Picture this: It’s January and you’re sitting on a beach with your toes in the sand and enjoying the sound of crashing waves as you stare out at the ocean and feel the warmth of the sun on your skin. Your baby of 6 months is napping on the towel next to you shaded by a sun umbrella and you smile as you watch your rambunctious 4-year-old playing happily with his dinosaur in the sand. Ahhhhh, vacation. What is not said in the aforementioned statement is what it took to get to paradise. There was saving, preparing, booking, planning, packing, driving, and flying. There were travel delays, tantrums, an in-flight "poo-plosion", and a forgotten toy. Nevertheless, you and your family persevered and here you all are (this is a true story, by the way, from yours truly). I often get asked about tips and tricks to travel with kids and whether or not it’s worth it. While the definition of vacation has changed with children, I would call it more of an adventure than a vacation. I’m here to tell you from experience, it’s always been WORTH it (see pictures below). I’ve broken up this post into three sections and I hope it helps inspire you and gives you the confidence to go explore our great big beautiful world.

PRE-TRIP: Once you’ve figured out where you’re going, it’s time to get excited and start doing your research as to what you’re going to need to do to prepare for your trip. A good place to start, especially if you’re traveling internationally, is to make sure your family is all up-to-date on all immunizations. Also, if you’re traveling internationally, you will want to make sure you don’t need any additional vaccinations in addition to the routine school immunizations. The Centers for Disease Control and Prevention (CDC) is a great resource for travel advice and needed vaccines (see here). You can also contact your local health department’s and make an appointment with a travel clinic. Finally, don’t forget to have your entire family get their flu shots if you’ll be traveling during flu and cold season. The more you can do to stay healthy and prevent illness, the better.

It’s important to be organized with all of your trip documents. If you’re flying internationally, make sure each member of your entire family has a passport and that the passports aren’t due to expire for at least 6 months from your travel dates. If you have to apply for a passport, don’t delay, it can take awhile to receive them after your application is submitted. It’s also not a bad idea to make photocopies of your passports/IDs, health insurance card, travel itinerary and important phone numbers. Stash those away in a carry-on as well as your checked baggage. I’ve gotten in the habit of doing that, in addition to keeping those items in google document that I can pull up anywhere that I can connect to the internet. That way I have a paper copy (should the internet not be available) and another one that I can access digitally as well.

PACKING: Packing for a trip is quite the task, but if there’s one thing I’ve learned over the years traveling it’s that less is more and to pack light. Yes, even with kids. You really don’t need as much as you think you do, especially if you’ll have laundry available. Of course, what you pack will depend on the time of the year you are traveling and your final destination. A trick I use is to always make a list prior to packing, that way I can check things off as I go and know I haven’t forgotten anything. About a week before the trip I start setting out piles of clothing and other necessities so I can easily visualize them and check them off finally as I pack them in their respective baggage. I also have gotten in the habit of packing an extra outfit or two for each person traveling (more if you’re traveling with an infant) and swimsuits in my carry-on. That way, should your checked luggage not arrive at your final destination or something unexpected happens while traveling, you’ll have something clean to change into. You guys, I can’t tell you how often this has saved me while traveling. 

If you are traveling with young children, make sure you bring along their car seats or arrange to have them at your destination. Many airlines will let you check car seats with no additional cost, but it’s not a bad idea to bring it on the plane for your child to use. Kids are safest when in a seat that is appropriate for their age, weight and height. If your child weighs more than 40 lbs, then he or she can use the aircraft safety belt. For those traveling with children less than 2 years of age and where purchasing an extra seat is not financially feasible, try to look into ways you could secure an extra seat for no additional cost. I always try to look into flights where it looks like there are a lot of empty seats and keep my fingers crossed that we can land an extra seat. 

Last, but probably most important, make sure you plan ahead if your child is taking daily medications like those for asthma or attention deficit hyperactivity disorder (ADHD). Make sure you have enough medication for the entire trip and always have it on your person, in other words, put it in your carry-on luggage, not in your checked baggage! You should bring Acetaminophen (Tylenol) or Ibuprofen (Motrin) with you as well just in case your child becomes ill enroute and make sure you know the appropriate dose for your child’s current weight. 

TRAVEL/FLIGHT:  The big day is finally here and you are headed on your adventure. I know for most families, myself included, it’s the actual travel day that brings the most anxiety. This may be especially true if you’re traveling with an infant or toddler. You have visions of  being “that family” on the flight whose child won’t stop screaming or throws a fit (Yes, I’ve been “that family” and I’ve lived to tell the tale). While I can’t promise you this won’t happen, what I can do is offer some suggestions to help avoid it or get through it. Make sure you bring plenty of distractions and snacks. One of my tricks is going to the Target dollar section or The Dollar Store and picking up a handful of random toys. I have found calculators to be a big hit as well as stickers and notepads. You would not believe how long you can entertain a preschooler as they try to finger tiny stickers onto a notepad. Make sure you don’t show these fun new toys to your kids until the flight and then you can pull out a new toy every 30 minutes or so (depending on the length of your flight) and hopefully it’ll provide some distraction. A colleague of mine also recommends wrapping up small toys that either your child loves or hasn’t seen in awhile. They will be thrilled at just opening it up (and recognizing their favorite toys) and others are obsessed with playing with the bows or wrapping paper. For snacks, pack a variety and pack things you know your children love. This not only saves you money in not having to buy overpriced airport or in-flight food, but gives you control over what your children are eating. I also recommend packing a few “special treats,” maybe some little candies, as rewards for listening and good behavior. You guys, I’m not above bribery when you’re just trying to get through a flight or long car ride-it works!

From a health standpoint, I always recommend wiping down your seating area once you get on the flight with a wipe that has antifungal, antibacterial and antiviral properties. I personally use Clorox® Disinfecting Wipes On the Go (see here). You also want to bring plenty of hand sanitizer for when soap and water is not available. As you know, your kids touch EVERYTHING and then they stick their fingers in their nose or in their mouth or rub their eyes. Any effort you make in trying to minimize what they come in contact with is a good idea in my book. Nobody wants to be sick on vacation.

Finally, the Benadryl conundrum. I often get asked whether or not it is a good idea to give children Benadryl while traveling. Forgive me for being so blunt, but NO. It is NOT a good idea to give Benadryl to your child while traveling. Benadryl is an antihistamine and recommended for those who suffer from allergies. Anytime you give a medication orally it enters the bloodstream and has a myriad of effects within the entire body. Benadryl given orally has effects on the brain, skin and gastrointestinal system. One of the more common side effects of Benadryl is sedation, meaning it makes you sleepy. I can see why some parents would find this effect desirable if they’re heading on a long flight hoping it might help their little one sleep, but the response to this medication varies from child to child, not to mention it can be harmful. Some unwanted side effects can include stomach ache, nausea, vomiting, dry mouth and, more rarely, an actual allergic reaction to the drug, heart palpitations, skin rash or other neurological changes. While some children may get sleepy on it, others can go completely bonkers. I’m talking “who are you and what have you done with my sweet child?” kind of crazy. This is called a paradoxical reaction. While a paradoxical reaction isn’t exactly harmful to a child, it’s definitely not something you want while traveling, especially confined on an airplane. One of our main roles as parents (and my role as a pediatric provider) is to protect our children. Anytime you use a medication not for its intended effect, you are playing with fire. We should never drug our children for our own convenience. I’m sure there are some pediatric providers (and parents) that may disagree with me on this topic and recommend this option to parents traveling with children. If that’s the case, please, do not try this method out for the first time while traveling. Practice first at home and make sure the dose you are giving is correct for your child’s weight. Also, NEVER use this medication in children less than 1 year of age (unless it’s being used for an allergic reaction under the direction of your child’s health care provider) as the sedation effect can have a much greater sedation response in younger children. 
​
Traveling with kids can seem daunting, believe me, I know (see below for some proof of travel photos!). It can seem especially daunting if you’ve never done it before. But, honestly, at the end of the day, it’s not anymore daunting than parenthood itself. Parenting is hard, wherever you do it. You might as well parent in fun and exciting new places from time to time, right? I can’t think of a greater gift to give your children than to discover new places and spend time with them as a family. Now, go EXPLORE! 

Information presented adapted from:

https://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Travel-Safety-Tips.aspx
https://wwwnc.cdc.gov/travel
https://seattlemamadoc.seattlechildrens.org/if-it-were-my-child-no-benadryl-for-the-plane/

You guys, I have a confession. Well, maybe not so much of a confession as much as it’s an admission. I don’t do vomiting. The sound of retching and subsequent vomiting makes me turn on my heels and run as quickly as I can in the other direction. I am fully aware how this is somewhat problematic in my line of work because I evaluate a lot vomiting children, but most don’t vomit while I’m seeing them. Thank goodness! We all have our strengths and weaknesses, and my friends, vomiting is NOT my strength, I’ll admit it. I’m even more acutely aware of this after taking care of my sick toddler over the past week that culminated in vomiting. He didn’t even vomit on me. He vomited on my husband. But just the idea of being puked on had me dry heaving and rendered me useless in helping to clean up the mess. Diarrhea, no problem. Removing sticky, caked on boogers to the face, I’m a pro. Vomiting, no thank you. Taking care of a sick child is tough. Believe me, I know. When you add vomiting and diarrhea to the mix it’s not only tough, but it can be scary as well. Please read on to find out how you can help your children when they get stomach bugs and when you should worry and have him or her seen by their primary care provider (PCP).

Vomiting is the forceful removal of stomach contents. It can be associated with or without diarrhea, which is two or more very loose or watery stools. Just having one loose stool is not diarrhea and can be totally normal from time to time. Both vomiting and diarrhea can be caused by gastrointestinal (GI) infection, either by a virus, which is the most common cause, or by bacteria. You can also get symptoms of vomiting and diarrhea from food poisoning which is ingesting contaminated food or while traveling. Have you heard of Montezuma’s revenge? Whatever the cause, vomiting and diarrhea can range from mild to severe and the biggest concern at the end of the day really is dehydration, which is what happens to your body when it has lost too much fluid.

