Baby Bottle Tooth Decay is a major cause of tooth decay in infants. Although baby teeth are eventually replaced by permanent teeth, severe decay to baby teeth can lead to pain, infection, and early tooth loss. If baby teeth are lost too early, the permanent teeth may become crooked or have no room to erupt.

Baby Bottle Tooth Decay can develop if your child’s teeth and gums are in prolonged contact with any liquid other than water. Tooth decay is promoted not only by what sugar the teeth are in contact with, but also how long the sugar is in contact with the teeth. Bacteria in the mouth change sugars to acid which then dissolve the tooth enamel. Major risk factors for Baby Bottle Tooth Decay include putting your child to sleep with a bottle and allowing your child to suck on a bottle or breastfeed longer than a usual mealtime.

Tips to preventing Baby Bottle Tooth Decay:

• Never put your child to bed with a bottle. This includes any lying-down position.
• Only give your baby a bottle during meals. Do not allow your child to walk around with a bottle for extended periods, and do not use the bottle as a pacifier.
• Teach your child to drink from a cup as soon as possible. Most children can learn to drink from a cup by 1 year of age.
• Do not continually breastfeed throughout the night. Nighttime feedings should be at least 2 hours apart.

You can clean your child’s teeth as soon as they erupt. When there are only a few teeth you can wipe them clean with a gauze pad or damp washcloth after feeds. When your child has 7 or 8 teeth, brush the teeth twice daily with a small child-sized toothbrush. Use a smear of fluoride-containing toothpaste; at 3 years of age, you can use a pea-sized amount

Since most municipalities in north New Jersey do not contain fluoride, almost all of our children are prescribed a multivitamin with flouride starting at 6 months of age. If you are not sure about the fluoride supply in your area, check the fluoride page of the New Jersey Department of Health and Senior Services.

Bedwetting is a very common problem. It occurs in 25% of kids at age 5, 10 to 20% at age 8, 5% at age 12, and 1% by age 18. Many children with prolonged bedwetting have small bladders and an immature feedback system that results in urine to be passed during sleep instead of awakening the child. Prolonged bedwetting is frequently familial and is rarely caused by a medical or physical problem. Almost all kids eventually outgrow it.

Recommended treatment steps include:

• Restrict fluids during the two hours prior to bedtime.
• Always have the child urinate prior to bedtime.
• Prepare the bed and child. A plastic mattress cover will keep the urine from soaking in. Your child should wear extra thick underwear (training pants) in addition to his pajamas.
• Consider awakening your child to void again right before you go to bed.
• Bladder stretching exercises may be helpful. During the daytime, if your child feels the urge to go, he/she should be encouraged to wait for 15 to 30 seconds for the urge to disappear. Each subsequent time he/she should wait longer, e.g. 1 minute, 2 minutes, etc.

Medications are occasionally helpful but are not a cure. Medications work best if a child is about to outgrow the bedwetting (i.e. not bedwetting as frequently over the past several months) and may be useful for certain situations, such as sleep-away camp, where it would be embarrassing for the child to be bedwetting. Alarm devices are based on behavioral modification feedback and work well in children 7 years and older.

Riding a bike is fun if it is done safely. Most people don’t realize hundreds of thousands of children are seriously injured each year in bicycle falls, and hundreds of children die in bicycle accidents each year. The most serious injury is head trauma, which can cause death or permanent brain damage. The severity of these head injuries can be reduced by 85% if all children wore bicycle helmets properly.

• It is important to wear a bike helmet on every ride, no matter how short or close to home. The Consumer Product Safety Commission (CPSC) or the American National Standards Institute (ANSI) should certify the helmet for bicycle use. Make sure the bicycle helmet is worn correctly and fits well! New Jersey State Law requires all children under the age of 17 to wear a helmet while biking, skateboarding, and in-line skating.
• Your child should never ride a bike that is too big. He/she should be able to sit comfortably on the seat with hands on the handlebars and the balls of both feet on the ground. Your child’s first bike should also be equipped with footbrakes, because your child’s hand strength and coordination are not mature enough to control hand brakes.
• Your child should always ride on the right with traffic! Almost one-fourth of bicycle-car collisions result from bicyclists riding against traffic.
• Your child should always use appropriate hand signals when riding in the street. They are an important communication link between cyclists and motorists.
• Never allow your child to ride their bike at dusk or after dark.
• Bicyclists should always respect traffic signals.

For more information on selecting and using bicycle helmets, visit the American Academy of Pediatrics web site information page at http://www.aap.org/family/thelmabt.htm.

Calcium & Vitamin D intake in childhood and adolescence is very important to help prevent future osteoporosis.

Recommended Daily Allowance of Calcium

• 0-6 Months – 200mg
• 7-12 Months – 260mg
• 1-3 Years – 700mg
• 4-8 Years – 1000mg
• 9-18 Years – 1300mg
• >18 Years – 1000mg

Dietary Sources of Calcium

• milk, 1 cup 300 mg
• soy milk calcium-fortified, 1 cup 200 to 400 mg
• sour cream, cultured, ½ cup 125 mg
• o.j. with calcium, 1 cup (8 oz) 300 mg
• plain yogurt, 1 cup (8 oz) 415 mg
• swiss cheese, 1 oz 270 mg
• mozzarella cheese, 1 oz 200 mg
• cheddar cheese, 1 oz 205 mg
• american cheese, 1 oz 175 mg
• cottage cheese, 1 cup 100 mg
• instant farina, 1 cup 100 mg
• almonds, 3½ oz 255 mg
• sardines, canned (5 small fish) 250 mg
• salmon, 4 oz 300 mg
• broccoli, 1 cup 130 mg
• spinach, 1 cup cooked 240 mg
• sunflower seeds (3½ oz) 120 mg
• chickpeas, ½ cup 100 mg
  baked beans, ½ cup 65 mg
• orange, 1 large 95 mg
• tofu, regular ½ cup 120 mg
• cereal, calcium fortified 1 cup 200 mg – 1000 mg
• oatmeal, instant 1 package 125 mg
• bread, calcium fortified, 1 slice 150 – 200 mg
• tortillas, corn – 2 medium 85 mg

The recommended daily dose of Vitamin D is 400 IU/day from 0-12 months, then 600 IU/day thereafter.  There is approximately 100 IU of Vitamin D in a glass of milk.

We recommend the following:

• Viactiv Calcium + D soft chews – 500 mg of calcium with 500 IU of Vitamin D
• Caltrate soft chews 600 + D – 600 mg of calcium with 400 IU of Vitamin D
• Oscal 500 + extra Vitamin D (chewable) – 500 mg of calcium with 400 IU of Vitamin D
• Oscal 500 + D caplets – 500 mg of calcium with 200 IU of Vitamin D

The American Academy of Pediatrics and the National Highway Traffic Safety Administration recommend the following guidelines to help keep your family safe in your vehicle. These guidelines will help prevent injury to you and your children in case of a car collision. Every state requires that infants and children ride buckled up. However, state laws do vary, and they do not always require the safest way to transport a child. More children are killed as passengers in car accidents than from any other type of injury.

• EVERYONE in the car must “buckle up” with age-appropriate restraint devices.
• The back seat is always the safest place for a child 13 years and under.
• Infants should be restrained in a rear-facing car seat until they are at least two years of age. If necessary, pad the sides of the seat with rolled-up receiving blankets to prevent your infant from slouching. When your infant is small, you may use an infant seat, but when your infant outgrows the weight or length limit (usually 20-22 pounds or 29-32 inches) you must use a rear facing convertible seat instead. Never mount a rear-facing infant seat in front of a passenger-side air bag. If the air bag deploys, serious injury and death may occur. Refer to your owner’s manual for recommendations regarding mounting car seats next to side air bags.
• A convertible car seat may be used after your child outgrows the infant seat. The convertible seat should be rear facing until the child is 2 years old, after which it may face forward. Each convertible car seat is different and so you need to check the height and weight restrictions of each individual seat.
• Belt positioning booster seats should be used after your child outgrows the convertible car seat. These seats are designed to be used between 40 and 80 pounds. Most children will not properly fit into a regular seat belt until they are 4 foot 9 inches. Before you allow your child to sit in a regular seat belt, check to see that the shoulder belt fits over the clavicle (collar bone), the lap belt fits snugly over the hips, and the knees are forward of the seat cushion. Never tuck the shoulder belt under the child’s arm or behind the child’s back!

For thorough information about car seat, you can access the following website: www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx.

You may also speak with a certified Child Passenger Safety (CPS) technician at 888-327-4236, 8 am-10 pm ET, Monday-Friday.

For information regarding a car safety seat recall, contact the manufacturer, the Auto Safety Hot Line at 888-327-4236 or 800-424-9393, or access www.nhtsa.gov.

