I think that’s why I’m having such a hard time with the recent eating habits of my older two children. They are so picky! As babies they seemed to eat most everything from my veggie tofu specials to the occasional hot dog at our favorite roadside grill. Now, at ages five and seven, the older two kids seem to eat hardly anything. Mealtimes are getting longer and becoming a source of aggravation instead of fun. What happened to my good little eaters? How can I get them back? A: First, I can reassure you that you are not alone out there. Many parents struggle to get their kids to eat right. I don’t think anyone really knows why some kids go through a phase in which they disdain mealtime, but I would not become overly concerned. I’m convinced that the more our kids know we are frustrated, the less pleasant the eating hour becomes. How will you win their good eating habits back? I don’t know exactly, but I’m certain you will. As with most parenting issues, there is no single answer to fit every family or every child. Trust your own ideas, and be creative. The following are some hints I hope might help. Common pitfalls:
  • 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.
Suggestions:
  • 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.
Good luck! (First published in the Upper Valley Parent’s Paper in April 2001)

Ouch! Splinters!

Posted August 5, 2013 by admin & filed under Uncategorized.

What do ice and tape and tweezers, fingernails and salt have in common?  They’re all useful in removing a common pain of summer. Q: All of you readers must be busy! Nobody wrote in with a question for this issue, so I’ll take this chance to answer one of the most common questions I get in the summer: “What are some tricks for removing splinters?” A: That’s a mighty good question! My family and I like to rent a house by the beach with loads of cousins and other kids nearby. We regularly have kids limping over to our house to ask for help pulling out a splinter – it’s almost a tradition. Sometimes removal is easy.  If the end of the splinter is hanging out enough to get a good grip, I grab it with my fingernails or tweezers. It’s done! We wash the wound afterwards, put on antibiotic ointment and a Band-Aid, and presto!  The child is back to playtime. Of course, if it’s that easy, you probably don’t need a doctor next door. Most of us know the frustration of going after a small splinter and having the exposed end break off with the part that counts left in the foot or finger. If you see that scenario coming-stop! Keep the child from digging at the splinter, and go get some tape. Any sticky tape will probably due, but the transparent nature of cellophane tape let’s you see what you are doing. Apply the tape over the splinter, and then pull the tape off in the opposite direction that the splinter went in. Ideally, the splinter comes out stuck to the tape. The next situation is the more likely one to end up on my doorstep: the splinter hurts but both ends are buried under the skin. Again, it is a good time to not move too hastily. My nieces and nephews will put up with more painful prodding from their uncle-the-doctor than their parents. But if I can numb the toe a little before I go after the splinter. I’ll improve my chances of a successful removal. The best at-home anesthesia is ice. First step, then, is to numb it. If there is a baby in the house, apply some of his teething medicine to the splinter site before the ice. While the foot is chilling, go get a needle and some tweezers. Good tweezers make all the difference. This is when you hope mom packed her $40 dollar eye-brow-grooming tweezers! Take the tweezers and needle, and dip the ends in rubbing alcohol, or quickly pass the tips trough a candle flame. By the time you find the tweezers and the needle the foot is hopefully good and numb. Use the needle to probe away skin making a small hole over the end of the splinter. Once the end of the splinter is in view, lift an edge with the needle, grasp it with the tweezers and gently pull. When all this fails it is time to be patient again.  Soak the affected foot or hand. Epsom salt or table salt in the water might help. Soaking frequently for 24-36 hours may loosen  the splinter enough so you can remove it on the next try. If the child is too uncomfortable for soaking and waiting, take him to the doctor’s office or local emergency room. It’s important to ask about the last tetanus shot. For patients who have not had a tetanus immunization within 10 years, it important to get a tetanus booster within 72 hours, so if you are away on a weekend getaway you should arrange for the tetanus shot on Monday. Once in a while someone asks about a toddler with multiple, tiny splinters that don’t hurt. Usually, the parent notices the splinters after the child’s been running around barefoot on wooden deck. If they don’t hurt they likely don’t go deeper than the callous or dead skin layer. These tiny splinters are safe to ignore. As the skin renews and flakes off, the little splinters will fall off on their own. I can’t write on a medical topic without commenting on prevention. Prevention is obvious – wears shoes!  But somehow bare feet and summertime fun just go together. Despite my lackadaisical attitude to summertime footwear I recommend caution for kids on decks or play structures constructed from pressure treated wood. A few years ago the EPA warned about possible health hazards from arsenic-based treated wood. It seems prudent to keep the kids shoes on while playing on this wood. That’s my answer to my own question! Perhaps you’ll find the unsolicited advice helpful. (First published in the Upper Valley Parent’s Paper in July 2006)