Most children with GI infections begin with severe symptoms and then will taper as they improve. For example, it’s typical of children with viral gastroenteritis to begin vomiting everything and not be able to keep anything down in the first few hours of illness. This can last anywhere from 3 to 4 hours, sometimes longer. From there, vomiting symptoms will decrease and they might have 1 to 2 episodes per day. Most vomiting will stop after 24 hours, but some children, especially younger kids, can have mild vomiting for a few days. After the vomiting subsides, many children will develop diarrhea or will have diarrhea with vomiting. Diarrhea can last days to even sometimes weeks.
So what do you do when your sweet little one starts vomiting? First, don’t panic. While it’s terrible seeing them in that state, it hopefully won’t last for long. If they’ve thrown up over themselves or over their bedding, clean them up and get them into clean clothes and make a pile of dirty laundry for when you have time to get to it. That washer will be working overtime for the next few days. I then recommend either having a big bucket or deep bowl by the bedside and placing towels all over their bed and on the floor surrounding the bed. This makes for super easy cleanup if they miss that bucket. Another option is making a little bed of towels on the bathroom floor, but when you’re sick, it’s often times nicer to be in your own bed.

Second, don’t let them eat or drink. Yes, you heard me right. During the first few hours of GI illness, what goes in, automatically comes right back out. Do yourself (and them) a favor and let those bowels rest for a few hours before offering anything. If they complain they’re thirsty, you can let them take sips of water, but make sure just sips, or ice chips if your child is old enough and not at risk for choking.

Third, once your child has not vomited for a few hours you can then offer more fluids, but again, don’t let them do too much, too fast. I like to recommend ice pops or popsicles. It’s a way to hydrate them and give a little sugar, but because it’s frozen they don’t consume too much fluid too quickly.

Finally, after they’ve kept fluids down for a few hours, you can them offer them food, but do so sparingly. Start with saltine crackers or toast and then add more foods as tolerated. If diarrhea is your child’s main issue, or it appears after the vomiting subsides, the no drinking rule does not apply. You can let them drink and eat as they please, but try to avoid fatty, heavy, or irritating foods. It is sometimes helpful to stick to the B.R.A.T. diet (bananas, rice, applesauce, white toast) because these foods act as binders and can help plug them up. Probiotics can also be helpful with profuse diarrhea, but be careful, in a few people probiotics can make diarrhea worse. Last, but certainly not least, horchata, also known as rice milk, is a great alternative to cow’s milk when your child has bad diarrhea. You can make it yourself (recipe here) or buy it at your local grocery store. The reason why I recommend avoiding cow’s milk in the days following a GI illness or with diarrhea is it can sometimes make diarrhea worse because the body can have trouble processing the lactose, which is the sugar found in milk.

Most children will be mildly dehydrated after a GI illness. Don’t fret as this is easily fixed by pushing fluids. At what point should you worry and when is it time to make an appointment with me? Well, first, if at any point your child has decreased urine and does not urinate for more than 8 hours or if urine is dark yellow, it may be an indication of dehydration. Second, if you notice that their tongue is dry as well as the inside of his or her mouth. Don’t worry so much about dry lips as it’s not as good of an indicator. Third, if your child’s eyes are dry and they don’t make tears as they cry. Fourth, if your baby has a sunken soft-spot. Fifth, if you press on your child’s thumbnail and make it pale and let go and then count the seconds for it to turn pink again and it takes longer than 2-3 seconds refill. Sixth, if your child is acting really sick, lethargic and is too weak to stand or, alternatively, if he or she is inconsolable and you can’t calm them down. These are all signs of dehydration or worsening illness and he or she should be been by their PCP immediately.

Finally, I’d like to leave you with a few more pointers and things I’ve learned taking care of my own sick kids. When there is vomiting or diarrhea in the house it’s time for paper towels, bleach and lots of handwashing. You guys, I’m all about saving the planet, but to help protect others in the family from a similar date with the porcelain goddess, ditch the hand towels and do single use paper towels in the kitchen and bathrooms for a week. Clean all household surfaces with diluted bleach water as this is the most effective way to kill some of the most virulent stomach viruses. Finally, wash those hands!!!!! In a pinch, a dollop of your hand sanitizer is a good option, but the best way to prevent illness is to thoroughly, and frequently, wash your hands with soap and water. My hope is that your little gal or guy is feeling better in no time and the rest of your family can get through it all relatively unscathed. Vomiting and diarrhea are no fun, but with this knowledge you will get through it. And, please, know that I’m here for you for all those questions and everything in between.
​
Information presented adapted from :
https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/symptomviewer.aspx?symptom=Vomiting+With+Diarrhea
https://www.cdc.gov/norovirus/about/index.html

Fall is in the air folks. The heat of the summer is giving way to cool and crisp mornings and I could not be more excited. Fall to me means pulling out those cozy sweaters, sipping on warm drinks, enjoying pumpkin spice treats and being amazed by the changing landscape from vibrant greens to fiery yellows, oranges and reds. It also means Halloween is right around the corner and, if you are the parent of little ones, there are few holidays that bring more joy (and cuter photo opportunities) than Halloween. Right now you may be in the midst of deciding on costumes, so I'm hoping that this post crosses your path at just the right time. While Halloween is super fun, we also want to make sure you know how to keep your kiddos safe for trick-or-treating.

When choosing your child's costume, make sure you choose a costume that is well-fitting and age-appropriate. You want to be sure that it's free of anything that could be hazardous like it being too long of a length that they could trip over; a sword, cane or stick that goes along with the costume that they could accidentally be hurt by; or a hat that's too big and blocks their eyesight. Speaking of eyesight, it would be a good idea to consider using non-toxic make-up instead of using face masks as those can often block your child's line of sight. Just be sure to test out the non-toxic makeup ahead of time to avoid any skin reactions on the big day. When buying a Halloween costume or accessories, make sure the label reads “flame retardant/resistant”. It may also be a good idea when picking out a costume, if possible, to choose bright colors or to add reflective tape to it or their treat-or-treat bag that will help make them more visible to motor vehicles and other people. Finally, it can be hot or cold on the night of trick-or-treating and it’s always a surprise what mother nature decides to do, so make sure your child is appropriately dressed for whatever she decides.

If pumpkin carving is part of your family's Halloween tradition, make sure that young children never do the carving. Have them draw a face or design and then you can do the actual cutting. Most kids don’t care to do the carving anyway, the real fun is getting to grab the squishy and gooey pumpkin contents. Also, don’t throw away those seeds; after separated and rinsed, you can bake those pumpkin seeds and they are delicious, healthy snack. If possible, avoid using real candles to light up your pumpkin as this presents a fire hazard. If you need to use real candles, votives are the safest. In addition, be sure to place your beautiful masterpiece on a sturdy table, especially if using real candles.

Now for the main event: the night of Halloween and trick-or-treating. Try to offer your kiddos a good meal prior to going out; this will ensure they don’t fill up too much on those goodies. A parent or responsible adult should always accompany young children trick-or-treating. If your child is old enough to trick-or-treat alone, which depending on the responsibility and maturity level of your child is usually between the ages of 10 and 12, be sure that they go in a group, as well as assign a buddy within the group. Review the route that is acceptable to you and the specific time they should be home. Also review how to call 911 in the event of an emergency or if they become lost. Be sure that all trick-or-treaters and their chaperones have a flashlight with fresh batteries. Only visit homes that have a porch light on and never, ever go into a home or car for candy. Always walk on sidewalks and well-lit streets and, if no sidewalk is available, walk along the farthest edge of the roadway. Do not cut through yards or alleys and always cross the street using crosswalks. Also, do not assume that you have the right away, many times drivers cannot see you; stop, and if you see an approaching vehicle, wait until the roadway is clear before crossing the street.

At the end of the evening, wait until you are home to go through your child’s Halloween loot and throw away any spoiled, unwrapped or suspicious items. Once sorted, you can give the stash back to them--but, if the idea of them on a non-stop sugar high for the next week makes your skin crawl, you can try one of the following ideas:

• Halloween Candy Buy Back, which is traditionally done at many dental offices. Your child hands in excess candy and will in return get a new toothbrush. Make sure you call-ahead to your local dentist and make sure they participate in the program.
• Support local troops overseas by donating candy to Treats for Troops (see here).
• The Switch Witch, this is where your child leaves all of their excess candy in their room and in turn gets a gift from the switch witch the next morning.

Happy Halloween and Happy Fall!
​
Information presented adapted from:
https://www.healthychildren.org/English/safety-prevention/all-around/Pages/Halloween-Safety-Tips.aspx