Cholesterol is an important substance that the body uses to build cell walls and manufacture hormones and vitamin D. In very young children, it also plays an important role in the the development of the brain. However, high blood cholesterol is one of the major risk factors that contribute to early onset of coronary heart disease, the leading cause of death in the United States. Research has shown that atherosclerosis (cholesterol plaques in the arteries) begins in childhood. Atherosclerosis can eventually lead to blockage of arteries, subsequently causing a heart attack or stroke. There are two strategies for lowering blood cholesterol: the first approach is to change diet and eating patterns, and the second is to encourage your children to exercise and stay fit.

There are two main types of cholesterol, bad (LDL) and good (HDL). LDL, or “bad cholesterol”, can be lowered by eating foods that are low in cholesterol and saturated fat; conversely, HDL, or “good cholesterol”, can be increased by staying active and in shape. LDL carries cholesterol from the liver to the arteries, contributing to the accumulation of plaque in the arteries, while HDL collects excess cholesterol and brings it back to the liver. Saturated fats can raise the cholesterol level in your blood regardless of how little cholesterol you may consume, since they are used by the liver to make cholesterol. Unsaturated fats, though, may actually lower your total cholesterol level.

It is very important not to restrict fat and cholesterol in children under the age of two years. The rapid growth of children at this time requires a diet with a higher percentage of calories from fat. Children over two years should have less than 30% of total calories from fat; in addition, less than 10% of total calories should be from saturated fat.

Foods high in cholesterol and saturated fat

• Meat, especially red, organ, or processed meats
• Bacon
• Shellfish
• Egg yolk
• Cheese
• Butter
• Whole milk/cream
• Ice cream
• Chocolate
• Coconut/Palm oil
• Avocado

Foods low in cholesterol and saturated fat

• Fish
• Lean meats, skinless white chicken or turkey
• Beans
• Vegetables/fruit
• Nuts
• Breads
• Unsaturated oils (canola/olive)
• Pasta
• Rice
• Nonfat/lowfat dairy products
• Soy

Achieving a Step-One cholesterol lowering diet

1. Switch to nontfat milk and lowfat dairy products. Do this gradually; switch to 2% milk for several weeks, then to 1% for several weeks, then to skim.
2. Choose lean meats, poultry, and fish. You may cook chicken with the skin on, but remove it before serving. Trim all visible fat from meat and fish. Choose lean cuts of beef and do as little frying as possible. Bake or broil meat, poultry, and fish instead.
3. Limit cookies, cakes, chips, and ice cream to no more than 2 or 3 small servings a week. These foods are loaded wih saturated fat and trans fat, which help to raise cholesterol. These foods typically get at least half their calories from fat and they have no significant nutrition.
4. Give you child at least five servings or fruits and vegetables daily. Limit juice to 6-8 oz. daily, however, since juice has no fiber and fewer nutrients.
5. Include plenty of whole grains and beans in your child’s diet. This includes high-fiber cereals, oatmeal, raisin bran, Cheerios, etc.
6. No more than 4 eggs per week. Consider using egg whites.
7. Get moving! Let your child choose forms of physical activity that he or she enjoys most. The goal is to do 30 minutes of aerobic-type activity at least 4 times weekly. Examples include biking, rollerblading, dancing, running, swimming, and even walking.

Upper airway congestion is very common in the first few months of life and can also be present with the common cold caused by viruses. There are no medicines that will completely make the symptoms disappear. The goal is to keep your child comfortable. In general, if a child continues to drink normally, there is no need for concern.

The following are suggestions to help your child breathe more easily:

• Put a few drops of saline drops in the nose, then gently remove the secretions with a bulb syringe.
• Elevate the head of the crib.
• Use either a cold air vaporizer or humidifier in your baby’s room. Make sure you change the water every night, and clean it well with bleach or Lysol once a week to eliminate mold and bacteria that grow in a wet environment.
• Always keep your baby away from irritants such as cigarette smoke, paint and gasoline fumes, aerosols, perfumes, and hair sprays.
• Keep your baby’s sleeping environment as dust free as possible.

We do not recommend any decongestants or cold medicines under six years of age due to excessive side effects.

Constipation is when your child has infrequent hard stools that are painful to pass. Newborns generally have stools 4 to 8 times a day. By the time they are 2 months old breastfed infants may pass stools as frequently as 4-6 times a day or as infrequently as once every 4-5 days; formula fed infants have stools 2-3 times a day to every other day. When your child is on solid food, stools usually pass 2-3 times a day to every other day. Occasionally with viral illnesses, when your child has a decreased appetite, stools may pass less frequently than normal.

If your child is constipated, we recommend the following treatments:

Infants under 1 year

Give 4 ounces of water mixed with 1 teaspoon of brown sugar once a day.

Give older infants strained apricots, prunes, or peaches twice a day.

Children over 1 year

Give fruits and vegetables (good examples include celery, lettuce, beans, raisins, peaches, pears, prunes), bran cereal, graham crackers, or oatmeal.

Make sure your child drinks plenty of water.

Give your child prune juice. If you mix prune juice with 7-UP, it tastes like Dr. Pepper.

Decrease constipating foods like milk, bananas, rice, apple sauce, and cooked carrots.

Do not overdo dairy products. More than 3 cups of milk per day can cause constipation.

Call us if your child:

has blood in the bowel movement

goes 3 days without a bowel movement despite trying the above treatments

has severe cramps

has any deep tears in the rectum that won’t heal

has any symptoms that concern you

Coxsackievirus belongs to a general group of viruses known as the enterovirus family. There are several kinds of enteroviruses, including coxsackievirus, echovirus, and reovirus. Each group in turn has numbered subtypes. Several types of enteroviruses, including coxsackievirus A16, cause the well-known Hand-Foot-and-Mouth disease, which consists of blisters on the hands, feet, and buttocks, as well as sores in the mouth and throat. Fever, malaise, and diarrhea frequently accompany the rash.

In temperate climates, the entire enterovirus family tends to predominate in summer and fall. In addition to Hand-Foot-and-Mouth disease, enteroviruses can be responsible for a wide variety of illnesses including the common cold, pharyngitis, fever, rash, and vomiting and diarrhea. The incubation period is 3-6 days and the mode of transmission is predominantly fecal-oral, although oral-oral (saliva) transmission is also important. Careful handwashing will limit spread.

If your child has Hand-Foot-and-Mouth disease, Tylenol or ibuprofen is recommended for the fever and discomfort. If your child has mouth ulcers, encourage plenty of cold fluids and offer a bland diet since the ulcers are frequently painful.

Croup is a viral infection (usually parainfluenza virus) of the upper airway, including the larynx and trachea. A hoarse voice and a barky, seal-like cough are the most common symptoms. When croup is particularly bad, it causes a crowing noise (“stridor”) every time your child takes a breath in. Croups usually lasts 3-5 days and is generally worse at night.

Treatment:

• Use a cool mist vaporizor or humidifier when child is sleeping. Make sure the water is changed every night, and clean it very well with bleach or Lysol once a week. This will kill the mold and bacteria that can grow in a wet environment.
• We do not recommend suppressing the cough with a cough medicine.
• Encourage your child to drink lots of clear fluids.

If your child makes a crowing noise while breathing:

• Take your child outside for 5 minutes in the cool night air.
• While you are outside with your child, have the hot shower or hot water running in the bathroom with the door closed. When the room is steamed up, take your child into the steam for 20 minutes. Sit in the bathroom steam with your child and read him/her a story. Remain calm, if your child is upset, scared, or cries, it can make the croupy cough worse.
• Most children will settle down in the steam and go back to sleep.
• Call us immediately if the crowing sound persists despite 20 minutes of steam.

The first year of life is an important time in your child’s nutritional development. It is a period of rapid growth for your infant. During this time your baby will make the transition from milk feedings to a varied table food diet.

Birth – 4 months:

Breast vs. formula feeding? There are many factors which need to be considered by a mother when she decides whether to breast or bottle feed. Whichever method you choose, we will support your decision.

Breast feeding is recommended as the initial method of infant feeding. In addition to best meeting the nutritional needs of your baby, breast milk contains important factors which will make your baby less susceptible to infection. Formula also provides balanced nutrients that your baby needs for optimal growth and development and is formulated to imitate the nutritional constituents of breast milk as closely as possible. Whether breast or bottle feeding, allow your baby to feed on a modified demand schedule. When feeding your baby, choose a position which is most comfortable for you and your baby. However, keep in mind that he or she should be in a semi-upright position during feedings.

Breast Feeding:

Most breast fed babies feed every 2-3 hours during the day and night. It is occasionally acceptable for your baby to want to eat in less than two hours. Do not let your baby go longer than 3-4 hours at night until you are advised by the doctor that it is ok to do so. A breast fed baby will have approximately 10-12 feedings (every 2-3 hrs.) per 24 hours in the 1st month, and 8-10 feedings (every 2 ó-4 hrs.) per 24 hours in the 2nd and 3rd months. The baby may nurse 15-30 minutes on one breast and 15 minutes or more on the other breast. Some babies become efficient nursers and can spend 5-10 minutes per breast once breast feeding is well established. Alternate the starting breast at each feeding. If you wish to supplement breast feeding, it is best to supplement once a day at a fixed time. You may give a bottle of expressed breast milk or formula as a supplement.