Pink Eye

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Q: My child caught a bad case of pink eye in February and experienced a lot of discomfort. What is it, why do kids get it so easily, and when does pink eye become a concern? A: Pink eye or “conjunctivitis” is an inflammation of the delicate surface that lines the eye and eyelid. Anything that irritates or infects the eye can cause conjunctivitis. Pool water, sand, hair spray, allergens like pollen or cat hair, and germs are all possible offenders. The more troublesome causes or “bad guys” as my son likes to say, are the germs: viruses and bacteria. When people call me with a concern about conjunctivitis, they are most often worried about bacterial conjunctivitis. This usually involves only one eye. It tends to become more and more swollen, red, and pussy until it gets treated with antibiotics. Bacterial conjunctivitis is very contagious among small children, and a good reason to keep them out of school or daycare. Any child who rubs his eye and touches a friend before washing his hands is likely to pass it on. Viral conjunctivitis, on the other hand, is not quite so worrisome, and antibiotics won’t help it get better. It typically affects both eyes. The eyes are more watery than really red, and the child frequently has associated cold symptoms like a runny nose or cough. It’s essentially a cold in the eyes–no more serious or contagious than any other cold virus. I recommend parents decide on school, daycare or playdates as you would for any cold. Remember that cold viruses are most contagious the 12 hours before the symptoms hit you, and for 48 hours afterwards. To prevent infecting others, wash hands frequently, and avoid sharing towels or washcloths. The difficult issue is that many daycare providers don’t like my advice. To ward off a bacterial outbreak they like all kids with conjunctivitis, viral or bacterial, to get antibiotic eye drops. In fairness to their concerns, it is sometimes difficult to tell the difference between the viral or bacterial variety. And if a child has a cold in his eyes for a long time, he could rub them enough to introduce a new germ, causing a secondary infection with bacteria. On the other hand, overuse of antibiotics is bad for your child and for the community. With all that said, let me share with you the advice I usually give. If your child has conjunctivitis that you think is bacterial, call or visit your doctor. If the child has other cold symptoms and both eyes are affected, it is probably viral. So it’s okay to treat at home by regularly cleaning the eyes with warm water and watching and waiting. If the eyes continue to become more red and gooey, a secondary bacterial infection may have developed. You should then seek out your doctor’s advice on antibiotic drops. Most cases of viral conjunctivitis won’t get worse after the first 36 hours, although the symptoms can linger for several more days. If they are really itchy, decongestant eye drops like Naphcon-A (purchased without a prescription) may help. When there is any suspicion of a foreign object in the eye, or that redness is spreading onto the outer eyelid, see your doctor right away. (First published in the Upper Valley Parent’s Paper in March 2000)

Pneumococcal Vaccine

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Q: I got a letter from my doctor recommending I bring my four-and-a-half-month-old daughter in to get a new vaccine. I want to do the right thing for her, but I worry about side effects. Besides she just got four shots at her last doctor’s visit two weeks ago. My insides quiver at the thought of another needle poking her tiny thigh. What’s your advice? A: I recommend the vaccine, but you’re right to be careful. Side effects? Well, I would be more comfortable if the vaccine had been around longer. And the pokes? Ouch! I hate that part too. Let’s talk about it.

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)

Poison Ivy

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Q: In the summer we are a camping family. We take our two kids and hike, fish, bike, and canoe. We love it. Last June, however, poison ivy nearly ruined our vacation. Is there any good way to avoid a repeat crisis on this year’s vacation? A: You could vacation in Nevada this summer since it is the only state in the continental U.S. without poison ivy or poison oak, but I don’t think that’s the kind of answer you were looking for. Let’s go over the “Dos” and “Don’ts” of poison ivy, and see if that helps you avoid a repeat of last summer.

DO

  • 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

  • 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.
If someone in your family does get poison ivy, there are some actions you can take to relieve the itch:
  • 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.
Those are the basics. But if you or your kids are prone to getting poison ivy badly, I would also considering looking into the Oak-n-Ivy Tecnu products. They make a “skin protectant” and a “skin cleanser;” one to put on before you venture into the woods, and one to wash off with afterwards. The products work. I can’t promise that it will work better than an application of bag balm and scrubbing with dishwashing detergent, but studies indicate the products help, and I have a couple of patients who swear by them. (First published in the Upper Valley Parent’s Paper in June 2000)

Restless Leg Syndrome

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: I read an article in the NY Times about “restless leg syndrome” and began to wonder about my daughters’ symptoms. Both my kids at various times have terrible leg aches when trying to get to bed. Massages seem to help. Otherwise they seem fine and are very active. I thought maybe they just had “growing pains,” but to be honest, I don’t know if there really is such a thing. Do you think I need to worry about restless leg syndrome? A: That’s a great question. I also find it fascinating that you became concerned after reading the article in the newspaper. Isn’t it typical that health articles that are meant to inform us often cause us concern? I suspect your intuitive parenting skill led you to the right diagnosis. It sounds to me like your daughters do have growing pains.

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.

Treatment

I 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 doctor

You 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)

School Colds

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: Once school starts each September, it seems like my children immediately come down with sore throats, bad colds or some other illness. Isn’t there anything I can do to help keep them well this school year? A: I’m sure many parents feel the same way. After a summer of good health, it is frustrating to have to deal with runny noses and fevers. Along with the cooler weather of autumn comes the start of cold and flu season. There are more viral germs around, and the close contact of children in schools allows for easy spread of germs from person to person. I probably don’t have any advice you haven’t heard before, but reminders never hurt.
  • 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!
If there’s anything I want to emphasize, it’s hand washing. One study done at an elementary school showed illness-related absenteeism was cut in half when the school put in place a rigorous schedule of hand washing before snack and lunchtime. It works. During the flu season I see a lot sick children in the office. Parents frequently ask how I keep from constantly getting sick. One of the biggest reasons is hand washing. I wash my hands between every patient. In terms of what types of soap to use, I have no specific recommendations. I know antibacterial soaps have become popular, but these are not especially helpful and may be harmful in the long run. The cold and flu germs that affect our children are caused by viruses, not bacteria. So antibacterial soap won’t help more than any other soap. And whenever antibacterial agents become widely used, the chance of bacterial resistance rises – so the antibacterial agents will no longer be effective when we really need them. Enjoy the crispness in the fall air, the back-to-school spirit, and wash your hands so you don’t miss out on any fun. (First published in the Upper Valley Parent’s Paper in September 2001)

Seasonal & Novel H1N1 Flu

Posted August 5, 2013 by admin & filed under Uncategorized.