     For those of you that read this blog, I’m sure you’ve noticed it has been radio silence on my end for about one year. Let me first apologize for my hiatus, but my friends, LIFE has happened. The full-human experience: the crazy, the heart-breaking, the miraculous and the beautiful. It is only now that I feel like I’m coming up for air. I will give you fair warning, this post is getting personal. Why? Well, I teetered for a while on this one, but I felt that I owed it to my patients and their families to be real and honest. Not that I wasn’t doing all these things before, but I could have just picked right up where I left off without mentioning what has gone on in my personal life this past year and I decided I didn’t want to do that.
     When I started this blog four years ago, I wanted a resource for my patients and their parents that would provide accurate and straightforward information on common pediatric problems and give general parenting advice. I know from personal experience that when you’ve lived something that others have lived, you become more relatable and what you say is taken more to heart because you've been there. As a new practitioner, and before having children of my own, I gave parenting advice as best I could. My education and training gave me a good base, but no amount of education or training could prepare me for the moment I welcomed my first son into the world four years ago. As a new parent, I entered into the same ranks as my patients’ parents. I immediately had more credibility as I knew what it meant to love and care for a child: the fears, the joys, the highs and the lows. I want you to know that this blog is not only written from the perspective of a Pediatric Nurse Practitioner, but also from the perspective of a mother, a sister, a daughter, an aunt and a friend. What you read here will not only be accurate and evidence-based, but it will also come from the heart.
     Approximately 1 year ago, my mother passed away peacefully after a long and valiant battle against breast cancer. Less than 3 weeks later, I gave birth to my second child, a sweet baby boy. In less than 1 month, I witnessed life leave this world and witnessed life enter it. I went from overwhelming grief to overwhelming joy and my life was turned upside down. Looking back, it is all a blur.  Nevertheless, the reason I mention any of this is that through it all, I had a very inquisitive and tender 3-year-old son who was also trying to make sense of everything that was going on. He had questions like “Where is yaya (my mother)? What is heaven? When I'm sick does that mean I'm going to die? Mommy, are you going to die too?” These are only a select few of the myriad questions he had, many of which I had trouble answering. You guys, I'm a Pediatric Nurse Practitioner, I'm supposed to know what to say in these situations, and I struggled. I felt I was often coming up short. I hope that you never have to have these tough conversations with your children. These are the kind of conversations that break your heart and bring you to your knees, but if you do, I hope this post makes them easier for you. And, my deepest sympathies to you as you grieve for that special person in your life who is no longer here. I'm so sorry for your loss.
     So what do you say to your child after someone close to you has died? Where do you even begin? This all depends on your child’s age. Your toddler isn’t going to comprehend death in the same way your teenager will, so, the method you choose to explain death will depend upon your child's age.  If you have an infant or toddler in the house, know that they will not understand that someone has died as they can’t comprehend death, but they will pick up on what you and other loved ones are experiencing. Let yourself grieve and know that it is okay to let them see you when you do. This is actually true for all ages. Grief is a funny thing sometimes, it sneaks up on you when you least expect it, so if and when you have a moment in front of them know that it’s fine. Hold them close and tell them you are okay, you are just missing whoever has died. Try your best to keep to a typical daily routine as this provides security for your child. If you can, avoid being separated from your children during this time and give more physical attention. Hug them, kiss them, and hold them. This not only comforts your child or children, but I promise it will comfort you as well.
     For those with a preschooler in the home, know that they view death as a temporary thing. It is important to give these concrete thinkers clear and simple explanations to what has happened. Avoid euphemisms like “He went to sleep” or “She is gone”. To your three-year-old “He went to sleep” becomes “when is he waking up?” Or, “She is gone” becomes “Where did she go?” Instead, tell them simply “Your grandma has died and that means we no longer can see her anymore.” These straightforward answers can be softened by reminding your child that they will always have memories of the loved one who has died. Finally, don’t be surprised if they will randomly bring up the person who has died, sometimes weeks or months after they’ve died. You may also see this in their play, so pay attention. If your child, all of a sudden, has a new-found obsession with his plastic dinosaurs dying as my son did—this could be his way of expressing your loved ones death. Continue to provide support and encouragement.
     School-age children may be able to understand that death is final, but they may not be able to comprehend that death is universal. It is best to be simple and honest with your explanations about what has happened and then be sure to ask them if they understand or have questions. It is also important to clear up any misconceptions. Your child may have trouble expressing his or her emotions. Try to listen more than offering words, give your support and repeated opportunities for them to express how they are feeling. Your child may also worry they will be left all alone. My son repeatedly asked me if I was going to die after my mother died, this was especially true when I was leaving for the hospital to have his baby brother. The fact that I was going to the hospital made him worry I wasn’t coming back because this was true of his grandma. Again, clarifying to your child that not everyone who experiences sickness progresses to death will help them, as will explaining that not everyone who goes to the hospital dies. Reassure your child of your health and that there are many people in their life that care for them. This should help ease their anxiety. Be patient, it’s a process.
     Your teenager is going to understand death in the same way an adult does but they may resist expressing any emotion about it. He or she is now able to think more abstractly and may start having some big questions into the meaning of life or futility of it. Do your best in answering these questions and supporting them. They may also rebel a little and participate in risky behavior, which is typical of teenagers. Try to be a model of healthy ways of grieving, be present, and keep them accountable.
     Whether you have babies, teens or are somewhere in between, experiencing the death of a loved one and discussing it with your children is no easy thing to navigate. Let your love be your guide. Be sure to be patient and be honest with your children. You will get through it. Life does carry on. Believe it or not, your heart will ache a little less with each passing day and your children will be lucky to have you there helping them through it as you are lucky to have them helping you. Hang in there and keep on, keeping on.
           
Information presented adapted from:
 https://www.healthychildren.org/English/healthy-living/emotional-wellness/Building-Resilience/Pages/How-Children-Understand-Death-What-You-Should-Say.aspx

Media screens. They are EVERYWHERE. You probably don't go through a single day without looking at some form of digital media as they have become ubiquitous in our culture and are often necessary to get through a typical day. This also means they are likely ever present in the lives of your children, or, if they aren't yet, they will be. Because of this, it is very important, as a parent, to know how digital media impacts your children and their development and what experts are recommending for proper use of screen time.

Let me first start by saying that while there are definitely negative aspects of digital media to the health and development of children, there are plenty of positives. The aim of this post is to help parents be more aware of how digital media affects their child (and themselves) and the best ways to incorporate it into their daily lives. The idea is for digital media to be complementary, not detrimental. Here are the recommendations:

• For children younger than 18 months of age, avoid use of media except for video chatting with friends or relatives (e.g. Facetime, Skype, etc.)
• For children 18 to 24 months of age, parents who want to introduce digital media should choose programming of high quality, such as Sesame Street, but watch it with their child so they can explain and help them better understand what they're seeing.
• For children 2 to 5 years of age, limit media use to less than 1 hour per day of high quality programming. Again, it is recommended that parents co-watch with their children so that they can be there to help them understand what they're seeing and help them apply it to the world around them.
• For children ages 6 and above, make sure there are consistent limits on the amount of time spent using media as well as the types of media. Also, make sure the media doesn't interfere with sleep, physical activity and other essential behaviors to your child's health.
• In all ages, screens should not be used during meal times or 1 hour before bedtime.

​So what happens when there aren’t restrictions placed on media use? There is concern that heavy use of media, especially during the preschool years, is associated with an increase in body mass index (BMI) and may increase that child’s risk for obesity later in life. There are also negative effects on sleep, especially when media is used prior to bedtime or when electronics are in the bedroom. There is also an association between fewer minutes of sleep per night when there is a television, computer or mobile device in the bedroom (that goes for adults too!).  I don’t know how many times I’ve seen children in clinic who have difficulty in falling asleep at night and one of the first questions I ask is about screen use before bed and whether or not there are electronics in the bedroom. This is the first thing that needs to be changed and is often the solution to the problem in most cases. There also have been population-based studies that show an association between heavy television viewing in early childhood and social/emotional, cognitive, and language delays. Screens cannot take the place of what our children need from us for proper brain development — our presence. Hands-on, unstructured, and social play is essential to build language, cognitive and social-emotional skills. Things like task persistence, controlling of impulses, emotional self-regulation, and creative, flexible thinking are taught best by social and unstructured playing and through a responsive parent child interaction, not through a digital screen. In summary, digital media should not get in the way of activities essential for proper child development such as playing, sleeping, being physically active, down-time and time spent as a family.  

I also get a lot of questions in clinic from parents, not only about what an appropriate time limit should be for viewing digital media, but also regarding the content of what their children are watching or playing on their screens. As a parent myself, I’m aware that there is a dizzying sea of available programs, movies, games that are accessible all day long. Knowing what is appropriate for your child isn’t always easy to figure out. Well, Common Sense Media to the rescue (see here)! Common Sense Media is a non-profit organization that is committed to providing unbiased information so that parents can decide what media is right for their family. They do the work of figuring out what is developmentally appropriate so you don’t have to.

So what happens if bad habits are already in place? And, what happens if you realize you, as the parent, may have a problem with media use yourself? The answer is, it’s never too late to change. And, the good news is, your children are learning by your example, so if you show responsible digital media use, they will too. The American Academy of Pediatrics (AAP) has a handy Family Media Use Plan that helps you and your children to think about media and create rules and goals that align with your family’s values. Fill it out and then print and place it where it’s visible to the entire family. It’s a great tool to make sure that in this digital age, we are being responsible media users and we don’t let technology get in the way of what matters most, the health and well-being of our families. Thanks for reading, until next time!
 
 
Information presented adapted from:
 
http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2591
 
http://pediatrics.aappublications.org/content/early/2016/10/19/peds.2016-2592
 
http://pediatrics.aappublications.org/content/140/Supplement_2/S57
 
https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/american-academy-of-pediatrics-announces-new-recommendations-for-childrens-media-use.aspx
 
 
 
 

Microorganisms are everywhere and are an essential part of our existence. Some carry the potential for harm, like germs that make us sick, but many others have the potential for good, such as probiotics. These particular microorganisms have gained a lot of attention in the past decade and have become quite the buzzword. There is a lot of interest and ongoing research on how our gastrointestinal (GI) flora affects our everyday health and whether or not taking probiotics can improve our health.  Proponents of probiotics claim a myriad of health benefits as well as the prevention and treatment of diseases. So, what does that mean for your child and should you be giving him or her a daily probiotic supplement? Well, please allow me to help you decide what might be right for you and your family. Read on to find out more information about the use of probiotics and whether it is right for your child.

Now, in order to understand what probiotics are, it is helpful to understand your microbiome (i.e. the bacteria that inhabits our bodies) in general. Large numbers of microorganims live in and on the body. In fact, these bacteria outnumber human cells by 10 to 1. Bacteria are normally present in our intestines as well because they help us digest the food we eat, they kill microorganisms that cause disease, and they produce vitamins. At birth, infants have a sterile GI tract and that quickly changes with bacterial colonization. The gestational age of the infant, the way in which he or she was birthed (C-section vs. vaginal), and the infant’s diet all influence this process of bacterial colonization. After infancy, the GI flora doesn't change much. The intestinal mucosal defense system is an essential part of a complex immunoregulatory network that includes GI microflora. It is a widely held belief that the incidence of many diseases, both intestinal and non-intestinal, are related to impairment in the regulation or interference with the early development of the intestinal mucosal defense system.

So then, what is a probiotic? A probiotic is any food or oral supplement that contains enough microorganisms to change the microbiome of the person ingesting them with the potential for improved health. The most studied strains to date are Lactobacillus rhamnosus GG (LGG), Bifidobacterium lactis, and Streptococcus thermophilus. You may recognize these names if you're a food label reader like me. Probiotic bacteria can be ingested as a medicine or as a supplement. They can also be added to or mixed with foods or naturally exist in functional foods, which is any food that contains a probiotic, like yogurt or kimchi.

Many parents have asked whether or not probiotic supplements are okay if given daily or if they could be helpful for their infant's colic? As mentioned above, the use of probiotics in the prevention and treatment of clinical diseases is an emerging science, meaning there is still much to learn regarding the benefits and potential dangers that may exist. There have been well-conducted randomized controlled trials (RCTs) to support the use of probiotics for the treatment of acute infectious diarrhea. One study suggested that the administration of LGG significantly decreased the duration of acute rotavirus diarrhea. At this point, however, there is no evidence that routine use of a probiotic prevents acute infectious diarrhea. There have also been other studies that suggest probiotic use in the earliest phase of illness not only decreases the duration, but also the amount of diarrheal stools. Probiotics have also been useful in the prevention of antibiotic-associated diarrhea. To date, there haven't been any studies to investigate probiotic administration in the treatment of antibiotic-associated diarrhea.