Formula Feeding:

If you are bottle feeding, start by putting 2-4 ounces of formula in every bottle. Let the baby take as much as he or she wants. Always try to have at least ó ounce of formula left in the bottle when your baby is finished eating. This will prevent air swallowing and let you know when the baby is ready to take a larger quantity. As your baby grows, gradually increase the amount of formula in each bottle to stay ahead of his demand. Always use an iron-fortified infant formula. Formula fed babies usually go 3-4 hours between feedings. If your baby sleeps longer than 4 hours during the day, we suggest that you wake and feed him or her. If your baby sleeps longer than four hours at night, depending on his weight and age, consider yourself lucky and do not wake the baby for a feeding. Between 2-4 months your baby will start to go longer stretches at night. By 4 months your baby should be sleeping a 6-8 hour nighttime stretch. Propping the bottle is not recommended. Never give a bottle in the crib.

4 – 6 months:

Breastfeed: 7-9 feedings 24 hours

Formula: 25-40 oz

Starting Solid Foods

Solid foods are not necessary for the first four to six months of life. Rarely an infant may need to start solid foods earlier. Indications for this may include consistently increased frequency of breast feeding or consistently taking more than 40 ounces of formula a day. Even if your baby seems hungry, solid foods should not replace breast or bottle feedings, but should act as a supplement during the first 6 months. Whenever starting a new food, introduce it early in the day (before 2PM). Do not introduce more than one new food at a time, and use the new food for a minimum of four to five days before introducing a different food. Whenever starting any new food, there may be a change in the child’s bowel habits.

Cereal: 4 – 6 months

Iron fortified cereal can be started between 4-6 months. Start with 2-4 tablespoons oatmeal, mixed with breast milk or formula twice a day, in the morning (6AM-10AM) and in the evening (4PM–8PM). Initially mix to a thin consistency and then thicken as your baby adjusts to spoon feeding. Never put cereal in a bottle. Bottles are for breast milk, formula, or water only. After at least 4 to 5 days of oatmeal you may then switch to barley or mixed grain cereal.

Fruits & Vegetables: 5-6 months

Begin the introduction of fruit with bananas (unless constipated) and then progress to: applesauce, pears, peaches and prunes. You may then introduce other fruits. Start with yellow vegetables (carrots, squash, or sweet potatoes), then progress to green vegetables (peas, green beans). Fruits and vegetables can be freshly prepared at home or may be served from store bought containers. Babies who enjoy yellow vegetables can develop a harmless yellow coloring of the skin called (carotenemia).

6 – 9 Months

Breastfeed: 4-6 feedings 24 hours

Formula: 24-32 oz. Start to offer sippy cup with formula or breast milk

Yogurt, soft cheeses: 6 months

Use live culture whole milk yogurt, such as, “Yo-Baby”. Do not use yogurt with large pieces of fruit. You can use fruit flavored whole milk yogurt or add your own pureed/mashed fruit to plain or vanilla flavored yogurt. Soft cheeses such as cottage cheese, ricotta cheese or cream cheese can also be introduced at this time. Feed your baby yogurt or soft cheeses once a day either during a meal or as a snack. REMINDER: Do not give your baby any milk products other than formula prior to 6 months.

Peanuts/Tree nuts: 6 months

Peanut butter is a great source of protein, magnesium, and healthy fats.  Peanut butter is the best way to expose your child to nuts when you are ready.  Peanuts and tree nuts used to be restricted in babies’ and toddlers’ diets until 2 years of age.  New studies indicate that this is an unnecessary precaution and may actually contribute to developing a nut allergy.  In a baby who has exhibited and allergic propensity with significant eczema or other allergic signs or symptoms, we may elect to send your baby to an allergist prior to beginning nuts.  We also may elect to send to an allergist if there is a strong family history of food allergies.

In all other babies, we recommend feeding a small “dab” of peanut butter daily for 2 weeks.  If there is no reaction, you may continue feeding it to your baby on bread or a cracker.  Once started, you should not go longer periods without reintroducing it.  The same procedure can be done with other nut butters, but not at the same time as doing peanut butter.

Meats/Poultry: 7 months

Make sure any meat you feed your baby is strained, shredded or ground. Start with chicken and turkey first and then veal, beef and pork. Feed your baby meat once a day.

Eggs: 7 months

Use hard boiled or well done scrambled egg.  Your baby may have eggs 3-4 times per week.

The consistency of the fruits and vegetables can increase as the baby gets older. Between eight to ten months your baby should be starting to eat soft, bite sized pieces of table foods; such as fruits, vegetables, meats, crackers, cereal, pasta, rice, cheeses, bread, waffles, etc. Stay away from choking foods. Formula and breast milk should be offered at meals in a sippy cup at 6-7 months. The sippy cup should have a valve mechanism that can be removed, so that the fluid flows freely upon tipping. Straw cups can also be used. It is very important to introduce your child to the sippy cup early and often. At 9 months your baby will begin to pick up objects with the thumb and forefinger (pincer grasp). He/She will also start to have a “do it myself” attitude. This should be encouraged! These are all signs that your baby is ready to start feeding himself. Between 9-12 months, your child should move toward a more toddler schedule of eating. We do not recommend juice as it consists of mostly sugar and has no nutritional value. If you do decide to offer juice, you should give no more than 4 ounces per day, and it should be diluted with water. Never give in a bottle.

Whole Milk: 9-12 months

DO NOT USE LOW-FAT OR SKIM DAIRY PRODUCTS UNTIL 2YRS OF AGE!

We usually switch your child from formula or breast to whole milk at 9-12 months of age. Timing will depend on your doctor’s assessment of your baby’s growth and nutritional intake. Occasionally, if your child has poor nutritional intake, was premature, or has other medical problems, we may extend formula feedings beyond 1 year of age.

To introduce milk, mix your baby’s cereal with milk for two to three days. If the baby tolerates the milk without a problem, substitute one bottle or one cup of milk for a bottle of formula (or one breast feeding). Gradually increase the number of bottles or cups of milk per day, until the child is taking only milk and no formula (or breast milk). Some mothers may wish to breastfeed until 1 year of age or longer. If you wish to continue breastfeeding longer than 1 year of age, do not nurse more than twice per day. More than this will impair your child’s intake of other nutrients. We do not recommend breastfeeding or bottles during the night as this leads to dental caries.

After 1 year of age, you should limit your child’s intake of milk to 12-24 ounces per day. Weaning from the bottle should begin at 12 months and be completed by 15 months. We do not recommend the use of “dripless” cups, as this will not help your child to learn to drink from a cup. This type of cup is based on the sucking mechanism, like a bottle. Instead your child should use a sippy cup that spills when tilted. Often the “dripless” attachment can be removed from the sippy cup. Bottles and “dripless” cups encourage drinking at the expense of nutritionally rich foods and when used for too long causes dental problems.

IMPORTANT FEEDING GUIDELINES

• Do not add sugar, corn syrup, or Karo syrup to foods.
• NO HONEY DURING THE FIRST YEAR!!
• We do not recommend the use of any nutritional supplements unless prescribed by physician. A prescription fluoride multivitamin is given to all children 6 months to 13 years of age. Do not give fluoride 30 minutes before or after any products with calcium (eg. Breast milk, formula, whole milk, yogurt, cheese, calcium fortified orange juice)
• Foods that contain high levels of fat and/or sugar:
  Bacon, lunch meats, hot dogs
  French fries
  Creamed vegetables
  Puddings
  Cookies, candy, cakes
  Sweetened drinks (iced tea, soda)
• Foods that can cause choking in small children (do not give until 3 yrs of age):
  Whole Hot dogs
  Whole grapes
  Whole Nuts
  Hard candies or chewing gum (we don’t recommend for any young child)
  Popcorn
  Thick, hard, raw vegetables or fruits
  Chunky pretzels
  Large pieces of meat
• Foods to avoid until 9 months:
  Citrus fruits and juices. (Citrus is very acidic and infants may experience digestive upset)
• Food high in cholesterol helps build brain and nerve tissue. Do not try to limit your child’s intake of cholesterol under 2 years of age.
• Your child’s appetite may start to wane around 12 months of age. This behavior may continue until the child is well over 2 years of age. Your child may eat only 2 good meals per day rather than 3.
• Avoid giving fluids prior to mealtime or at the beginning of a meal as this may decrease your child’s appetite for food.
• Avoid fish that are high in mercury including, tilefish, swordfish, seabass, mackerel, shark and tuna (ahi, yellowfin, canned (white albacore). Children can have two (2-3oz) servings per week of low mercury fish like salmon, tilapia, canned light tuna, pollock, halibut and catfish.