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.
* Though the scientific evidence is not as extensive as that on hand washing and alcohol-based sanitizers, other hand sanitizers that do not contain alcohol may be useful for killing flu germs on hands in settings where alcohol-based products are prohibited.

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

Skeletal Planning

Posted August 5, 2013 by admin & filed under Uncategorized.

Now is the time when kids will get the best return on their calcium ingestments Q: In your September Parent’s Paper article, you wrote that many teenagers don’t get enough calcium in their diet, especially soda-drinkers. The article has led to quite the discussion in my house, where I have three teenagers. Just what is the importance of daily calcium for teenagers? What’s the recommended daily amount of calcium? What do I do about my non-milk drinking daughter? A: Calcium is a vital nutrient in the body. Most people are familiar with the integral role calcium has in building strong bones and teeth, but calcium is also vital to multiple functions of the body at the cellular level. For example, our body needs small amounts of calcium to ensure rhythmic heartbeats, muscle contraction, blood pressure control, and neural message transmission. And, the body places priority on these functions over the building of strong bones, so if there is not enough available calcium from our dietary intake, the body actually borrows calcium from the bones. Insufficient calcium intake over years leads to “thin bones,” or osteoporosis.
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 menu
In 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
AGE
Calcium
4-8
800mg
9-18
1,300mg
19-50
1000mg
 

Sources of Calcium
milk 1 cup
300mg
yogurt 1 cup
300mg
cheeses 1.5 oz
300mg
broccoli 1 cup
150mg
spinach 1 cup
200mg
raw medium-size carrot
25mg
one orange
50mg
almonds 1/4
90mg
  Don’t forget to read nutrition labels on all boxed food For teens who like milk, three servings a day of a dairy product combined with a diet balanced in fruits and vegetables will provide all the calcium needed.
Calcium Supplements
I’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.

Sleep Needs

Posted August 5, 2013 by admin & filed under Uncategorized.

On the first day of school my son’s first-grade teacher made one request: “Now that summer is over,” she said, “please get your child to bed early so he is rested and ready for school.” I realized that my son probably stays up later than most first-graders because his two sisters are teenagers. I think he sleeps enough, but then I began to wonder how much sleep is enough? A: I think your son has a smart teacher. When my son was in first grade the teacher gave the same advice. Boy was she right! To this day he still is a grump when he has too many activities (or too much homework!)and doesn’t get enough sleep. The truth is children (and adults too) need their sleep. Lack of sleep adversely affects moods, performance, and alertness. Some estimates suggest that 30 – 40 percent of school-age kids don’t get enough sleep. That’s very hard on teachers as it seriously hinders our kids’ abilities to learn. If sleep deprivation continues over months and years it can lead to compromised cognitive function, weight gain, and depression. Sleep is important, and not to be taken for granted!

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

Age Sleep Needs
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 Teenagers

You 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

  1. Make a consistent sleep schedule.
  2. Bedtime routines are good: use them as consistently as possible.
  3. Go to bed in the same sleeping environment every night.
  4. It helps to be in a cool, quiet and dark room (without TV or computers).
  5. For more ideas check out the website of the National Sleep Foundation.
I wish the best to your son in his first year in all-day school. Sweet dreams to the whole family. (First published in the Upper Valley Parent’s Paper in September 2007)

Some Time Alone

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: When I was in the office for my five-year-old son’s annual check up, you asked him if his Mom and Dad went out on dates alone without kids sometimes. I sensed that question was really directed at me.  I’m afraid the question caught me off guard, and I didn’t really listen after that. What was the message you wanted to give? A: Well, I feel a little crimson in the cheeks as I read your question. Most of us primary care doctors pride ourselves in making patients feel that the office environment is a comfortable place to communicate, so I’m sorry if it seemed awkward. Honestly, I feel funny replying in the public forum of this article.  Most of my “Ask Dr. Lyons” questions  have answers with a medical basis. Your question brings out the “softer” or psychosocial side of caring for children. Although I believe the psychosocial aspects of our lives strongly influence our health, I’m more comfortable addressing those issues face to face. Actually, I asked my editor to pick another topic, but he encouraged me to reply to your question. So here goes. I routinely ask parents at well-child visits if they are spending some scheduled time together without children to help take care of themselves and their marriage. The actual question varies, but my point is simple really: we all want to raise happy children. Happy kids tend to have happy parents, either married or single, leading the family. My sense is that most parents give all their energy to the kids: from outward expressions of love to mundane chores like laundering their favorite jersey before every soccer game, to driving them to violin practice. What with laundry, meals, housework, and the attention children need, the self-care and time to cultivate the sparks of love between the adults in a kid’s life can take a back seat. In the long run, I think kids will grow up happier if they sense a content spirit in their home. I know I’m not giving earth-shattering advice. In fact, a family therapist once told me that was probably the single most common piece of advice she gave out.  I recall a discussion with a friend who said he had recently been seeing a marriage counselor. When the counseling sessions were coming to an end the therapist recommended that he and his wife spend the same amount of time and money to do something fun together – just as a couple. He thought it was as effective (and more fun!) as the counseling sessions. It’s more a gentle reminder to do what might seem obvious from an outside perspective, but difficult when in the thick of kid rearing, especially in those preschool years. I think it helps adults to be reminded, and it helps kids to hear that the adults in their lives need time, too.  So, in my office, I try to do my small part by asking this question.  I need reminders, too: it’s tough to balance kid wrangling and marriage tending – I know I’m not the perfect example. (First published in the Upper Valley Parent’s Paper in December of 2005)

Sun Protection

Posted August 5, 2013 by admin & filed under Uncategorized.