There also is a lack of evidence for the efficacy of probiotics for many diseases such as eczema, chronic inflammatory bowel disease, irritable bowel disease, infantile colic and cancer. That being said, just because there is a lack of evidence currently, does not mean that with further study, potential benefits won't be established. However, for right now, the area in which probiotics have shown the greatest benefit is with the treatment of acute diarrheal illness and the prevention of antibiotic-associated diarrhea.

So what does this mean for your child and should you give him or her a daily probiotic supplement? As long as your infant or child is healthy, probiotic supplements seem to be safe. Furthermore, they seem to be beneficial in treatment of acute diarrheal illness and prevention of antibiotic-associated diarrhea. Patients that should NOT take a probiotic unless directed by their primary care provider are those who are immune-compromised; this includes ill preterm neonates and children who have intravenous catheters or other indwelling medical devices.

I hope this post was informative and answered some questions you had about probiotics. Please contact us at ABC Pediatrics if you have any further questions.
 
Information presented was adapted from:
http://pediatrics.aappublications.org/content/126/6/1217
https://nccih.nih.gov/health/probiotics/introduction.htm

It's officially summer and that means it's shorts and tank-top season. It also means that you may have noticed some bumps or growths on your child's skin you've never noticed before. Many of these skin lesions can just be left alone and monitored, but some may require that you make an appointment with your child's primary care provider (PCP) to make sure all is well. 

​If you've recently taken a look at your child's skin and found tiny, skin to pink colored lesions, approximately pinpoint to pencil-eraser in a size, these could be molluscum contagiosum (see here). Molluscum contagiosum sounds scarier than it actually is, but they can become troublesome if not closely monitored. They are warts caused by molluscum virus, which is a poxvirus and causes these annoying non-cancerous lesions. They are painless and spread by direct skin-to-skin contact or by sharing towels with someone who has molluscum contagiosum. The good news is, most times, if left alone, they will resolve on their own. The bad news is that it can take anywhere from 6 months up to 2 years for these pesky little lesions to go away and during that time there is risk of it spreading to other parts of the body, especially if your child has atopic disease like eczema. 

​So what to do? Honestly, less is more. Make sure your child keeps his skin well-moisturized. That way he will be less inclined to scratch at the bumps and spread them to other places. Also, pay attention to where and how many lesions he has. If you start noticing more lesions appearing or if they spread to other parts of the body, you should make an appointment with his PCP for further evaluation. Your PCP can assess the situation and decide whether or not your child can continue to wait it out or if treatment is necessary. While there are many treatment options available, there aren’t any that are approved by the Food and Drug Administration (FDA) for children, and none are guaranteed to speed up resolution. Nonetheless, and depending on the comfort level of your PCP, some treatment options include destruction of molluscum lesions with liquid nitrogen or cantharidin. Liquid nitrogen causes destruction of the lesions by using extremely low temperatures to destroy the tissue at the cellular level. Cantharidin, on the other hand, is a colorless, odorless, terpenoid that is secreted by blister beetles. This causes the skin to blister and in turn, theoretically, destroys the tissue onto which it is applied. Both of these treatments, while effective, can be painful and often leave a pinpoint scar behind after they heal. Other treatment options include application of topical imiquimod or retinoids, oral cimetidine, and Candida antigen injections. 

If you’ve recently noticed firm, rough, flesh-colored bumps on your child’s body, most often hands or feet, these could be warts. They can also be tan, yellow, grayish, brown or black in color and sometimes they are flat and smooth (see here). Warts are caused by the human papillomavirus (HPV). They are contagious, but more easily acquired with a cut or scrape on your skin. Warts will often go away by themselves without requiring treatment, however, there are some over-the-counter salicylic acid preparations (see here) that are effective and your child’s PCP can treat stubborn ones in the office using liquid nitrogen. In some cases, your child’s PCP may refer you to a dermatologist for reasons such as multiple, recurring warts, if the wart is in sensitive areas such as the face or genitalia, large or painful warts, or if the wart is bothering your child. If you have questions or concerns, just give us a call at ABC Pediatrics. We’d love to see you!

Information presented adapted from:

https://www.aad.org/public/diseases/contagious-skin-diseases/molluscum-contagiosum

https://www.aad.org/public/diseases/contagious-skin-diseases/warts#symptoms

https://www.healthychildren.org/English/health-issues/conditions/skin/Pages/Molluscum-Contagiosum.aspx

https://www.healthychildren.org/English/health-issues/conditions/skin/Pages/Treatment-For-Warts.aspx

http://www.mdedge.com/pediatricnews/article/102139/infectious-diseases/expert-shares-treatment-tips-molluscum-contagiosum

Probably one of the most asked about topics I encounter during toddler well-child examinations relates to potty training. Whether it's recognizing the signs that your child is ready, to which method is the best, to how to actually do it; potty training causes many parents anxiety and undue stress.

Potty training is a momentous milestone in your child's development and as parents, we want it to be a positive one (hooray, no more diapers!). This is precisely the reason why I'm going to take time this month and next month to discuss everything you ever wanted to know about potty training. This month I'll go over the basics and next month I'll dive deeper into common problems that arise after your child has been toilet trained. It is my hope that through these posts, it'll be a positive experience, not only for your child, but you as well.

First, and probably most important, is we have to change the way we talk about potty training. The term “potty training” is a misnomer. Here at ABC Pediatrics, we like to think of it more like “potty learning.” Our children are our little apprentices. Like it or not, they learn by watching, listening and the example we set for them. For example, if you don't get excited about vegetables and eat them regularly, would you expect your child do the same? It's the same way with learning to use the potty. Your child needs to see and hear you talk about using the potty before she can be able to do so herself. Think of this like hands-on learning. For the sake of being more simple, I will use the term potty training, but please, think of it more as active potty learning.

So how will you know your child is ready? Well, that answer is two-fold. Most children are physiologically ready, that is, their digestive and urinary systems are developed enough that they can hold their urine and stool long enough to make it to a toilet, between 18 and 30 months. That being said, this doesn’t mean that your child is psychologically ready. In other words, at 18 months or 2.5 years of age, your child may not have the mental capacity or desire to be potty trained. Some signs your child may be ready to initiate potty training include: your child begins to demonstrate independence by saying “no,” your child is able to walk and sit down, your child imitates your behavior, your child expresses interest in using the toilet (i.e. wants to flush the toilet, watches you use the bathroom, etc.), your child can tell you when she is peeing or pooping and then begins to tell you that she needs to pee or poop before she is actually doing it, and, finally, your child has the motor skills to pull her clothes up and down or on and off. Physical, emotional, and cognitive readiness happens at different ages for all children, so don't rush it. Just pay attention to these clues that your child may be ready to start the process.

There are a plethora of different potty training methods out there and it can be difficult as a parent in deciding which one to implement. Ultimately, the two most common methods in a study conducted by the Agency for Healthcare Research and Quality were the child-oriented approach and the Azrin and Foxx “Toilet Training in Less Than a Day” method, and, both have been found to be effective. The American Academy of Pediatrics (AAP) recommends using a child-oriented approach as it seems to be the most agreeable and reasonable one for most families. This method has parents slowly introduce the potty chair and begin educating their child as soon as she starts showing interest in using the potty. This touches upon what I was discussing earlier regarding how our children learn by watching us. For example, expressing to her when you feel like you have to go the bathroom, letting your child follow you into the bathroom and showing her what you're doing while you're going to the bathroom, have her sit on the potty when you sit on the potty, demonstrating proper wiping technique and subsequently flushing the toilet and then showing her how to wash her hands properly are all ways to begin potty education. Now, if you're like me, the few minutes I use the restroom each day may be the only time I have to myself in a given day. Or, you could be like some fathers I know out there, who are calling the bathroom their new “man cave.” All joking aside, you don't have to take your child on every trip to the bathroom and you'll be surprised how these simple steps spark a whole new interest for your toddler. The biggest take-home point to this child-oriented method is to not push too hard. The key is slow and gentle encouragement.

Another common and effective method for potty training that parents have asked me about is the Azrin and Foxx method which uses behavior modification to potty train. Simply put, you pick a day where you don't have to go anywhere, free from other distractions, and you can devote all of your attention to your child, preferably a block of 4 to 6 hours. You then give your child plenty of fluids and snacks and have her sit on the potty regularly with the idea this will help her need to go to bathroom more frequently. Rewards are then given for using the potty and not soiling her underwear and redirection and education if there's an accident. The key to this method is positive reinforcement with successful use of the potty. There is no punishment with accidents. While this method may work for some families, it is not something I typically suggest because it's a very intensive process. That being said, with proper preparation beforehand, it can be very effective (see here).

I'd like to leave you with some final tips. Know that with any type of learning, it is a dynamic process and it will likely take some time to master. Setbacks are likely, but with practice, things should improve. Don't be discouraged and remember to stay positive and encourage your child. Once you begin talking about using the potty, bring your child with you to have her pick out a potty. Picking it out herself may give her more motivation to start using it. Also, bringing your child to pick out her underwear can be helpful. I will often recommend parents displaying the underwear in an out-of-reach place as incentive. Your child will likely be excited to put her favorite Disney character or superhero underwear on and will likely not want to dirty them by going to the bathroom in them. Pull-ups are generally unhelpful and should be used sparingly, if at all. They sometimes become a crutch and you don't want the use of a pull-up to give her permission to just pee or poop in the pull-up instead of using the potty. Finally, pick up some of these books from your local library or purchase them for your own library (see here, here and here). They are great introductions for your child and super cute reads. As always, don't hesitate to contact us here at ABC Pediatrics if you have any specific questions or concerns. We'd love to help in any way we can. Happy learning!