Feeding toddlers can be challenging. Toddlers enjoy becoming independent eaters. They are picky eaters, slow to try new foods, and don’t appear to eat very much. They are also “grazers” – preferring small, frequent meals and snacks. Children have been shown to increase their acceptance of a new food after repeated exposure to that food. It may take up to 10 exposures to a new food for a toddler to accept it. All too often, parents give up after only 2 to 3 exposures. Most children do not eat a balanced diet each and every day, but over the course of a week or so their diet will be well-balanced.

Parents are often concerned whether or not their child has eaten enough. Remember that as long as he/she is gaining weight and is active and healthy, then he/she is likely getting enough calories. The meals presented to toddlers should be healthy and balanced. There should be regularly scheduled meal times and toddlers should eat with the rest of the family. The meals should be social and it is good for the entire household to sit together for at least one meal/day. Meals should not be eaten with the television on and children should be fed in a seated environment.

You should always encourage your toddler to eat but you should not force them. You will never win a food battle and it can create long-term eating problems. Model behaviors that are nutritious and your child will eventually follow them. This is the time to modify your own eating habits to healthy and nutritious ones. Remember that good eating habits are formed early in life.

In planning your toddler’s diet, remember that portion sizes for toddlers are actually a quarter of the portion size for adults. Children do not grow as fast as they did during their first year of life and therefore have lower energy needs. Your child will determine how much he or she wishes to eat and research has shown that they are very good at listening to their own hunger and satiety cues. A recommended guide is to provide 3 main meals and 2-3 small snacks/day.

Here are some guidelines for daily servings for toddlers:

Fruit: 3-4 servings/day. A serving of fruit consists of 1/2 to 1 small fruit or 2 to 4 tablespoons of canned fruit.

Vegetables: 3 servings/day. A serving of vegetables consists of 2 to 3 tablespoons of cooked vegetables.

Dairy: 4 to 5 servings/day. A serving of dairy consists of ½ cup of whole milk, ½ cup of yogurt, or a slice of cheese.

Protein: 2 servings/day. A serving of protein consists of 1 to 2 ounces of meat, poultry, fish; 1 egg or 4 to 5 tablespoons of legumes.

Grain: 3-4 servings/day. A serving of grain products consists of 1/2 to 1 slice of whole grain bread, 1/4 to ½ cups of rice or pasta (preferably whole grain like brown rice, whole wheat pasta or quinoa pasta), 1/2 cup to 1 cup of dry low sugar cereal, 1/4 to ½ bagel, 1/2 to 1 whole wheat or corn tortilla.

Fats and sweets: Limited.

Milk

Your child should be on whole milk until the age of 2. This is because their energy requirements are great and they also need cholesterol for the formation of their still developing nervous system. After the age of two, we recommend changing to skim or 1% milk. You should be giving your child the milk in a non-dripless sippy cup, straw cup or regular cup. The amount of milk should be limited to 16 to 24 ounces per day. Too much milk will curb your child’s appetite for solids which are important for a growing toddler. Milk is the preferred form of calcium because it also contains vitamin D.

Juice

Juice is not a necessary part of your child’s diet. If you do decide to give your child juice, you should do no more that 4-6 ounces/day which should be watered down. Juice adds calories without significant nutritional value and extensive juice drinking will decrease your child’s appetite for nutritious whole foods. Never give juice in a bottle. It should always be in a sippy cup, straw cup, or regular cup.

Fluoride

All children from 6 months until 13 years in areas without fluoride in the water should be on a fluoride supplement. This can be part of a total vitamin or as fluoride only. We usually change the children from a liquid to a chewable version at the age of 18 months. Do not give fluoride 30 minutes before or after any products with calcium. (eg. Milk, yogurt, cheese, calcium fortified orange juice)

Fish/Shellfish

Fish can be an important part of a toddler’s diet. Aim to serve fish two times per week. Fish is low in saturated fat and high in protein, vitamin D, and many of the B vitamins. Fish like salmon and mackerel are high in omega-3 fatty acids which help brain development. Safe fish that are low in mercury include the following: Pollack (found in fish sticks), wild Alaskan salmon, tilapia, catfish and canned chunk-light tuna. If children are over the age of 2 and there is no family history of shellfish allergies, they may also have scallops and shrimp. Shellfish is highly allergic and some allergists do not recommend giving these foods until age 4 in an allergic family. When giving shellfish for the first few times, always watch for signs of an allergic reaction.

Cholesterol and Saturated Fats

Children under the age of 2 need a higher fat and cholesterol intake. Their energy requirements are great and they also need cholesterol in the formation of their developing nervous system. As mentioned above, children under the age of two should be on whole milk.

Eggs can be a healthy part of a toddler’s diet. Eggs are high in protein, iron, minerals and B vitamins. Since an egg contains 213 mg of cholesterol, eating eggs too often can cause your child to have a diet that is high in cholesterol. He/She should not eat more than 3 to 4 egg yolks per week.

Your whole family will benefit from eating more fish, poultry, and legumes and less red meat. A diet low in cholesterol and saturated fats will help prevent future heart disease.

Fiber

Fiber is an important part of your child’s diet. It is recommended that toddlers consume at least 10-19 grams per day of dietary fiber. Fiber passes through his or her digestive tract relatively intact and helps form normal stools. Fiber also aids in controlling blood glucose and cholesterol levels. Vegetables that are great sources of fiber: cabbage, brussel sprouts, broccoli, cauliflower, carrots and corn. Legumes such as peas, beans, and lentils also are great sources of fiber. Fruits that are high in fiber: blackberries, raspberries, blueberries, strawberries, pears, apples, peaches, plums and dried fruits such as figs, dates, and prunes. Make sure you cut the dried fruit into small pieces so that it is not a choking hazard. Whole grain rice, cereals, pasta, and breads are great sources of dietary fiber. You can look for bread and cereal products that carry the American Heart Association’s “whole grain” heartcheck mark symbol.

Sugar

Sugar is not a nutritionally important food. Research shows that when children eat more sweets, they eat less produce, grains, and dairy. This puts them at risk for poor bone density, obesity and type 2 diabetes. Sugary foods also promote dental caries. Sugary foods have not been shown to cause behavioral changes or hyperactivity. Sugar treats may be used on occasion with appropriate tooth brushing.

Choking

It is the consistency of the food and the size of the piece of food that is most important. Do not feed your child foods that he or she may choke on. These include the following: nuts, chunky pretzels, whole hot dogs, whole grapes, whole dried fruit, popcorn, hard candy, gum, cherries, olives, and large pieces of raw vegetables or fruit. Any round smooth object may be choked on. Be aware of your child’s developing chewing skills and gradually introduce foods that are difficult to chew. Serve foods in small pieces that are easy to pick up. Remember that gagging is not something to panic about – it is learning how not to choke.

Nutritional Supplements

If you plan to use any nutritional supplements, special vitamins, teas, herbal preparations, etc., please consult with us first. There are some that could be harmful to your toddler.

Fever is an elevation of the body’s temperature that usually occurs in response to an infection. A fever that is mounted in response to an infection is not harmful. The height of the fever does not correlate with the severity of an infection unless it is above 106, at which point a bacterial infection becomes more likely. It is much more important to assess how your child is acting; if your child is playful and attentive, the fever is usually not a cause for alarm. The reason we encourage you to bring you child’s temperature down is to make your child more comfortable and to help you assess how your child is acting.

The normal body temperature is 98.6 F orally and 100.2 F rectally. This may vary slightly at different times of the day. Ear thermometers are okay to use as a screening for fever, but for accuracy, we recommend confirming a fever with a rectal temperature for infants and oral temperatures for older children. A temperature less than 100.4 F is not considered elevated.

You may give Tylenol, or any other acetaminophen preparation, every four hours for temperatures of 101 and above. Other acetaminophen preparations include Tempra, Panadol, Liquiprin, and Feverall. Dosages should be according to weight. It is important that the temperature be checked BEFORE the medication is given. Do not give Tylenol to an infant under two months of age since these children need to be evaluated immediately and we do not want to mask the fever.

Aspirin should NOT be given unless advised by a physician.

Lukewarm water baths are another form of fever management and are useful for temperatures above 103. Bathe for at least 20 minutes, sponging the child well, including the head. Alcohol should not be used. Dress your child lightly; do not cover him or her with blankets. We also encourage drinking plenty of fluids.

You may use ibuprofen (Advil, Motrin) as an alternative to acetaminophen. Ibuprofen may be used every 6 hours. We do not recommend alternating between acetaminophen and ibuprofen. Do not use ibuprofen with chicken pox. Ibuprofen should not be used in infants under six months of age.