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.

Sunglasses

Posted August 5, 2013 by admin & filed under Uncategorized.

Q: My ten-year-old-girl came home from school saying I need to buy her sunglasses. Now, I’ve heard about her “needs” before – scooter, tank top, Gap jeans. But then she tells me that the school nurse gave a summer safety talk and recommended sunscreen, hats and, yes, sunglasses to ward off all those harmful effects from the sun. When I was a child only the kids who were too cool wore sunglasses. Do my children really need to wear sunglasses? A: Yes, I recommend that kids wear sunglasses. When I make this recommendation I always hesitate because I’m not sure how practical it is for young kids to keep on a pair of dark glasses. In my house my wife and I probably misplace our sunglasses once a week, so how can we expect our kids not to lose them? On the other hand, a lot of us early-middle-age parents are already showing signs of eye damage from the sun. Truth be told, I wish I’d been “cool” enough to don the shades more often in my youth.

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.
Good luck. Have fun in the sun! And if you have any tips for keeping sunglasses on a four-year-old, let me know. (First published in the Upper Valley Parent’s Paper in June 2001)

Swimmer’s Ear

Posted August 6, 2013 by admin & filed under Uncategorized.

Q: During last summer’s vacation we wasted a sunny afternoon in the waiting room of an out-of-town ER  because my daughter got “swimmer’s ear.” It seems like she gets the same thing every summer. Is there a way to avoid this infection, or treat it at home? A: Swimmer’s ear is an infection of the ear canal. Another name for it is an “outer-ear” infection, because the infection is outside the eardrum. Kids with outer-ear infections commonly say they’ve been swimming recently. Water that mixes in the ear canal with a little earwax makes a good place for bacteria to grow – hence the name “swimmer’s ear.” It can be helpful for parents to try to distinguish between a swimmer’s ear and an inner-ear infection. Inner-ear infections are usually preceded by a cough, cold or sore throat; swimmer’s ear is not. Swimmer’s ear may hurt worse when you chew or when someone presses on the tag on the inside of the ear lobe.

Prevention

  • 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.

Treatment

Once 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.
And in the end, if you must break from your vacation activities to seek a doctor’s advice, don’t let it dampen your vacation spirit. Your kids might even remember time out from the fun and games fondly. I can recall a trip with ear pain to the doctor’s office the summer I was eight years old. As one of six kids, I relished the delicious time alone with my mom, not to mention the ever-so-special orange ice cream soda after the doctor’s visit. Have a happy and healthy summer vacation. (First published in the Upper Valley Parent’s Paper in July 2002)

Teenage Knee Pain

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Q: My 16-year-old daughter has been complaining of pain in her knees for the last several months. It seems to be getting gradually worse. She is a skier on her high school team, but she does not remember falling or injuring her knees in any way. Should I be concerned? Should I hold her out of skiing? What should we do? - Concerned in Norwich A: Good Question! And I know just the person to help me answer it. My new partner, Dr. Peter Loescher, just finished a fellowship year in Sports Medicine. I promised him that the first time I got a sports question, I’d call him in. Here’s what Dr. Loescher says: Dear Concerned: Thank you for your question. There are a number of knee conditions that can cause gradual onset of knee pain. Your daughter should see her doctor to have her condition evaluated and diagnosed definitively. That said, her symptoms are classic for a condition called patellofemoral compression syndrome, (PFCS), the most common knee problem seen in sports medicine and orthopedic practices. PFCS is caused by irritation and inflammation of the cartilage located on the underside of the kneecap (aka, the patella). While there are many causes of cartilage irritation, the most common is overuse – repetitive flexing and extending of the patellofemoral joint (the joint formed by the kneecap and the thigh bone). Activities that demand repetitive motion include: jumping, running, skating, and skiing. The kneecap cartilage can also be irritated through direct trauma, as with a blow to the knee or a shift of the kneecap out of its normal groove in the thigh bone. While PFCS can affect anybody, certain people are more prone to developing the condition. These people include: females, and people with flat feet, a weak inner quadriceps muscle (the vastus medialis), a strong outer quadriceps muscle (vastus lateralis), a shallower than normal groove in the femur, or a kneecap that sits high and/or to the outside of the knee joint. Females suffer from PFCS far more often than males due to their wider hips. Because of their wider hips, their thigh bones form the knee joint at an angle that makes it more likely for the kneecap to track to the outside of the groove where it is supposed to sit. This can lead to irritation of the patellar cartilage as it rubs against the thigh bone instead of sliding in the smooth groove where it was made to travel. The most common symptoms seen in PFCS include: pain around the front of the knee, pain that increases with physical activity or when descending stairs or hills, and pain upon arising from a sitting position. Patients will often complain of popping and cracking sounds with movement, and they may feel a sense of catching or instability in the knee. In severe cases, swelling of the knee may be present. Most cases of PFCS will improve with a combination of exercise and stretching. Strengthening the inner thigh muscle and stretching the hamstrings is critical to improving the stability and tracking of the kneecap. Activity modification and anti-inflammatory medicine can also help, as can knee braces and taping techniques designed to help hold the kneecap in place during activity. If PFCS does not improve from these treatments, surgery may help. Surgery is really a last resort for PFCS, and all non-surgical options should be exhausted before surgery is considered. Finally, patients with PFCS must remember that once their diligent stretching and strengthening programs have resolved their knee pain, their anatomical predisposition to the condition still exists. Therefore, any rehabilitation program successfully undertaken must, in some form, become a part of a regular routine, to ensure continued pain-free activity and the ability to lead an active life. (First published in the Upper Valley Parent’s Paper in December 2002)