Information presented adapted from:
​
American Academy of Pediatrics. Toilet training guidelines: Parents -- the Role of the Parents in Toilet Training.
http://pediatrics.aappublications.org/content/pediatrics/103/Supplement_3/1362.full.pdf

American Academy of Pediatrics. How to Tell When Your Child is Ready. https://www.healthychildren.org/English/ages-stages/toddler/toilet-training/Pages/How-to-Tell-When-Your-Child-is-Ready.aspx

American Academy of Pediatrics. Toilet Training 101.
http://www.aappublications.org/content/28/5/16

Schmitt, Barton D. Toilet Training: Getting it Right the First Time.
http://contemporarypediatrics.modernmedicine.com/contemporary-pediatrics/news/clinical/pediatrics/toilet-training-getting-it-right-first-time#1

As things are beginning to sprout and bloom in Utah, many seasonal allergy sufferers are bracing themselves for the symptoms that often come along each spring. These include runny nose, post-nasal drip, nasal congestion, nasal itching and sneezing. This constellation of symptoms is known as allergic rhinitis in the medical world (I kid you not, I just sneezed while typing this sentence, how’s that for ironic?). If symptoms are mild, they are just annoying, but tolerable. However, if symptoms are severe, they can disrupt daily life and make life miserable. Children, like adults, can also suffer from seasonal allergies. If you suspect this in your child, keep reading along for more information on how to tell if your child may be suffering from seasonal allergies and what you can do to help them.

Allergic rhinitis can be categorized based on the temporal pattern of triggering allergens, the frequency and severity of the aforementioned symptoms. For example, temporal patterns include seasonal (tree or plant pollens at certain times of the year), perennial (year-round allergens such as dust, mold), and episodic (environmental exposures not typically experienced in one’s own home or visiting a home with pets). Frequency of symptoms is divided into intermittent, (< 4 days per week and < 4 weeks per year) and persistent (>4 days per week and > 4 weeks per year). Finally, severity can be categorized by mild (when symptoms do not interfere with activities of daily living) to severe (when symptoms interfere with activities of daily living).

So what causes these annoying symptoms of allergic rhinitis? Well, in someone with allergies, whenever his or her body comes into contact with whatever his or her allergic trigger is (pollens, dust, pet dander, etc.), the body releases many compounds, one of which is called histamine. Histamine causes nasal swelling, watery eyes and runny nose. Other symptoms include itchy eyes, nose and mouth and sometimes a rash on the skin (hives).

If any of the above sounds familiar, it may be helpful to bring your child into his or her primary care provider (PCP) to be evaluated further. Seeing your child’s PCP is always the first step in managing his or her allergic rhinitis. Most mild to moderate seasonal allergies can be effectively be managed by your child's PCP. At your child’s visit, his or her PCP will get a detailed history and perform a thorough physical examination. If it seems your child is suffering from seasonal allergies, your child's PCP will often begin empiric treatment with an over-the-counter antihistamine. An antihistamine is a medication that blocks that annoying compound your child’s body releases in response to an allergen, histamine. Typically, these medications work well for allergic symptoms, but they may cause drowsiness in some, so often times, your child's PCP will recommend giving it to your child before bed. In addition, he or she will advise your child to avoid known allergic triggers, as that is a huge part in managing allergic symptoms. Finally, depending on the severity of your child’s allergies, or if your child concurrently suffers from asthma, eczema, or food allergies, he or she may refer you to a pediatric allergic specialist for further evaluation, testing and management.

The good news is there are ways to treat allergic rhinitis that are safe and effective for children. If you are concerned that your child may have allergic rhinitis or any other allergies for that matter, give your child’s PCP a call to schedule an appointment. As always, don’t hesitate to contact us at ABC Pediatrics for any questions regarding your child’s health. We are happy to help! Please see below for some links for more information on seasonal allergic rhinitis.
​
Information presented adapted from:
American College of Allergy, Asthma and Immunology. Seasonal Allergies.
http://acaai.org/allergies/seasonal-allergies
American Academy of Pediatrics. Allergy Tips.
https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/pages/allergy-tips.aspx
American Academy of Pediatrics. Diagnosing Allergies.
https://www.healthychildren.org/English/health-issues/conditions/allergies-asthma/Pages/Diagnosing-Allergies.aspx
American Academy of Otolaryngology Head and Neck Surgery. Clinical Practice Guideline: Allergic Rhinitis.
http://journals.sagepub.com/doi/pdf/10.1177/0194599814561600

Our homes are our safe spot, our comfortable place. It's easy to have a false sense of security at home and there may be lurking dangers for your little ones that you are unaware of. It's always a good idea to make sure your house is safe for your little ones. As a pediatric nurse practitioner (PNP), I am not only responsible for caring for children when they are sick, but I am also responsible for promoting the health of children and preventing disease. This includes the prevention of injury as well. This month, I'd like to focus my attention on safety in the home as there have been two, recent, local events of children who experienced preventable accidents while at home.

You may have seen in the news recently a pair of twins who caught national attention after a dresser fell and pinned one of them underneath it (see here). It's a terrifying video for any parent or anyone, for that matter, to watch. Thankfully, neither child was hurt and this brave family has shared their story in order to spread awareness of the dangers of not anchoring unstable furniture. They are especially near and dear to our hearts at ABC Pediatrics because they are our patients (Don't worry, I've received special permission from their mother to share this). It is extremely important to test stability of large furniture pieces: this includes television stands, bookshelves, standing lamps, and dressers. Can they easily tip over if pushed, pulled, or if drawers are opened and climbed on? If so, then they should be anchored to the wall with something like this (see here). Even though I give this advice on a weekly basis, until I saw this story, I had yet to get the dresser and bookshelves in my own two-year-old son's room anchored to the wall. I was aghast to see how easily the dresser tipped over with all the drawers open prior to anchoring. So, thank you Shoff family for the friendly reminder.

The next news story, sadly, ended tragically, but it highlights the hidden danger of window-blind cords. This past November, the three-year-old daughter of Reno Mahe, former NFL Eagles player and current running back coach at Brigham Young University, died a week after injuries she sustained from getting tangled in a window-blind cord while at home. Unfortunately, she's not the first child that has died from a window-blind cord strangulation. The U.S. Consumer Product Safety Commission estimates that approximately one child dies each month from window cord strangulation (see here). It is recommended that cordless blinds be used in the home if possible. If those are too cost prohibitive, thoroughly examining all blinds in the home is an absolute must. Be sure to attach the cords for window blinds to wall brackets to keep them well out of reach of children. Any window blind cords with loops should be cut and safety tassels attached as children can be strangled by them if left loose.
​
Anchoring furniture and examining cord blinds are just two home safety items as part of a whole house survey that should be visited every 6 months according to the American Academy of Pediatrics (AAP). The AAP provides a handy check-list that you can take with you and check-off as you go through your house looking for hidden dangers. We provide it as part of our 12-month well-child check packet on our website (see here). It really is amazing how children can turn a seemingly innocent item into something profoundly dangerous. Please make sure to examine your house and do it often. Remember, as your children grow, what once wasn't within their reach, becomes available to them. If you have any questions or concerns, please don't hesitate to contact us at ABC Pediatrics.


Information presented adapted from:
American Academy of Pediatrics. “Home Safety: Here's How”
https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Home-Safety-Heres-How.aspx
Cable News Network. “3-year-old Dies After Tragic Window Cord Blind Accident”
http://www.cnn.com/2016/12/01/health/elsie-mahe-window-blind-cord-death/
U.S. Consumer Product Safety Commission. “Kids and Cords Don't Mix”
https://www.cpsc.gov/s3fs-public/windowcover.pdf

I hope you’re having a happy holiday season and that this post finds you well in this last week of 2016. Whether you enjoyed the holidays in the winter wonderland of the Wasatch mountains or lounging in a beach chair near the ocean, I hope you had a joyous holiday weekend. With all that hustle and bustle and being in close quarters with friends and family, you or your children, may have returned home with a little more than some presents. The symptoms of sudden fever, body aches, chills, headache, fatigue, sore throat, cough, and stuffy, runny nose are all characteristics of influenza, more commonly known as the flu. If any of your little-ones are currently experiencing these symptoms, there is a chance they could have the flu. Read on to learn more about what the flu is, how you can help your child get through it, and how you can prevent them from getting it in the first place.

Along with the aforementioned symptoms, children can also experience vomiting and diarrhea while sick with the flu. Furthermore, flu symptoms will typically last one week (7 days) or more. I’m often asked in clinic how parents can know if they or their child has the flu, and my answer is often “Oh, you’ll know.” What do I mean by that? Well, the symptoms of flu are typically much more severe and last longer than a common cold virus. Believe me, if you have ever had the flu, you know you never want to get it again. The flu makes you feel miserable. Your child is also at risk for complications from the flu, like secondary bacterial infections such as an ear infection, sinusitis or pneumonia. If your child is complaining of ear pain, has a lingering cough that’s not getting better, or a fever that persists or suddenly develops again after not having one, you should take your child to see their primary care provider (PCP).

Influenza is caused by a respiratory virus that is spread via droplets in the air or by touching infected surfaces and then touching your nose, eyes or mouth. For example, if someone with the flu sneezes, virus particles are released into the air, and if your child happens to be nearby and inhales those particles, he now has a chance of coming down with flu. Similarly, if someone with the flu sneezes into their hands and then touches a door handle to open a door and then your child touches that same door handle and then rubs his eyes, he could come down with the flu. The flu virus is most contagiousness in the first few days of the illness, but it can be spread a day before symptoms start and up to a week or more after symptoms began. This is another reason to keep your children home when they are sick, so as to not spread disease.

​The flu is treated with supportive care; lots of rest, lots of fluids, and lots of love. If your child seems like they are in pain or uncomfortable from the fever or other flu symptoms they are experiencing, you may give a pain or fever reducing medicine such as Acetaminophen. Make sure to use the correct dose for you child’s current weight (see here). Because the flu is caused by a virus, antibiotics are not helpful. However, if your child has a chronic health problem like asthma, diabetes, sickle cell disease, a chronic neurological condition then he or she may benefit from an antiviral medication that is only available by prescription from his or her PCP. Antiviral medications are most effective at reducing influenza severity and illness duration if start within forty-eight hours of symptom onset.

The single best way to prevent your child from getting the flu is to have him or her vaccinated against the flu each year. The American Academy of Pediatrics (AAP), recommends that an influenza vaccine be given each year to all children beginning at six months of age. Children 6 months through 8 years of age may need two doses given at least four weeks apart if they’ve never received 2 in one season. Children ages 9 and older only need one dose. In addition, it is also recommended that anyone who will be in close contact with your child or any other caretakers receive an annual flu shot as well. This is especially important if your child is not old enough to receive a flu shot. The flu shot is safe and effective and has few side effects, if any. The most common are local injection site redness, soreness, or swelling, and fever. In Utah and the surrounding Intermountain West the best time to get your child his or her flu shot is October through November – sooner if your child has a chronic illness that may make the consequences of an influenza infection more severe (see conditions listed above). That being said, if you haven’t had a chance to get your child vaccinated yet this season, it’s not too late. Go get them vaccinated as soon as possible. Finally, practicing good hand hygiene, eating a nutritious diet, and getting adequate rest are all great ways to prevent your children from getting sick. Please, if you have any questions or concerns about what was discussed in this month's post, don't hesitate to contact us here at ABC pediatrics. We are happy to answer any questions you might have. Wishing you and yours a very happy and healthy 2017!