We should be notified immediately for the following:

• an infant less than 2 months with a temperature of 100.4 or greater rectally
• any temperature of 106 F or over

We should see the following within 24 hours:

• an infant between 2 and 6 months with a temperature over 100.4 rectally
• any temperature over 105 F
• Any child between 6 months and 3 years should be seen with a fever for longer than 48 hours.
• Any child over 3 years of age should be seen if fever is lasting more than 3 days.
• Any child of any age should be seen as soon as possible if they are very ill-appearing or have symptoms that our nurses feel could indicate a severe or bacterial illness.

Fifth disease, or erythema infectiosum, is a very mild viral illness characterized by a bright red or rosy rash on both cheeks for one to three days (“slapped cheek” appearance), followed by a pink “lacy” or “net-like” rash on the extremities. The lacy rash appears primarily on the thighs and upper arms. It can come and go several times over one to three weeks, particularly after warm baths, exercise, and sun exposure. The rash does not itch. Your child may have a low-grade fever (less than 101 degrees F), slight runny nose, and sore throat, but he or she may have no other symptoms at all. Adults may develop joint and muscle aches, but these symptoms are rare in children.

Fifth disease is caused by the human parvovirus B19. It was so named because it was the fifth of six infectious rashes to be described by physicians. For historical interest, the six in order are measles, scarlet fever, rubella, “Dukes’ disease” (now recognized as variants of existing infectious rashes), erythema infectiosum (fifth disease), and roseola.

The incubation period of fifth disease is usually 4 to 14 days, but may be as long as 21 days. In some children the illness begins with a brief, mild, nonspecific illness consisting of fever and flu-like symptoms. The rash then follows 7 to 10 days later, or 2 to 3 weeks after initial acquisition of infection. Fifth disease is contagious before the appearance of the rash. Immunity is thought to be lifelong, and more than 90% of elderly people are seropositive for antibody against parvovirus B19.

No treatment is necessary for fifth disease. By the time the rash appears, your child is not contagious and may return to school.

In the rare instance that a susceptible pregnant woman contracts fifth disease, there is a small possibility that the virus may be harmful to the fetus. If a pregnant woman is exposed to a child with fifth disease before the child develops the rash, she should contact her obstetrician.

Frostbite occurs when the skin and the outer layers of tissue become frozen. It tends to affect the extremeties (fingers, toes, ears and nose) and cause them to become pale, gray, and blistered. Children are more susceptible to frostbite than adults because they lose body heat faster and are less likely to heed the warning signs (e.g. numbness) when they’re having fun in the snow!

The early stage of frostbite is frostnip, and often can be treated at home by removing wet clothes and immersing the affected area in warm water or in warm compresses until sensation returns.

If warming the skin doesn’t help, call us immediately. In the meantime, do the following:

• Give your child something warm to drink and wrap a blanket around him/her.
• Warm the skin by using warm compresses or immersing the area in warm water until sensation returns.
• Apply clean cotton or gauze between fingers and toes if they are affected.
• Wrap warmed areas of the skin to prevent further damage.
• Don’t rub or massage the affected area.
• Don’t use direct heat such as heating pads or fires.
• Don’t disturb any blisters.

The American Academy of Pediatrics recommends keeping all of a child’s body parts covered (with gloves, hats, waterproof boots, layers of clothing, etc.) in order to prevent frostbite. It is a good idea to have your child come inside if mittens or boots get wet, and it is a good idea to have your child come inside at regular intervals.

Gastroesophageal reflux is a common occurrence in early infancy. It occurs because the junction of the esophagus and stomach does not close completely, causing regurgitation and vomiting. Reflux usually improves as your infant gets older, generally by 6-8 months.

Tips to decrease reflux include:

• Feed slowly and burp frequently.
• Decrease the number of ounces per feeding while increasing the number of feeds per day.
• Keep your baby upright, on your shoulder or in your lap, for 30-40 minutes after feeding.
• Elevate the head of the crib.

Contact us if your child continues to have problems with reflux despite the above measures. In general, if a child is happy and gaining weight, we will wait for the child to outgrow the reflux.

Head injuries are quite common in childhood, often resulting from falls and collisions. Most head injuries are not serious, but it is important to pay attention to warning signs of a serious head injury. After a fall or a head injury, a child may sustain a bump, called a hematoma, on the head. This is a collection of blood under the skin that will be reabsorbed over time. The presence of a hematoma is not necessarily associated with a serious head injury.

If your child lost consciousness at the time of the fall or collision, you must call us immediately.

If your child did not lose consciousness, you may watch your child at home. Signs of serious head injury may develop over a 24 hours period after a fall or collision. Potential warning signs include:

Difficulty awakening or excessive sleepiness. You may allow your child to sleep, but for the next 24 hours you should awaken him every two to three ours to see if he or she is acting normally (i.e. recognizes you, talks to you, etc.)

• Persistent vomiting
• Severe headache that does not improve with Tylenol (acetaminophen)
• Convulsions or seizures
• Unsteadiness while walking
• Difficulty talking
• Double vision
• Persistent dizziness
• Fever

If any of the above signs are present within 24 hours of the head injury, you must call us immediately.

We follow the immunization schedule as set by the Advisory Committee on Immunization Practices (ACIP), American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). This schedule is updated yearly and regularly incorporates new vaccines and revised recommendations. The vaccines given protect against the following illnesses:

• Hepatitis B
• DTaP–Diptheria (bacterial throat infection), Tetanus (lockjaw), Pertussis (whooping cough)
• Hib—Hemophilus Influenzae type B, a bacterial cause of invasive blood infections and meningitis
• IPV–Polio
• Prevnar–Pneumococcus, a bacterial cause of invasive blood infections and meningitis. This vaccine protects against the thirteen types of pneumococcus that are responsible for 98% of pneumococcal blood infections and meningitis.
• Varicella–chicken pox
• MMR–Measles, Mumps, and Rubella
• Meningococcus
• Human Papillomavirus (HPV)
• Rotateq – Rotavirus is a virus which causes diarrhea and can lead to dehydration.
• Hepatitis A

We also carry the influenza vaccine in the fall. The ACIP and AAP recommend that all children 6 months and older receive the influenza vaccine.

While all vaccines are extremely safe and have been extensively tested, there are potential minor side effects for all of them. The most common side effects are a low grade fever and irritability. For more information, refer to the vaccine handouts given in the office or to the web sites listed at the end of this page.

For the exact schedule of immunizations, refer to the well child visit schedule shown under the “About our practice” section of this web site.

Place an emergency sticker on the telephone in an area where children spend a lot of time! This sticker should contain the telephone numbers of the police, fire department, ambulance, local hospital, physician, , and your home address and telephone number.  Poison control number is 1-800-222-1222

Teach your children–even at a young age–to dial 911 in case of an emergency and to be able to state their full name and address.

All baby sitters should be at least 13 years old and mature enough to understand parental instructions and handle common emergencies.

Choking, Strangulation, and Suffocation

Choking and suffocation are among the most common causes of preventable death in children less than 1 year old. They also cause many deaths in children less than 14 years of age every year. It is a good idea to learn CPR in case of a choking emergency.

The most common objects that cause choking are:

• Foods such as hot dogs, grapes, nuts, popcorn, and hard candy.
• Toys or parts of toys that are small enough to place in the mouth.
• Uninflated balloons or pieces of a burst balloon.
• Small items such as coins, marbles, buttons, beads, watch/camera batteries, and safety pins.

Strangulation of infants and children in the home is most commonly linked to:

• Drapery and extension cords–remove cords out of reach by tucking them under furniture or tying them well out of reach
• Cords used to suspend rattles, pacifiers, or jewelry around a child’s neck

Suffocation in the home is linked to:

• Plastic bags (e.g. grocery, dry cleaning)
• Laying infants on their stomach to sleep, particularly if done on soft materials, pillows, comforters, or toys. Always place your baby on his/her back to sleep, refrain from having stuffed toys in the crib, and make sure bumpers are securely tied.

Inhalation and Burns

Inhalation

Most fire-related deaths and injuries are caused by smoke inhalation.

Install smoke detectors on each level of your home. Check the batteries twice a year–daylight savings time change is a good reminder.

• Do not smoke in your home–particularly in your bed! Smoking is an important cause of home fires.
• Keep matches and lighters away from children.
• Do not use electrical appliances with frayed cords or damaged plugs.
• Keep a fire extinguisher in the house, particularly in the kitchen and any room with a fireplace.
• Develop an escape plan in case of fire. Identify appropriate exit routes and a family meeting point outside the house.
• Teach children to stay close to the floor if there is smoke in a room.

Burns

Most scalds are caused by a hot liquid that spills on a child. This type of injury can cause pain, infection, and long-term scarring and disability.