The Common Cold in Kids

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By Joanne Hayes, first published in the Parent’s Paper, 2007 It has started again this year for my kids.  It seems that my 3 ½ year old’s nose does not stop running from fall through mud season.  How do I know when a cold is more than a cold? And now with all this confusion about cold medicines, what can I do to help her feel better? Cold Season is upon us.  Certainly kids (and grownups) can get colds year-round, but there is an increase in incidence during the fall and winter seasons.  Different viruses peak in different months and are more easily spread as we move inside and are in closer contact with one another.  The feeling that the cold starts sometime in September/October and ends in April is not uncommon. This “super long cold” is especially noticeable in children because kids get more colds and their colds last longer.  On average, adults get two to four colds per year having symptoms for five to seven days.  But your daughter and other kids younger than six, average six to eight colds per year with symptoms usually lasting 14 days.  That’s a lot of days – a cold a month from September to April! To make matters worse, kids often have more symptoms and depending on the age of the child, they may not be able to tell you exactly what isn’t right.  The main feature of colds in adults is nasal congestion.  Nasal discharge is also very common in children and is often accompanied by fever during the first few days of the illness.  Other symptoms in children may include sore throat, cough, irritability, difficulty sleeping and decreased appetite. So, with all these symptoms, it is certainly understandable that you may be confused about when a cold is not a cold.  First off, let me just make a comment about nasal discharge.  Colored discharge does not mean bacterial infection.  Rather it is part of the natural course of the cold and is more an indicator of certain white blood cells in the discharge. Colds – also known as upper respiratory infections – are caused by different viruses.  Sometimes the cold persists beyond the normal course and may lead to other complications.  These complications include ear infections, asthma, pneumonia and sinusitis.  In general, I suggest using your good parenting sense.  If something just doesn’t seem right, have your child be seen.  If your child has a constant runny nose and no other cold symptoms, perhaps there is an allergic component.  And if your child seems to have a common cold that changes or fevers return, then a complication may have developed. Let’s assume that you’ve determined it is a common cold that is causing your daughter’s symptoms.  Now what?  There has certainly been a lot of publicity lately about over-the-counter cold remedies for children.  In October 2007, an advisory panel to the Food and Drug Administration voted to ban over-the-counter cold remedies for children under the age of six.  Earlier in the fall, several large companies voluntarily withdrew all cold medicines for children under two years of age. There are no studies that show a benefit of using cold medicines in children for treating cold symptoms. However, there is potential harm in using some cold medicines.  Cough suppressants can cause mucus plugging and worsening of respiratory symptoms as well as insomnia.  Decongestants are often helpful for adults in decreasing nasal congestion, but studies in children do not show that same benefit.  Side effects of decongestants include increased heart rate and blood pressure and palpitations.  Antihistamines do not relieve cold symptoms, but often cause drowsiness which may help some children sleep.  Studies looking at zinc and echinacea also have shown no benefit. Despite the studies, some parents report that some cold medicines do help relieve symptoms for their children.  If this is the case, I recommend not using any medications in children under two and being extremely diligent in following dosing guidelines for older children.  Also make sure that ingredients to different remedies aren’t duplicate, potentially causing an overdose.  Several thousand phone calls are placed each year to poison control with questions about overdoses of cold medicines. Treatment of cold symptoms has not changed much.  Using normal saline drops for the nose can help relieve nasal discharge.  Tylenol and ibuprofen are safe to use for fever relief and air humidification can help ease breathing. The most effective treatment of the cold is prevention.  Colds are caused by viruses that are present in respiratory droplets.  Some cold viruses can survive on hands for hours and surfaces for several days.  Luckily, most cold viruses do not survive long on porous surfaces like tissues.  Covering mouths when coughing and sneezing, good and frequent hand washing, and not touching your nose and eyes are some helpful practices in preventing the spread of the cold. These practices are difficult for adults – try going through an entire day without touching your nose – and nearly impossible for a three year old.  Some kids get really good at coughing into their elbows instead of hands and hand washing can be a fun activity.  I hope your cold season this year is full of sharing fun activities and less of sharing colds.