Information presented adapted from:
American Academy of Pediatrics, Recommendations for Prevention and Control of Influenza in Children, 2016-2017
http://pediatrics.aappublications.org/content/early/2016/09/01/peds.2016-2527
American Academy of Pediatrics, The Flu
https://www.healthychildren.org/English/health-issues/conditions/chest-lungs/Pages/The-Flu.aspx
Centers for Disease Control and Prevention, How Flu Spreads
https://www.cdc.gov/flu/about/disease/spread.htm

Just when you thought you wouldn't survive the “terrible twos,” there is yet another age to fear during your child's growth and development and that's the year of the “threenager.” What is a threenager you ask? If you do a basic search on the web, you can get a variety of equally funny, yet terrifying answers (this was my personal favorite). Most suggest that a threenager is a three year old that acts and has the attitude of a teenager. In case you're not parenting a teenager at the moment or you've forgotten what it's like to be one, let me refresh your memory. Think: mood swings, emotional outbursts out of nowhere, angst, and fighting for independence, but all the while still needing mom and dad. All joking aside, my hope is to explain what your three-year-old child is going through and why many of her actions are developmentally appropriate. Maybe that will ease some of the frustration and the “I’m going to pull out my hair if she refuses to put on her pants one more time!” moments. I also hope that I am able to give you some tools on how to better parent your threenager so you are more prepared once they become actual teenagers!

To understand why your once darling child is behaving like a megalomaniac it first helps to explain what’s going on in her brain. Dr. Daniel Siegel, a child and adolescent psychiatrist, and Tina Bryson, Ph.D., a pediatric and adolescent psychotherapist, break down brain development quite well in their book, “The Whole-Brain Child.” Our brains are divided into two hemispheres, the left and the right. Our left brain is logical; our rational, literal, linguistic and linear centered thinking occurs here. Conversely, our right brain is more emotional; It is non-verbal and holistic. It sees the entire picture and the feelings that go along with it. From a developmental standpoint, toddlers--children ages one to three--are right-brain dominant. That means they have not yet developed a logical way of thinking. Therefore, they are living “emotionally” and cannot use words or logic to describe their feelings and live completely in the here and now. Have you ever wondered how your child has the uncanny ability to drop everything she’s doing to gaze at every rock or animal on the way to get in the car to drive to school, not caring that you clearly have some place to be? It’s not that she’s trying to drive you crazy, it’s that she has no sense of time and can’t rationalize that getting to school on time is more important than staring at rocks and cute animals. Is this sounding familiar? That being said, when your child finally begins to ask the dreaded “why?” use that as a clue that her left brain is emerging. The reason she wants to know why you have to get in the car, and why she must get in her car-seat and why she needs to go to school is that her left brain, that part of our brain that likes to know the cause and effect of relationships, is waking up. Furthermore, your child wants to be able to verbalize those rational thoughts with language.
In addition to right and left-brain dominance, the prefrontal cortex (the part of the brain that provides behavior regulation and carries out executive function) is also still developing and will continue to mature through adolescence and into early adulthood. In other words, this is the part of the brain that helps differentiate among conflicting thoughts, good and bad, better and best, same and different, and performs social “control.” So, the reason your child unexpectedly lashes out at you because you (heaven forbid) cut her grilled cheese in half is because that part of her brain has not fully developed yet. It’s going to take some time for her to be able to self-regulate and control these emotions.
At three years of age, your child is officially out of the toddler stage and into the preschool stage. Socially and emotionally she likes to imitate adults and friends. She is beginning to show affection for friends without being prompted. She displays a wide variety of emotions (sometimes to your dismay!) and may get upset by changes in her routine. She begins to engage in fantasy play and she may have a difficult time telling the difference between what’s real and what’s not. As far as language development goes, she can speak in sentences of five to six words and speaks clearly enough for most strangers to understand. She may begin to tell stories and she has mastered some basic grammar rules. Cognitively, she can name some colors, she can count and may know a few numbers. While most toddlers have no concept of time, three-year-olds are starting to have a clearer sense of it. She can follow three step commands (when she wants to) and she now understands the concepts of “same” and “different”. In a nutshell, your threenager is practicing her independence. She wants to make her own decisions and feel like she’s in control, but she also needs you, her parents, as well. Tovah Klein, Ph.D., professor of psychology and director of the Barnard Center for Toddler Development in Manhattan, as well as the author of “How Toddlers Thrive” writes that children this age have primary needs that are motivated by two instinctual drives “the need to separate and the accompanying desire to become an independent being with a sense of self.” Even though she wants to begin to separate from you, she also wants to know you’re still there to set limits, provide comfort, guidance, and protection. It’s what she calls the “toddler paradox,” they push us away, only to pull us close again.
All of this right brain dominance with left brain emerging, lack of self-regulation, wanting control, push and pull, can make the task of parenting very challenging for us parents. Fortunately, instituting a few the following tips can make life a little easier (see here for entire list). While I don't have the time to discuss all of these tips, there are two I'd like to highlight. One is to be attuned to your child. This may be one of the most important tips because when we are seeing the world through our child's point of view we can better understand why the melt-downs take place. For example, let's say your child throws a fit each time you try to put her coat on her while you're trying to get out the door in the morning. The morning rush can be difficult for three-year-olds and for parents alike. It's often hurried and your child's needs or wants may be overlooked in the chaos. Being attuned means figuring out why she doesn't want to put on her coat in the first place. When you take the time to slow down and ask her, you find that she doesn't want to wear the pink coat, she wants to wear the blue coat. Aha, problem solved!
Another important tip I'd like to discuss is to be consistent. This means that, as a parent, you consistently address behaviors that are problems. Three-year-olds need this consistency. They want to know what to expect in a given situation, but it is also natural for them to test their limits. For example, if you don't want your child to play with her food at the table today, you act on it right now, and then again tomorrow and the next day if she does it. Calmly say “Please don't play with your food. You can either eat in the chair or play on the floor, but you can't play with your food at the table”. If she begins to play with her food, you gently and calmly take away her food, take her out of her highchair and place her on the ground. What you've done here is given her a choice, which she made, and now come the consequences of that choice. This needs to consistently happen for the misbehavior to be replaced with good behavior. Also, make sure that other caregivers are on the same page as well. Finally, please don't forget that for each time you correct your child, you should be offering praise or loving words ten times more and praise effort, not the outcome. This way she gets positive attention and not negative attention.
Now that you are equipped with the knowledge of your three-year-old's current developmental state, coupled with some tips to help you parent her, you will survive the year of the threenager. Think of this year as being Mother Nature's way of helping you survive the teenage years. Good luck!

Information presented adapted from:
American Academy of Pediatrics, Tips to Survive the Terrible 3s.

https://www.healthychildren.org/English/ages-stages/preschool/Pages/Tips-to-Survive-the-Terrible-3s.aspx

American Academy of Pediatrics, Developmental Milestones 3 to 4 Year Olds.

https://www.healthychildren.org/English/ages-stages/preschool/Pages/Developmental-Milestones-3-to-4-Year-Olds.aspx
Klein, Tovah, How Toddlers Thrive

https://www.amazon.com/How-Toddlers-Thrive-Children-Lifelong-ebook/dp/B00DPM7V20

Siegel, Daniel J & Bryson, Tina P, The Whole-Brain Child

https://www.amazon.com/Whole-Brain-Child-Revolutionary-Strategies-Developing/dp/1491514817

In last month’s post I shed a little light on infant sleep patterns (see post). This month, I will try to do the same by discussing common sleep problems in the toddler years and beyond. I have organized this month’s post into a question and answer format as I did in last month’s post, based on similar questions I’ve received in clinic. Please don’t take the following advice as “the end all be all.” What works for one child, doesn’t always work for another. However, I have found many of these suggestions to be helpful to my patients and their families and personally as a mother myself.
           
1) We recently moved our 3-year-old son to a toddler bed to prepare for his baby sister’s arrival in a few months. Prior to this, we had no trouble putting him to sleep in his crib. Now, bedtime is a struggle and we cannot seem to get him to stay in bed. As soon as we put him down for the night, he either calls out crying for us to come into his room or he just gets up out of bed. Sometimes this happens multiple times a night. How can we get him to stop this behavior?

Answer: It is normal for children of this age to resist going to sleep, especially if they have older siblings that are still awake. First, it is important to have a bedtime routine in place and that you are consistent with it. For example, I often suggest that the hour before bed be designated “quiet” time. This means no stimulating activities about an hour before bed. This is true for all age groups. This includes TV, video games, electronic toys, and active play. All of these activities could make your child too excited to sleep. It is also helpful to use this time to carry out a bedtime routine--taking a bath, brushing teeth, listening to quiet music or reading a story, and then going to bed. It is also helpful to have your child take a favorite thing to bed each night like a teddy bear or blanket and to make sure he or she is comfortable. By addressing your child’s needs (a drink of water, using the bathroom or leaving the door open a crack to let a little light in the room) before bedtime this will hopefully make it less likely that he or she will feel the need to use them as excuses to avoid going to sleep later.

The preschool age group (children ages three to five) is also a time when I like to discuss the idea of a “bedtime pass”, especially for parents who are at their wits end. The bedtime pass is basically a 5 x 7 index card that you give to your child explaining that the pass is good for one bedroom exit per night. That could be anything, an extra hug and a kiss, a trip to the bathroom, or a drink of water. After the pass has been used for one choice off the list each night, your child is not allowed to leave his or her bedroom or call out for you as the pass has been used. The idea is that, over time, your child won’t want to use up their one pass at night because they want to be able to use it when they REALLY need it and the night time “calling outs” and getting up out of bed will happen less and less until they become non-existent. The bedtime pass also makes a highly stress-ridden situation less emotional and more transactional, giving both the parent and child control in the matter. It ends up being a win win.
 
2) My 2-year-old daughter has been waking up screaming in the middle of the night. When I go to check on her, she looks like she's still sleeping, but it sounds terrible. Is there anything I can do to help this?