• Always turn pot handles toward the center and the back of the stove.
• Keep cups of hot liquid away from the edges of tables and counters. Don’t drink hot tea or coffee while holding a child!
• Make sure your hot water heater is set between 120 and 130 degrees. Skin will take 5 minutes to burn at 120 degrees F and 6 seconds to burn at 140 degrees F.. Check the hot water temperature with a meat thermometer from the faucet located closest to your hot water heater.
• Keep irons out of your child’s reach and place a leavier around wood stoves, radiators, and other heat sources.
• When purchasing a humidifier or vaporizer, always buy the cold air model. Hot water humidifiers are unnecessary and may cause burns in an accidental spill.

Carbon Monoxide

This gas is invisible and odorless!

• Use kerosene and gasoline powered heaters only in well ventilated areas.
• Install a carbon monoxide detector in your home.
• Have your heating system checked by a professional once a year and have your chimney cleaned once a year.

Firearms

A child is killed with a loaded gun every two hours.

• Injuries cause by firearms are a leading cause of death and disability in children and adolescents. These injuries are almost always self-inflicted or caused by a sibling or a friend. Most firearm injuries result from handguns, and most child-related shootings involve guns obtained in the home of the victim or a friend.
• Firearm ownership is correlated with higher rates of injuries to children. If you own a gun, store it unloaded in a locked cabinet or drawer, and store the ammunition locked in a separate location. Check the guns frequently to make sure children have not played with them.

Falls

Falls are commonplace and often minor, but they are the most frequent cause of injury in children less than 6 years o age. Approximately 200 children die as a result of falls each year.

Common causes of falls include:

• Sinks, countertops, bathtubs, and changing tables. Never leave an infant unattended on a raised surface–your infant could roll over at any point.
• Stairs. Twenty percent of falls occur on stairs. Provide adequate lighting, remove toys from stairs, tack down loose carpet, and use appropriate gate enclosures that are securely fastened to the wall.
• Walkers. Every year 29,000 serious injuries occur to children in walkers. The American Academy of Pediatrics does not recommend the use of walkers, and they do not help the child walk independently any faster.
• Windows. Open windows only from the top or no more than 4-5 inches from the bottom. Secure them at the proper height with a burglar lock (available from hardware stores). Keep furniture that a toddler may climb on away from windows.

Drowning

Drowning is a major cause of death and disability in children and may occur indoors as well as outdoors. The household bath is the most common site for drowning for infants up to 1 year of age and only requires a few inches of water. Always closely supervise infants, toddlers, and preschoolers in the bath and near any container of water, including buckets and toilets.

Crib safety

• Always place your child to sleep on his/her back to help prevent Sudden Infant Death Syndrome (SIDS). The peak incidence of SIDS is 4-6 months and may occur up to 1 year of age. Other risk factors for SIDS include cigarette smoke exposure, overwrapping, soft sleeping surfaces, bed sharing, and lack of breastfeeding.
• Crib slats should be no more than 2-3/8 inches apart. Modern crib regulations require this spacing; check your crib carefully if you have an older model.
• Never leave the crib rails down when your baby is in the crib.
• Hanging crib toys should be out of the baby’s reach. Any hanging crib toy must be removed when your baby first beings to push up on his hands and knees or whenever your baby is 5 months old, whichever comes first. These toys can strangle a baby.
• Bumper pads should be used until the baby begins to stand, at which point they should be removed since they can be used as steps.
• The crib mattress should be lowered to its lowest position before your baby can pull to stand, usually by 7-8 months.
• Keep blankets, pillows, and toys out of the crib to prevent suffocation. It is safer to dress a child in multiple layers of clothing.
• Never place a crib near cords from a hanging window blind or drapery.
• When your child attempts to climb out of the crib, he/she is ready for a toddler or regular bed.

Toys

• Pay attention to the age label on toys. A young child can easily choke on a small part of a toy designed for an older child.
• Avoid toys that shoot objects or have sharp edges or points.
• Repair or discard broken toys.
• Toys intended for older children should not be accessible to toddlers and preschoolers.

Influenza, or the “flu”, is caused by the influenza virus. There are two types of influenza virus, type A and type B, and type A is further divided into subtypes based on two surface antigens (proteins which induce the immune response). Yearly changes in the surface antigens affect a person’s immunity, and large changes in the antigen will cause a person to become susceptible to the virus again. Influenza viruses circulate predominantly in the winter months and are easily spread from person to person through the air or by direct contact. Between ten and forty percent of children will contract influenza during any given winter, with the highest rates among school-age children.

In April 2009 a new strain of influenza type A, called the “novel H1N1” strain, was recognized in Mexico and has since spread around the United States and the world. The CDC now refers to “seasonal” influenza, which is comprised of the usual circulating influenza A and B viruses, and “novel” influenza, consisting of the new H1N1. Children and young adults seem to be particularly susceptible to the novel influenza viruses because of the lack of immunity, but thus far the virus appears to be acting like any other influenza virus: bad cold and flu-like symptoms that generally resolve over several days.

The incubation period of influenza is 1-4 days, with an average of 2 days. Symptoms of influenza include the sudden onset of fever, headache, muscle aches, sore throat, and dry cough. Other respiratory tract signs including sore throat and nasal congestion develop over the next several days. Most children have a self-limited illness that subsides after several days, but influenza can exacerbate underlying lung or heart disease and cause either viral or secondary bacterial pneumonia. The chances of pneumonia or other complications (such as myositis–inflammation of the muscle) are significantly higher for children with underlying chronic disease, particularly any longstanding lung disease (including asthma), diabetes, kidney disease, and hemoglobinopathies (congenital problem with the oxygen-carrying protein in blood cells). Infants are also susceptible to prolonged influenza disease, although other viruses–particularly respiratory syncytial virus–are by far more likely causes of serious illness in very young infants. In uncomplicated influenza, a person is contagious for approximately 24 hours before the onset of symptoms and 5 days after the onset of symptoms.

The hospitalization rate for influenza is about 1 in 1000 for children between 0 and 4 years, with the rate being five times higher for high-risk children. Influenza is rarely fatal in children; it causes about 36,000 deaths a year in the United States, but >90% of these deaths are in older adults. The death rate for influenza in children is 3.8 in 100,000.

Influenza can be diagnosed by rapid testing, although the test is not 100% accurate. On occasion we may send your child to a laboratory for a rapid influenza test to confirm the diagnosis. The influenza virus can be cultured, although the time it takes to grow the virus limits its usefulness in an office setting.

The best way to prevent influenza is to vaccinate. Each year a new vaccine is produced based on what the anticipated strains of influenza viruses will be. The American Academy of Pediatrics now recommends that all children over six months of age receive the flu vaccine. The vaccine needs to be given yearly because the previous year’s vaccines may not adequately protect against the current year’s circulating influenza viruses.”High risk” children especially recommended to receive flu vaccine include:

• All children between 6 and 59 months due to increased risk of hospitalization and complications
• Asthma or other chronic pulmonary disease such as cystic fibrosis or bronchopulmonary dysplasia
• Heart disease that significantly affects the heart’s ability to pump blood
• Children with immune system defects or on chronic medications that affect the immune system
• Diabetes
• Chronic kidney disease
• Hemoglobinopathies (congenital problem with the oxygen-carrying protein in blood cells), including sickle cell anemia
• Diseases requiring long-term aspiring therapy, such as Kawasaki Disease
• Any siblings of children with the above conditions

Seasonal influenza vaccine is now available (August 2009). Novel H1N1 vaccine, which is being produced separately, is currently being developed.

Influenza vaccine takes several weeks to become effective and should ideally be completed by the end of November. Children under the age of 9 years receiving influenza vaccine for the first time need to have two doses spaced one month apart.

Side effects of the influenza vaccine are rare. The influenza vaccine contains inactivated influenza virus and cannot cause influenza. Fever in the first 24 hours is not uncommon under 24 months of age, and local reactions (redness, soreness, and warmth) occur in approximately 10% of adolescents. The influenza vaccine is not recommended if your child has had a severe allergic reaction to egg (anaphylaxis); in the case of a minor egg allergy (hives), we may consider giving the influenza vaccine only if your child is high-risk and is thus likely to benefit from a flu shot. In that case we ask that we observe your child for 30 minutes after the flu shot. Influenza vaccine does not exacerbate asthma.

Some influenza vaccine contains thimerosal, a preservative containing mercury, but the dose is minute (12.5 micrograms) and well below the FDA guidelines of toxicity so it poses no risk to your child.

An intranasal vaccine called FluMist was licensed in 2003. The vaccine is given by nasal spray, and is approved for healthy children two years and older. The vaccine is a live virus vaccine, and as such is extremely effective in addition to being “child-friendly”. The vaccine is an excellent option for healthy children, particularly since universal flu vaccination is now recommended. The side effects of the vaccine are usually limited to a couple of days of congestion and a runny nose.