The Flu Shot

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Q: Our doctor suggested that my ten-year-old son get a flu shot because he has asthma. I’ve heard some stories of people getting sick from the flu shot, and other stories of people getting the flu even though they got the flu shot. What should I do? A: I too, recommend the flu shot to my patients with asthma. There always seems to be a little mystery with the flu vaccine, so I’ll try to clear up what I can. Here are some common questions and answers: Q: What is “the flu,” really? A: Most people use the word “flu” loosely. In common language, “flu” is frequently used to describe anyone with a bad cold or even someone with a diarrhea illness. In doctor language, “flu” means specifically the influenza A virus. The hallmark symptoms of influenza A are: abrupt high fever, body aches, and cough. While these three symptoms may be caused by several types of germs, doctors usually attribute them to the influenza A virus when they are not accompanied by a runny nose or sore throat, and when a patient appears significantly sicker than he would appear with other flu-like illnesses. Diagnosing the flu can be difficult, and patients may need a culture (test) to confirm or rule out a diagnosis of influenza A. Q: How is the flu vaccine developed? A: The flu vaccine is developed anew each year because the genetic make-up, or strain, of virus changes from year to year. This is why the vaccine must be given annually, rather than just once in a lifetime. Each year scientists study the virus and make an educated guess about which genetic strain is most likely to hit North America. The virus is isolated, reproduced in a lab, and then killed. The vaccine is made from dead virus. Vaccination with the dead virus allows a child’s immune system a preview of the flu germ, so if he is exposed to the live influenza virus later, he will already have antibodies to fight it off. Q: Does the vaccine work? A: The vaccine is only as good as scientists’ ability to predict the main viral strain. If a child is infected by a viral strain that differs from the vaccine, she will only have partial immunity. So, a child who had the flu shot might still get the flu, but she won’t get as sick as she would if she hadn’t received the vaccine. For a child with asthma, the vaccine might help her ride out the infection without missing school, or could perhaps keep her out of the hospital. This is why I recommend the vaccine for kids with asthma. Unfortunately, the vaccine only protects against influenza A. The vaccine won’t help at all with the multitude of other viral germs to which our kids get exposed each winter. Q: Can the flu vaccine make my child sick? A: The vaccine may cause mild side effects, such as aches or a low-grade fever, especially if the child has never had any strain of influenza A or its vaccine. The side effects are probably an expression of the child’s immune system responding to the vaccine. Theoretically, the vaccine won’t make a child truly sick because the vaccine doesn’t contain any actual live virus. However, I’ve heard enough adults say the vaccine made them sick that I’ve begun to wonder about this. To minimize the chance of side effects or symptoms, the vaccine is usually given in split doses (two shots) to children who have never before had it. While we don’t know how to predict if an adult or a child will get more than a few mild side effects from the vaccine, we do know about, and have proven, the wellness the vaccine provides. Q: Who should get the flu vaccine? A: Doctors recommend the vaccine for children with chronic lung conditions such as asthma or bronchopulmonary dysplasia. They also recommend the vaccine for these children’s families. In addition, we recommend the vaccine for people with certain heart conditions or other diseases that compromise a person’s immune system. The vaccine is available to healthy children at their parents’ request, during years when the vaccine is in plentiful supply. Q: Who should not get the vaccine? A: Because the vaccine is cultured in chicken eggs, children with an allergy to eggs should not get the vaccine. Q: Is there an option other than the vaccine? A: Yes, if you know your child has been exposed to influenza A, there are anti-viral medications that can help reduce his chances of getting the virus. I hope your winter is free from “the flu!” (First published in the Upper Valley Parent’s Paper in October 2002)

The HPV Vaccine

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Q:  I want to know more about the vaccine that prevents cervical cancer. When should my daughter get it? Should boys get the vaccine too? Have there been any bad side effects to the vaccine? A: I’m glad you asked because lots of people want to know about the new HPV (or human papilloma virus) vaccine. It’s a big deal, and a giant step forward in women’s health! HPV is a major cause of cervical cancer. So, preventing women from getting infected from HPV can prevent cervical cancer. There are dozens of different types of genital HPV viruses. The new HPV vaccine, Gardasil, prevents four particular types of HPV: types 6 and 11 which cause 90% of genital warts, and types 16 and18, which are responsible for 70% of cervical cancer. The US Food and Drug Administration has approved the new vaccine for girls (and women) aged 9-26 years. The vaccine is a series of three shots given over six months. It has not been tested in boys, and therefore not approved for boys, or men, yet. A national committee that advises on immunization policy recommends vaccinating girls beginning at age 11 and 12. This timeframe has sounded early to some parents: after all, most girls will not become sexually active until a number of years later (in fact, the median age for American teenagers is about 17 years old). Although the easiest way to contract HPV is through sexual intercourse, it’s possible to become infected through intimate petting or tampon use. Vaccinating in the preteen years makes sense to me for a couple reasons. For one, it’s important that girls get all three doses before they come in contact with HPV. And two, 11 and 12 are likely ages we parents can ensure our daughters get all three doses. Once they become teenagers it’s more and more difficult to get them to the doctor’s office (or anywhere else they don’t really want to go for that matter). And it’s not too early to realize that all our daughters will become sexually active someday, so it’s good to get them protected them when we can. You asked about vaccine side effects. Vaccines like any medication have potential for side effects. Fortunately, there have been only a few side effects with Gardasil. The most common side effects have been pain, swelling, or redness at the injection site. More rarely still, patients have had fever, nausea, dizziness or vomiting. The vaccine has been in widespread use since October 2006, and there have been no reports of worrisome complications. If you are want to be extra cautious about side effects it’s not unreasonable to wait until the vaccine has been out for closer to twelve months. Another reason that some people are waiting for the vaccine is because some insurance companies have not formally agreed to cover it yet. In the absence of insurance coverage the three-shot series is about $360.00. At this point it’s probably worthwhile to check with your health insurance carrier before making a specific appointment for your child to get the vaccine. Just think. In the time it probably took you to read this, 10 women somewhere in the world died of cervical cancer. Most of those cancers could have been prevented by this vaccine. (First published in the Upper Valley Parent’s Paper in March 2007)