Answer: Night terrors are particularly distressing for parents. They occur most often in toddlers and preschoolers and take place during your child's deepest stages of sleep. Some signs of night terrors are crying uncontrollably, sweating, shaking, or breathing quickly. Your child might have a glassy-eyed gaze, a terrified or confused look on his or her face. He or she may thrash around in bed, scream, or kick. Your child may not recognize you or realize you are there and they may push you away if you tried to hold him or her. Night terrors can last anywhere from seconds to minutes, sometimes up to 45 minutes. Most children will fall back to sleep immediately following a night terror because they actually haven't been awake. Also, most children don't end up remembering night terrors and will have no recollection of the events of the previous night the next morning. Night terrors are often an inherited disorder, meaning parents of children with night terrors often suffered from night terrors themselves. They also are a product of sleep debt or being overtired, meaning your child likely hasn't been getting enough sleep recently.

So what can you do? If your child is having a night terror make sure that you relax, as again, they are usually more frightful for you than for your child. Don't try to wake him or her. And, keep your child safe. If your child tries to get out of bed, gently restrain him or her. Finally, the best way to prevent night terrors from happening in the first place is to make sure your child is getting enough sleep. For example, if your child's current bedtime is 8 pm, try putting him or her down about half an hour earlier, so 7:30 pm and see if that helps. Many times, parents can recall a week of late bedtimes or not good sleeping as the culprit and once back into a good routine, they happen less or not at all.
 
3) My 5-year-old son is constantly bouncing off the walls. He has trouble focusing during the day, sitting still, and is quick to act out. He will often lose his temper and lash out at his younger siblings too. He seems to be doing fine in school, but I worry that these might be the beginning signs of ADHD? What should I do?

Answer: While these can all be signs of a child with ADHD (see this post for more information on ADHD), what is more likely, given his age, is he’s not getting enough sleep. There exists a lot in the scientific literature that shows getting less the recommended amount of hours of sleep each night leads to attention, behavior and learning problems in children. In addition, in a child with ADHD, poor sleep can make these condition even worse. However, as a clinician in this scenario, it is important to make sure that this child is getting adequate sleep before jumping to any conclusions. According to the American Academy of Sleep Medicine, there are an average number of hours of sleep per night your child should be getting for optimal health and functioning. The amount of hours differs depending on the age of your child and it decreases as your child grows, but it is probably more than you think it is (see here). Some of my first questions to this parent would be what time is bedtime, what does your child do in the hour leading up to bedtime, and do you have a nightly routine? More often than not, we find that the hyperactivity and temperament of the child is due to a late bedtime or poor sleep pattern more than ADHD or any other medical diagnosis.
 
4) Help! I feel like I always have to drag my 15-year-old daughter out of bed in the morning. She says she “just can’t fall asleep at night.” She is in bed at 10 pm most nights, but says she lies in bed, tossing and turning for hours each night. Should I start her on a sleep medication?

Answer: Before starting your daughter on any kind sleep aid medication, it is important to first make sure she doesn’t have any bad bedtime habits that are making it difficult for her to fall asleep. We live in a technological age and that has made falling asleep more difficult for many people. So what to do in this situation? First, make sure your daughter avoids any kind of screen time one hour or more before bedtime. That means no cell phone, computer, tablet, TV screen, etc. Basically, "if it lights up it’s off limits." Many of my teenage patients are aghast when I suggest this. They tell me “How will I get up in the morning? My cell phone is my alarm clock.” I think they are even more surprised to realize there were and still are these things called alarm clocks that ring and they can be used instead of their cell phones to wake up in the morning. Now, I know sometimes this rule isn’t always realistic because homework sometimes needs to be completed on a computer and it can’t always be started by a certain time with activities and/or sports in the mix. However, if for the most part, this rule and bedtime is respected, falling asleep will become easier.
Second, no electronics are to be allowed in her bedroom. For example, if her phone is on silent or sleep mode, her brain still knows the phone is in the room and she could be tempted to look at it and see who texted her. By not allowing electronics in the bedroom, it is used only for sleeping and her body will know that too. Many parents will have their kids “turn in” their cell phones for the night after a certain hour which helps carry out this idea.

Finally, as mentioned in the first question above, a nighttime routine is helpful for good sleep hygiene. A ritual of quiet time, taking a shower or bath, brushing teeth and reading before bed, can help settle down the brain at night. Hopefully, by making these simple changes, your teenager will be falling asleep easier in no time.

It is my hope that you found some applicable solutions to sleep challenges your family is facing at the moment. If you have more specific questions, or any question for that matter, please don’t hesitate to contact us here at ABC Pediatrics. Sweet dreams!
 
Information presented adapted from:
American Academy of Pediatrics, Bedtime Trouble. https://www.healthychildren.org/English/healthyliving/sleep/Pages/Bedtime-Trouble.aspx
 
American Academy of Pediatrics, Sleep Problems.
http://www.pediatricspec.com/resources/SleepProblems.pdf
 
American Academy of Pediatrics, AAP endorses new recommendations on sleep time.
http://www.aappublications.org/news/2016/06/13/Sleep061316
 
Clark, Wendy Mitman, The Bedtime Pass Help Parents And Kids Skip the Sleep Struggles.
http://www.npr.org/sections/health-shots/2015/09/18/441492810/the-bedtime-pass-helps-parents-and-kids-skip-the-sleep-struggles

Sleep. Everyone needs it. We don't get enough of it. Most people wish they got more of it. Whether it’s tired parents of newborns who are up every few hours in the middle of the night to feed their baby, frustrated parents of toddlers who won't stay in their beds, or exasperated parents of teenagers whose children won’t get out of bed because he or she stayed up until midnight binge-watching Netflix, parents are concerned about their child’s sleeping habits and with good reason. No matter the age, sleep is extremely important to our overall health and well-being. A well-rested body and mind is a well-functioning body and mind. While I can't make your child sleep, I can try to give you suggestions to foster a positive environment for sleeping and prevent bad habits from taking root, no matter what stage of life your child is in. Because sleep is such a broad topic, I've broken it up into 2 parts. This month, I'll discuss sleep in infancy, that is, newborn to 1 year of age, and next month I'll tackle some sleep issues for toddler years and beyond. I've organized this month's post in a question/answer format. These are similar questions to those I have received at clinic regarding infant sleep.

1) How much sleep should my baby be getting everyday?
Answer: It depends on how old your baby is. Newborn sleep patterns differ greatly from the sleep patterns of older children and adults for they will not develop a regular sleep pattern until about 6 months of age. Newborns up until 6 months of age need a total of about 16 to 18 hours of sleep daily. In the newborn period, this sleep is broken up into increments and babies will wake every 2 to 3 hours to eat and then fall back asleep again sleeping only 1 to 2 hours at a time, with some periods of wakefulness. At about 2 months of age, infants will start stretching out their sleep with a preference for sleeping at night, about 5 to 6 hours at a time, and then are awake for longer periods during the day. By 6 months of age, many babies are sleeping at least 10 hours at night with 2 to 3 naps during the day. This longer stretch of sleep at night is again mirroring the sleep patterns of older children and adults. By one year of age, most babies are sleeping 11-12 hours at night and have 1 to 2 naps during the day.

2) When can I expect that my baby will be sleeping through the night?
Answer: Sleeping through the night during the first few months of life means a baby is sleeping about 5 to 6 hours at night without needing to eat. This usually happens around 2 months of age, although some babies begin earlier. Most parents of newborns will agree, that first time your baby gives you a 5 to 6 hour stretch of sleep, you feel like a new person, especially if it continues. As your infant grows, that stretch of sleep will increase, and your baby will baby able to go for longer stretches of time without eating.

3) Why isn't my son a good sleeper like his cousin? My son is 2 months old and his cousin who is the same age sleeps 10 hours a night without waking up. What am I doing wrong?
Answer: First, let me describe what a good sleeper is at 2 months of age. A good sleeper is a baby that sleeps at least 5 to 6 hours at night and during those long stretches may wake up every so often, but can put himself back to sleep. I would be concerned if the parents of a 2 month old told me that their baby slept 10 hours a night without waking. It is developmentally appropriate for a child to wake often, as this shows the infant can wake in situations where they're not getting enough oxygen or if they are having trouble breathing. Because infants wake often in their sleep, this is another reason why it's important to not always rush and get them out of bed at each little cry. I call this the “declaration period”. Let your baby “declare” himself awake. In France, they call this “Le pause”. Many times babies cry out as they are transitioning from one sleep cycle to the next. Give it a few minutes and see if he can soothe himself on his own and fall back to sleep before taking action. If he is still crying after 2 to 3 minutes, go check on him.

4) My daughter is 3 months old and needs me to rock her to sleep. How can I get her to fall asleep on her own?
Answer: The trick to getting her to sleep on her own is putting her to bed when she’s drowsy, but not asleep. For example: if she needs you to rock her to sleep to put her down at night, then anytime she gets up in the middle of the night she will likely need you to rock her to put her back to sleep. This then creates a vicious cycle. Pay attention to signs that she’s getting sleepy, this might include her yawning or rubbing her eyes, but be sure to not wait too long until she’s over-tired, as that makes getting her to sleep on her own even more difficult. Don’t worry, as time goes by, you’ll get to know your baby’s tired cues and by putting her down as the first signs of sleepiness and she will learn to settle herself to sleep.

Another good habit to develop is a bedtime routine. You can even begin this when your baby is still on the every 2 to 3 hour feeding schedule. Early on, this is teaching your little one that nighttime is for sleeping and daytime is for playing. Also, a bedtime routine creates consistency and consistency is key in parenting. By performing the same ritual each night, babies will come to know it’s bedtime and, therefore, will have an easier time falling asleep. This bedtime routine could be as simple as making sure lights are turned down low about an hour before bed, giving a bath, doing the final feeding of the night, reading a book and putting your child to bed while drowsy, but not asleep. Finally, always be sure you’re putting your infant on his or her back to sleep. The best sleep is safe sleep, so remember Back to Sleep!