There are two antiviral medications approved for treatment of influenza: oseltamavir (Tamiflu) and baloxavir (Xofluza).  Their usefulness is limited and resistance to Tamiflu has risen in the last year. When given within 48 hours of the onset of symptoms, the medications do reduce the duration of influenza symptoms, but only to a small extent; oseltamavir and baloxavir will shorten the symptoms only by 1 day. None of the antiviral medications will prevent the development of complications such as pneumonia.  Baloxavir is only approved for children 12 and up.

For more information see the CDC influenza web page and the flu links at the American Academy of Pediatrics web page.

The most effective insect repellent is DEET (N,N-diethyl-m-toluamide), which has been in use as an insect repellent since 1957. DEET comes in concentrations ranging from 4% to 100%, and appears to work better up to a concentration of 30%, after which it simply lasts longer. Products containing 10% DEET works for about 2 hours, 24% DEET works for about 5 hours, and over 30% DEET lasts 8 to 12 hours.

The side effects of DEET include hives and skin irritation, although these side effects have generally been reported with chronic overdosing. There are a few rare reports of seizures, most of them related to very high doses of DEET.

The American Academy of Pediatrics recommends that DEET concentrations of up to 30% are considered safe for children over two months of age.

Our recommendations on DEET use:

• Older children can have 20%-30% DEET applied. Younger children and infants should have lower concentrations applied.
• DEET is not approved for under 2 months of age. For children under 1 year of age, you should consider using other protective measures such as netting, long sleeves and pants, and avoiding outdoor activity during high insect activity (e.g. dawn) before using DEET.
• Apply the lowest amount of DEET that will be effective for the amount of time spent outdoors.
• Apply DEET sparingly on exposed skin. Do not use under clothing.
• Do not apply DEET to the hands and mouths of very young children. For older children, apply to face by rubbing product on with adult hands; avoid eyes and mouth.
• Apply DEET no more than once a day and wash skin after use.
• Do not use a combination DEET/sunscreen product as sunscreen needs to be re-applied regularly.
• Do not use DEET over cuts, wounds, or irritated skin.

Anemia describes a condition where the number of red blood cells is below normal. The function of red blood cells is to carry oxygen from the lungs to the rest of the body. Iron deficiency anemia is usually caused by a child not getting enough iron in his/her diet or by drinking low iron formula. Children with anemia may be tired, restless, irritable, and pale; they may also have developmental delay and have difficulty paying attention.

It is important to maintain your child on a diet rich in iron. Examples of iron rich foods include:

• Meats–liver, beef, lamb, pork, chicken
• Fish, particularly sardines, clams, oysters
• Eggs
• Vegetables–lima beans, peas, kale, swiss chard, spinach, beet greens, turnip greens, tomato juice
• Fruit–prunes, dates, watermelon, raisins, dried peaches and apricots
• Breads and Cereals–enriched Farina, egg noodles, enriched waffles
• Legumes–black-eyed peas, chick peas, dried lima beans, cowpeas, navy beans, chestnuts, lentils

Drinking too much milk may cause anemia. We recommend no more than 24 ounces (3 glasses) a day for young children.

If your child is prescribed an iron supplement, give the medicine while your child has a full stomach to prevent stomach upset. Mix the medicine with juice or another food containing vitamin C. Avoid giving milk with iron. The iron can change the color of stool to green or black; this is not a cause for concern if the iron is given as prescribed.

Keep the medicine out of reach since iron poisoning is very serious.

This page discusses jaundice in the first month of life. If your older infant or child appears jaundiced, he or she should be evaluated by us.

Jaundice is a yellowish tinge of the skin and (occasionally) the “whites” of the eyes. Jaundice is caused by a rise in the amount of a substance called bilirubin in the bloodstream. Bilirubin is a by-product of the breakdown of red blood cells. Since old red blood cells are constantly being broken down, bilirubin is a substance that is always present in the bloodstream. Bilirubin levels are kept low by the liver, which metabolizes bilirubin and excretes it into the gut where it is subsequently eliminated in the stool.

All newborns have a transient rise in bilirubin before the level settles down to adult levels. There are several reasons for the rise. Red blood cells that are produced by a fetus are broken down more quickly compared to red cells produced after birth. The newborn’s liver takes several days to begin processing bilirubin, since bilirubin prior to birth is eliminated through the placenta. Lastly, the newborn’s bowel often moves sluggishly, resulting in reabsorption of bilirubin that has already been excreted by the liver.

Occasionally there are other factors that may exacerbate a rise in bilirubin. Bruising of the face and under the scalp (“cephalohematoma”) that occurred from passage through the birth canal can result in a more rapid rate of blood cell breakdown. If the mother and infant have different blood types, antibodies that the mother naturally harbor against different blood types may find their way into the baby’s bloodstream and cause the baby’s blood cells to break down faster than usual.

Breast fed babies tend to have a higher bilirubin rise because breast milk is not produced for 48-72 hours after birth. The newborn does get colostrum, which contains antibodies and other proteins, but in much smaller amounts compared to the breast milk he or she will eventually receive. As a result, the newborn may not excrete bilirubin in the stool as rapidly. It is imprint for mothers to nurse frequently during the first several days of life to increase the breast milk supply, thus enabling the newborn to excrete bilirubin more rapidly. Jaundice is not a reason to discontinue breastfeeding.

Bilirubin levels generally peak by the fourth day of life and then decrease to normal levels by one week of life. While all infants have a rise in bilirubin levels, approximately half of infants will have a bilirubin level high enough to cause jaundice that is apparent on the skin. Jaundice is not dangerous except in very rare instances when the bilirubin level rises to very high levels. We check bilirubin levels if a newborn appears very jaundiced, and we also take contributing risk factors (e.g. blood type incompatibility, bruising, dehydration) into account. Treatment may consist of increasing fluid intake (e.g. supplementing with formula) and phototherapy, which consists of placing the infant under special fluorescent lights which will decrease the bilirubin level. Most phototherapy is done in the hospital, but sometimes it can be done at home.

How can you tell if your baby is jaundiced?

Jaundice initially appears as a ruddy orange-yellow hue of the skin. Often the “whites” of the eyes appear yellow as well. A yellow hue is often seen in skin creases. Jaundice begins on the face and travels downward with higher bilirubin levels. If the yellowish color is limited to the face and upper trunk, the bilirubin level is not seriously elevated.

We should be notified if jaundice is present on the thighs and/or the “whites” of the eyes appear yellow. If lethargy or poor feeding is present we should be notified immediately.

Occasionally mild jaundice can be present in breast fed infants beyond a week. This is called “breast milk jaundice” and is different from the jaundice that is seen right after birth. Breast milk contains a factor that can transiently slow the liver’s metabolism of bilirubin. Breast milk jaundice is always mild and never serious. It usually resolves after 3-4 weeks.

Lead poisoning is a serious problem in children. It is estimated that 900,000 children ages 1 to 5 have an elevated blood lead level. The human body absorbs lead because it cannot tell the difference between lead and other minerals such as calcium that are nutritionally important. Elevated lead levels may affect the neurologic system such as learning problems, hyperactivity, poor muscle strength, and seizures. It may also cause abdominal pain, constipation, and kidney disease.

Children are exposed to lead in several ways:

• Paint. Lead paint has been banned for use in residences since 1978. Older homes, especially those built before 1960, are at increased risk for having lead paint. Peeling paint chips, dust from window and door sills, and soil contaminated from exterior lead paint are possible sources of lead. The use of lead paint on children’s toys and furniture was also banned in 1978, but toys made abroad may still contain lead paint.
• Water. Lead was used in pipes, solder, and fixtures until 1988.
• Food cans. Lead solder has been used to seal food cans. Although this practice was banned in the United States in 1995, lead solder may potentially still be found in food cans imported to the United States.
• Pottery and cookware. Some pottery and ceramic ware have been glazed with lead and may leach into food.

Preventative measures

• Avoid having any chipped or peeling paint in the house. Lead-based paint is usually not harmful if it is not chipping or flaking.
• Clean your house regularly. Wet clean areas that potentially harbor lead dust. Use a vacuum cleaner equipped with a HEPA filter.
• When doing home renovations, avoid having your children at home. You may want to have your home tested for the presence of lead paint and dust. If present, have lead abatement performed at the time of renovation.
• If you have lead in your pipes, let the tap run for 15-30 seconds before using it for drinking or cooking if the tap has not been used for 6 or more hours. Only use water from the cold tap for drinking, cooking, and preparing formula.
• Have your child play in grassy areas. Dirt may contain lead and sticks to hands.
• Never store food, especially acidic food, in cans.
• If you work in lead production or usage fields (e.g. firing range, battery plant) change clothes and shower before coming home.
• Keep your children healthy with good nutrition, particularly foods high in iron and calcium. A child whose body is lacking iron and calcium tends to absorb more lead.

We routinely test children at risk for lead poisoning at 12 months and 2 years.

For more information, call the National Lead Information Center at (800) 424-LEAD, or visit the EPA web site at www.epa.gov/lead.