Thinking ahead: Peanut Allergies on the Rise

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Q: I don’t remember any of my childhood friends or classmates being allergic to peanuts. Recently, my nephew was diagnosed with a peanut allergy, and I’ve learned it’s a lot more common than I ever thought. Or, has something changed, making more children allergic to peanuts these days? I’m concerned because I’m three months pregnant and I wonder: is there is anything I can do to prevent my child from having a peanut allergy? A: Your suspicion about peanut allergies is correct: there really are more kids allergic to peanuts today than there were a generation ago. Roughly one percent of American children are allergic to peanuts-the rate has doubled in ten to fifteen years. Why the increase? Well, the truth is that no one really knows why some kids develop peanut allergies and some don’t, or why the numbers are going up. There are theories and a lot of active medical research, but no one has satisfying answers yet.

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.

Prevention

I’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.

Treatment

Although 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 robin.a.goodrich@hitchcock.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)

Vaccination Boosters

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Q: My 11-year-old son is not so crazy about the doctor’s office, and he especially doesn’t like needles. When I scheduled a check-up for him, I was told he should expect a tetanus booster. My needle-phobic son clearly remembers the doctor saying he wouldn’t need any shots, tetanus or otherwise, till age 15. When my son asked about the change, I had no answer. A: Your son has a good memory. We doctors used to say that the next routine shot after age five was the tetanus/diphtheria booster at age 15. But…things change – sometimes for good reason. I think that this is the case here, and I hope you will agree. Medical professionals call the tetanus shot “Tdap,” because it actually contains protection against  tetanus, diphtheria and pertussis. The impetus for re-immunizing at age 11 or 12 instead of 15 is actually driven by the pertussis part of the vaccine.  To answer your question more thoroughly, I’ll go over all three parts of the vaccine here.

Pertussis

Pertussis 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.

Diphtheria

Like 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)

Vitamins

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Q: My 3-year-old is a good eater. Meats aren’t her favorite, but she loves milk, pasta, and especially fruits and vegetables. Does she still need a daily vitamin pill? A: If your daughter eats a selection of fruits and vegetables daily, she doesn’t need to supplement her diet with vitamin pills. Fruits and vegetables have the most vitamins and minerals of any food group, and the best way to ingest those nutrients is through their natural source as opposed to drops or pills. Encouraging a diet high in fruits and vegetables has lots of benefits. In fact, I believe the single best piece of dietary advice for all age groups (adults too) is to eat five servings from the fruits and vegetables group each day. (Good thing the Food and Drug Administration agrees with me!) Our American diets have way too much fat and sugar. Eating a selection of fruits and vegetables daily will add vitamins and fiber the body needs instead of the fat and sugar it doesn’t need. Furthermore, there is a growing body of medical evidence that all those fruits and vegetables can help prevent heart disease, stroke, and cancer. Many readers are probably thinking that you’re a lucky parent because their 3-year-old looks at the fruit and veggies on the plate as if they are poison. If that’s the case, it probably makes sense to provide a daily vitamin supplement. Although no supplement can replace a good diet, the pills offer some nutritional insurance to get you through the picky eating toddler years. When it comes to selecting a supplement here are my recommendations:
  • 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.
It sounds like your daughter likes a wide variety of foods. That’s great! Keep up the fruits and vegetables and don’t worry about the supplemental vitamins. (First published in October 2000)

Warts

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Q: Why do my kids gets warts? Yuck! I know the warts bother me more than my kids, but…How do I get rid of them? Can I clean better or do something to prevent them? id=”system-readmore” /> A: The warts that we adults and children get on our hands and feet are called “common warts” (verrucae vulgaris and verruca plantaris). Warts affect ten percent of school-aged children, so most families sooner or later have at least one kid with a wart or two. The warts are caused by viruses and these viruses are everywhere: our homes, our schools and offices, playgrounds, etc. They’re unavoidable. Most of the time we doctors have no way to know why some kids get lots of warts, and other kids don’t get any. I guess you could say it’s bad luck.

Prevention

The wart virus is all around us. There is no practical way to guard against it.

Treatment options

There 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 Remedies

There 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)

Water Safety

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Q: Summer rolls around and we attend pool parties and take trips on the lake in our boat. While most of my friends and my husband relish these summer events as the best of the year, my enjoyment is hampered by anxiety about my children’s safety. I can’t help but worry when they are playing around water. I know my anxiety bothers my husband, and I feel like I’m nagging my children. I want them to have fun, yet be safe. Are there rules you could recommend, or safety guidelines that might help husband and I come to some agreement? id=”system-readmore” /> A:There are no proven standards for water safety, or rules that fit every situation or each family’s needs. I suggest that you and your husband sit down each summer and decide on family rules for pool play or boating based on the kids’ ages, their swimming ability and your comfort level. That way you can relax and the whole family can enjoy the water more. My wife and I have wrestled with the same issue. After our first baby we eventually settled on a house rule of no boating until age two. There ‘s no medical evidence to support our decision, yet it sure did make our summer vacations less stressful. Now that our children are older we have new family rules. The kids sometimes protest because our rules are stricter than the ones used by some of our friends and relatives, but that’s okay. Every family needs its own rules. I encourage parents to talk about water safety and set family rules. While I can’t give you a recipe, I’ve listed guidelines adapted from the American Academy of Pediatrics’ policy statement on injury prevention.