5) Help! My 6 month old son still wakes up every 2-3 hours in the middle of the night to nurse? He acts so hungry and then immediately goes back to sleep when he’s done. I’m so tired though, I can’t go on like this.
Answer: One common phrase I often hear from parents of older infants who aren’t sleeping through the night is “He must wake up because he’s hungry because once he eats he goes right back to sleep”. And, while this seems logical, this is one of those instances where he’s likely gotten in the habit of snacking in the middle of the night and this is not a necessary feeding. A healthy, thriving 6 month old does not need to eat in the middle of the night. I will often say to parents “Well, if you offered me chocolate chip cookie, I’d eat it too”. So, what to do now? Well, we have to rid him of this bad habit. The best way to do this is still quite the debate and many people feel strongly that some ways are better than others. There are a plethora of different methods (extinction i.e. “cry it out”, graduated extinction, bedtime fading, scheduled awakenings) and the good news is, no matter what method you choose they work. A recent New York Times article highlighted a systematic study that was published in 2006 in the journal of Sleep on the efficacy on these interventions. After reviewing fifty-two studies, 94 percent of those reviewed reported improved sleep with implementation of any studied intervention. Hooray, there is hope!

What I would recommend in the case of this 6 month old that is nursing every 2 to 3 hours is the extinction method with some slight modifications. The extinction method has parents let their infants “cry it out”. After performing a nightly bedtime routine, parents do not go in the room until morning. Now the traditionalists of this method would say to not go in the room, under any circumstances. That may be quite harsh for some parents (It was for me!). What I have parents do is set a timer, usually 10 minutes. If after 10 minutes, he is still crying (which he likely will be) it is okay to go in his room and make sure he’s okay. If all is well, and he’s just upset that he’s not getting his 1 am snack, you tell him you love him, that he’s safe and he needs his sleep just like mommy and daddy do. This is another French parenting tip – talk to your babies. The French believe babies understand what you’re saying (as do I) and it makes you feel better too. The first night of this method will be brutal, but it will get better. If he cries on and off the first night for 3 hours, by night two it may only be 45 minutes, and by night three it may be only 30 minutes, and most often, by 1 week, they are sleeping through the night. I’m not going to lie, there is nothing easy about listening to your baby cry, but you have to keep the end goal in mind and that is, a night of good sleep, for your child and for you.

You will sleep again, I promise. I won’t ever forget that one of the most helpful words of encouragement I received in the first few weeks after becoming a parent myself was “I know you are tired right now, try not to worry, you will sleep again”. During that time, with sleep deprivation weighing heavy, to hear that sleep deprivation was only temporary was a tremendous relief. It is my hope that whatever sleep struggles you are experiencing at the moment you'll find some guidance and comfort in reading this post today. As always, if you have a more specific sleep concern or any other questions, please don’t hesitate to contact at ABC Pediatrics. We are here for you!

​Information presented adapted from:
American Academy of Pediatrics, Sleep: What Every Parent Needs to Know.
http://shop.aap.org/Sleep-What-Every-Parent-Needs-to-Know-Paperback/
American Academy of Pediatrics, Sleep Problems in Children.
http://www.pediatricspec.com/resources/SleepProblems.pdf
Carroll, Aaron, Putting Your Baby to Sleep: Some Advice and Good News
http://www.nytimes.com/2016/08/02/upshot/putting-your-baby-to-sleep-some-advice-and-good-news.html?smprod=nytcore-iphone&smid=nytcore-iphone-share&_r=0
​Druckerman, Pamela, Bringing Up Bebe
https://www.amazon.com/Bringing-Up-B%C3%A9b%C3%A9-Discovers-Parenting/dp/0143122967

Do you have a child that is always on the go, talks too much, won't sit still, can't seem to follow directions or complete tasks, doesn't pay attention, can't keep track of his or her things, cannot play quietly, or is forgetful? Sure, many of these qualities are just kids just being kids, especially if they are younger in age. However, if these symptoms don't improve over time and are beginning to affect your child's school, family and social life, they could be due to something called Attention ­deficit/Hyperactivity Disorder (ADHD).

ADHD stands for Attention­Deficit/Hyperactivity Disorder and it is a common behavioral disorder that affects approximately 10% of U.S. children ages four to seventeen. Symptoms usually arise in early childhood, and can continue throughout teenage years into adulthood. Despite numerous studies, researchers have yet to pinpoint an exact cause of ADHD. Nonetheless, these studies have suggested there is a strong genetic link because ADHD can run in families. There also is evidence to suggest that exposure to pesticides or lead in early childhood, brain injury, and prematurity and/or low birthweight may increase likelihood of having ADHD.

ADHD is characterized by developmentally inappropriate levels of inattention, impulsivity and hyperactivity. It is classified into three subtypes, “primarily inattentive”, “primarily hyperactive” and “combined type” which would be inattentive and hyperactive. There is a common misconception that ADHD only applies to the child who is hyperactive, impulsive and is always bouncing off the walls. This isn't true because the calm and quiet child could also have ADHD with predominantly inattentive symptoms. In addition to sub­types, ADHD can be classified as “mild”, “moderate” or “severe”. In the same way a child may have mild asthma with symptoms occasionally affecting activities of daily living, you can also have mild ADHD.
​
There is no single test to diagnose ADHD. It is a complex process that takes time and effort and involves collecting information from the child's parents, teachers, and health careprofessionals. The most recommended method by medical organizations is to complete an ADHD rating form by at least 2 adults from 2 different settings, usually home and school. ABC Pediatrics uses the Vanderbilt, (click here), but other institutions may use the Conners evaluation forms. In order for a diagnosis of ADHD to be made, children should have 6 or more symptoms of the disorder present for greater than 6 months and symptoms must have appeared before 12 years of age. In addition, the child's health care provider will do a thorough medical history and physical examination in order to screen for other conditions that could be affecting the child's behavior.
​
If a diagnosis of ADHD is made, the treatment varies depending on the child's age and severity. Treatment for ADHD is multi­modal, usually consisting of behavioral, educational, medical, and psychological intervention. Many parents are hesitant to put their child on medication, but it seems to be an essential part of treatment for ADHD as medications have outperformed behavioral and nutritional therapy alone in clinical trials. The medications for ADHD fall into two categories: psycho­stimulants and non­stimulants. Stimulants are the first ­line therapy as they have been the most widely studied. The effectiveness of non­stimulant medication is based on limited clinical trials and, mostly, clinical experience. The child's provider will tailor medication to the special needs of the child and his or her family with the end goal being the best possible outcome with the least amount of side effects. Most side effects are mild and short-­term and include appetite suppression, insomnia, anxiety, and agitation. In the same way some parents might be hesitant to put their child on medication, they also need to be aware that there is no magic pill to cure ADHD. Medications will not control the child's behavior, but they will decrease symptoms of ADHD so the child can function more effectively at school and at home.

Finally, parents need to be aware that after a diagnosis is made, it is just the beginning of a long journey ahead. The first step is to become better educated in all things ADHD. Read as much as you can and don't hesitate to contact your health care provider with any questions that may come up.

Parenting a child with ADHD can be difficult, confusing and stressful. Parents may have to change the way in which they rear their children in some instances. There are a wealth of resources available and I will often direct my patient's families to the Children and Adults with Attention­ Deficit/Hyperactivity Disorder (CHADD) website (click here) and if you live in Utah, the Utah Academy of Child and Adolescent Psychiatry (UACAP) (click here) is great as well.

Last, but not least, the following informational brochure is loaded with tips for parenting a child with ADHD (click here) As always, please do not hesitate to contact us here at ABC Pediatrics with additional questions. We are here for you!

*Information provided adapted from the American Academy of Pediatrics “ADHD: Clinical Practice Guidelines for the Diagnosis, Evaluation, and Treatment of Attention ­Deficit/Hyperactivity Disorder in Children and Adolescents”, the Utah Academy of Child and Adolescent Psychiatry's website on ADHD, and from the Children and Adults with Attention Deficit/Hyperactivity Disorder's website.

If you've been reading news headlines the past month you probably know two things for sure. First, we are in an election year and we will keep hearing why such and such candidate is better than so and so candidate until the talking heads are blue in the face. And, two, that a mysterious virus by the name of Zika is wreaking havoc in much of the Southern hemisphere. While I can't help you with your decision on who to vote for in November of 2016, I can help shed some light on Zika and how it affects you and your family.

Zika is a virus that can cause symptoms of fever, rash, pink eye and joint pain. These symptoms usually last about one week and are typically mild. Rarely are the symptoms so severe that they require hospitalization. It can be spread from person to person via the bite of a mosquito and through sexual contact, from an infected male to his partner. The Centers for Disease Control and Prevention (CDC) is still investigating if it can be spread via saliva and urine, but that has yet to be determined. So, why all the fuss then? The World Health Organization (WHO) has issued a public health emergency as it investigates the possible link of babies born with abnormally small heads, known as microcephaly, and other birth defects, and the Zika virus. Additionally, there may be a possible link between Gullian Barre syndrome, a disorder characterized by progressive muscle weakness that can lead to entire body paralysis, and the Zika virus. As of now, it is unknown whether the increase in microcephaly cases or the cases of Gullian Barre are directly caused by Zika.

It is because of the possible link of Zika to microcephaly that the CDC has issued warnings to pregnant women and women who are trying to get pregnant. If you or your partner is pregnant or trying to get pregnant, it would be best to hold off on travel to areas with Zika (http://wwwnc.cdc.gov/travel/page/zika-information). If you must travel to these places, first talk to your doctor before you go and be sure to take special precautions while there -- specifically, avoid getting mosquito bites. Also, if you do travel to one of these areas while pregnant, it is recommended you get tested between 2 and 12 weeks after your return, even if you are not showing symptoms.

I’ve received some questions in the last few weeks from families who are traveling to areas with Zika and what they need to do to protect themselves. The best way to prevent you or your family from getting Zika virus is to prevent against mosquito bites. Make sure you wear clothing with long sleeves and long pants that have embedded Permethrin, use insect repellants, and sleep in places with screens or air-conditioning, or use mosquito netting over your bed.

Thankfully, as of right now, there have been no confirmed Zika cases acquired in the United States (U.S). All the cases confirmed in the U.S. have been acquired in other countries with Zika. There is some worry that with warmer weather on the horizon the mosquitos that carry Zika will make their way North, although for right now it’s not the case. Currently there is no vaccine or treatment for Zika, so the best way to avoid the effects of Zika is not getting in the first place. Researchers are working on developing a vaccine, although that could take years before it is available to the masses.

Check out the CDC's website for more detailed and up-to-date information. Or, if you have more specific questions, don’t hesitate to contact us at ABC Pediatrics. We are happy to help!

*Information presented adapted from Center for Disease Control and Prevention information on Zika http://www.cdc.gov/zika/index.html