Safety Recommendations

Think 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.
Ages 5-12
  • 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.
Ages 13-18
  • 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.
Sunny summer days by the water with the family are precious, especially in our northern New England climate. Be safe and most important, enjoy! (First published in the Upper Valley Parent’s Paper in July 2001)

West Nile Virus

Posted August 6, 2013 by admin & filed under Uncategorized.

Q: I think I need some perspective on the West Nile virus. The articles in the Valley News last summer alarmed me. After each one I would worry about my kids playing in our mosquito-ridden backyard. But I certainly wasn’t going to lock them inside. What’s a parent to do? A: I agree with your decision wholeheartedly: Let the kids play outside. With the all the things parents have to worry about, I wouldn’t even put West Nile virus on the “Top Ten” list. Still, it makes sense to educate yourself about it. The better you understand the health risks for your family, the easier it will be to feel comfortable with your decisions.

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)

Women, Girls and Knee Injury

Posted August 6, 2013 by admin & filed under Uncategorized.

Get a Leg-Up on ACL Tear-Prevention Q: My sports-minded 12-year-old daughter injured her knee this past soccer season. I was dismayed to hear from the orthopedic specialist just how common knee injuries are in adolescent girls. I’ve got two adolescent girls. Downhill ski racing is their favorite sport, and that sounds like one of the riskiest athletic activities for knees! What should my daughters and their friends be doing to prevent injury? A: Great question! With all the national statistics showing that our adolescent children are becoming more and more sedentary, I want to promote athletics, and yet keep them healthy at the same time. My partner and office-mate, Dr. Loescher, has graciously agreed to help answer your question. Dr. Loescher is a specialist in sports medicine and has been a tremendous help treating our patients with sports injuries. Dr. Loescher writes: Thanks, Dr. Lyons, for allowing me to take a swing at this question! As women and girls have become increasingly involved in competitive athletics over the past 20 years, we have accumulated a great deal of data about the injuries that these pioneers are suffering in comparison to their male counterparts. Some alarming trends have been uncovered as we crunch these numbers: women and girls are injuring their knees at a far higher rate than men and boys. Why?
Cause
Female 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:
  1. stopping suddenly
  2. sudden change of direction
  3. landing after jumping with knee extended
In a sport like alpine skiing, athletes are particularly susceptible to ACL tears when landing jumps, skiing moguls or during twisting falls. Low speed twisting falls where bindings fail to release are a common cause of ACL tears in skiers. Especially in sports such as skiing, soccer, and basketball, females are between two and eight times more likely than males to tear an ACL. Many theories have been proposed by medical researchers to explain this phenomenon. (Note: these are only theories, and I am only listing them!):
  1. Females are smaller and have smaller ACLs, which tear more easily.
  2. 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.
  3. The “Q angle” (the angle at which the thigh bone enters the knee joint) in women is not as suited to running and jumping.
  4. Women in general are more flexible, with looser ligaments, tendons and muscles. While this prevents certain injuries, it increases the risk of ACL rupture.
  5. Monthly hormonal fluctuation may relax ligaments at certain times, increasing risk of ACL tear.
  6. Muscles are important stabilizers of all joints, and females in general have smaller and less developed muscles, increasing ACL tear risk.
  7. 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.
  8. 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.
  9. 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.
When studied and tested, none of these hypotheses alone could explain the higher rate of ACL tears in women, but taken together, they may begin to explain the discrepancy. A couple of studies indicate that muscular imbalance and hamstring weakness may be the most important variables. This, I believe, is good news, because hamstring strength and balance are things that we can do something about.
Prevention
A 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:
  1. jump training, plyometrics and stretching
  2. weight training
  3. balance training
Jump training focused on teaching girls to land lightly with knees bent after jumping (land “light as a feather” was the motto). Plyometrics incorporated the jumping skills in a program designed to increase hamstring and quadriceps strength, flexibility and balance. Weight training focused on developing the ideal ratio of hamstring to quadriceps strength, which is 66% – meaning that the hamstrings should be at least 2/3 as strong as the quadriceps. Balance training, or proprioception, helped to develop the involuntary fine muscular control needed to make adjustments in a game or athletic activity to prevent injury. Participants worked each of these areas for 20-30 minutes, 3 days a week for 6 weeks prior to the start of the season. All drills focused on keeping hips and knees flexed at all times during athletic activity, especially when landing and stopping. Several subsequent studies have shown up to a 5 fold decrease in ACL tears in female athletes who undergo similar preseason training programs. Similar studies with male athletes have shown similar declines in ACL injuries. The knee is vulnerable to injury during strenuous athletic activity. Some anatomic factors cannot be controlled, but risk of serious injury can be greatly reduced with proper preseason training. There are good training programs available online for guidance as your athlete prepares for her sport. Review any program with a knowledgeable coach, physical trainer, therapist or sports medicine doctor. Any program should include elements of stretching, balance training, hamstring strengthening and dynamic position training in order to protect the ACL. As always, proper preparation is the key to success. A timely and focused preseason training program can keep your athlete in the game and out of the doctor’s office. Now get out there and enjoy the great winter season.


The material on this website is provided for information purposes only. It should not replace a conversation or office visit with your healthcare provider.

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