Dosage Table

**** Please note NEW acetaminophen oral suspension dosing below, this will replace the OLD infant concentrated drops. There may be a time when both preparations will be sold or you still have them in your cabinet. It is OK to use either preparation, just verify which preparation you have and be sure to administer the correct dose according to the chart below.**** July 2011

Tylenol Dosage Table

Ibuprofen (Advil/Motrin) Dosage Table

Ibuprofen may be given every 6 hours.

We do not recommend Ibuprofen drops because of potential confusion in dosing.

We do not recommend Ibuprofen for children under 6 months of age.

“Meningitis” is an infection of the meninges, the membranes that surround the brain and spinal cord. Bacteria, viruses, and parasites alike can cause meningitis with varying degrees of severity, and indeed, when one has viral meningitis, the illness generally is mild and self-limited and usually causes nothing more than a bad headache and a somewhat stiff neck. Bacterial meningitis, however, is much more severe and can lead to brain damage and even death. Several bacteria are known to cause bacterial meningitis, including pneumococcus, Haemophilus influenzae type B, and meningococcus. All three bacteria, in fact, cause not just meningitis but also blood infections, pneumonia, and many other “invasive” infections. Fortunately we immunize against the first two bacteria with the Prevnar and Hib vaccines, which is why we generally do not see bacterial meningitis and invasive bacterial disease any more in childhood.

Nowadays when we hear about “meningitis” in the news, it is usually meningococcal disease. Meningococcal disease is extremely rare–the incidence is 0.8 to 1.3 /100,000 people, some of which will be meningitis and some of which may be “meningococcemia”, a blood infection. However, when meningococcal disease occurs, it is fulminant and may be very rapidly fatal, sometimes under 24 hours. Currently the death rate is 10%, with a significant portion of the survivors (11-19%) having permanent disabilities. Meningococcal disease is most prevalent under one year of age, then rises again for 15-24 year olds.

Bacterial meningitis, whether it is caused by meningococcus or another bacteria, presents with a fever, headache, stiff neck, and irritability. Vomiting is frequently present as well. Keep in mind that meningococcus disease may not present as meningitis, however; if it presents as a blood infection (meningococcemia), the initial signs will be fever and extreme irritability, but may be very nonspecific. Meningococcal disease can be treated with antibiotics as long as it is diagnosed quickly, which can be difficult. A child who is seriously ill will not drink, will not smile, and cannot be comforted. If your child is drinking and smiling when the fever is brought down with Tylenol or Motrin, your child is extremely unlikely to have meningococcal disease.

Meningococcal disease tends to present in clusters, including the military, colleges, families, and child care settings. Close contacts of a person with meningococcal disease will receive antibiotics to prevent the illness. The illness is passed through close contact with a person’s respiratory passages–you have to be next to an infected person’s face to be at risk. Meningococcal disease is a reportable illness and public health officials make recommendations for treating close contacts with any illness. If your child is at school with a child who comes down with meningococcal disease, your child would receive antibiotics if he or she was in the same classroom with the infected child; if your child is in another class–even if it is next door–your child is not at any increased risk for becoming sick.

There is one vaccine for meningococcus , Menactra, that protects against four of the five serotypes of meningococcus that cause disease and thus overall reduce the disease incidence about 80%. Menactra was licensed by the FDA in 2005 and is now recommended by the Centers for Disease Control (CDC) and the American Academy of Pediatrics (AAP). Menactra is now recommended for all adolescents starting at the 11-12 year age range. There is also a booster recommended for all adolescents at age 16. The vaccine is also currently approved for children two and older who have a damaged spleen or have had their spleen removed as well as those children with an immune deficiency. Vaccine side effects are minor and include low grade fever and soreness at the injection site.

Mononucleosis (often called “mono”) is an infection that can be caused by several viruses, with the most common one being the Epstein-Barr virus (EBV). Many children become infected with EBV either without any symptoms or, if symptoms do develop, with a mild illness that is indistinguishable from many other viral illnesses. However, when infection with EBV occurs during adolescence or young adulthood, it causes infectious mononucleosis 35%-50% of the time.

Signs of infections mononucleosis usually occur about 4 to 7 weeks after exposure to the virus. It usually manifests as a fever, sore throat, and enlarged lymph nodes in the neck. People also can be tired and not feel hungry. There may also be an enlargement of the liver and spleen.

Mono is not as easily spread as other viruses such as the common cold. EBV is found in saliva and mucus. You may have heard mononucleosis described as the “kissing disease”, but there are many other ways that you can obtain the virus, including coughing and sharing utensils. Transmission of the virus through the air or blood does not normally occur.

The main serious concern with mononucleosis is rupture of the spleen. The spleen is an organ in the left upper quadrant of the abdomen that helps to filter the blood and produce antibodies; it has the potential to become enlarged during mononucleosis. Splenic rupture is a rare event in children, and even in adolescents and adults the risk is only 0.2%. Even though this risk is low, contact sports (even wrestling with siblings at home) should be avoided for 4-6 weeks after recovery. Our office will let you kinow when you can resume normal activity.

If we believe that your child could have mononucleosis, we will send him/her for bloodwork. It may take up to 3-4 days for us to obtain the full results of the bloodwork. When we review the bloodwork, we are looking for an increased percentage of certain “atypical” white blood cells and a positive reaction to a “monospot” test.

There is no treatment for mononucleosis. Therapy is only to relieve the symptoms. Most patients require some period of rest. As with other viruses, you should drink plenty of fluids. Tylenol or Motrin may also be taken to relieve pain and fever; do not give aspirin! Occasionally children may become dehydrated because they are unable to drink with the sore throat. Tonsillar enlargement may cause your child to drool or have difficulty breathing. If any of these symptoms occur, please call our office immediately.

Mono is a self-limiting disease. Symptoms usually subside within 2-4 weeks. The fever and sore throat usually subside after 2 weeks, but the enlarged spleen and lymph nodes may persist for several additional weeks. In some children, particularly teens, fatigue and weakness can last for weeks, occasionally months. Remember that every child reacts differently to mononucleosis. There is also no proven connection between Epstein-Barr virus and chronic fatigue syndrome.

Every newborn in New Jersey is required to be tested for certain diseases. These diseases were selected because the cost of screening is low and early diagnosis can make a significant difference in the outcome. Currently, New Jersey screens for the following:

• Phenylketonuria (PKU)–inability to digest the amino acid phenylalanine, resulting in mental retardation
• Congenital hypothyroidism–low thyroid hormone levels, resulting in developmental delay
• Galactosemia–inability to digest the sugar galactose, resulting in cataracts, liver disease, and poor growth
• Hemoglobinopathies, including sickle cell disease–body produces abnormal hemoglobin with resulting anemia and a variety of medical complications
• Congenital Adrenal Hyperplasia–the adrenal gland fails to produce certain hormones resulting in salt and water wasting
• Cystic Fibrosis–a condition where thick mucus accumulates in the lungs and other organs, resulting in frequent lung infections and poor digestion
• Maple Syrup Urine Disease–inability to digest certain amino acids, resulting in poor feeding and seizures
• Biotinidase Deficiency–inability to process the vitamin biotin, resulting in seizures and developmental delay
• Fatty Acid Oxidation Disorders–inability to digest fat properly, causing serious illness when a child does not eat
• Urea Cycle Disorders–ammonia accumulates in the blood, resulting in mental retardation, coma, and death

All of these tests will be run from a blood sample taken from your baby’s heel before discharge from the hospital. The sample must be taken at least twenty-four hours after a child has a good initial feeding.

While every state screens for diseases, there is currently no national standard for which tests are done. If your child was born in New York state, you should know that the New York state newborn screen is very extensive and covers just about every test that is run in New Jersey.

Two laboratories in the United States commercially offer supplemental metabolic screening in addition to a state’s newborn screen. The two laboratories–Neo Gen (in Pittsburgh) and Baylor (in Houston) offer a test called Tandom Mass Spectrometry (TMS), which analyzes a newborn’s blood for minute quantities of chemical metabolites and can detect the presence of over 30 different rare metabolic disorders. While each individual disorder is extraordinarily rare, the chances of TMS diagnosing one is as high as one in several thousand.

The only test which the New Jersey newborn screen does not cover that other tests do is G6PD. If you have a family history of G6PD, you should let us know while your child is in the hospital so that we can add on this test.

Poison ivy dermatitis is a rash caused by the oils of the plant. These oils cause a rash in sensitized individuals either by direct contact or indirectly from clothing or a pet. The rash is characterized by itching, redness, and vesicles. Often the face is red and swollen. The rash is not contagious. The fluid in the blisters does not spread to the rash. The rash can appear anywhere from 4 hours to 10 days after exposure to the plant oils, with the average being 24-72 hours after exposure. Typically the rash lasts for one to three weeks. If the rash is very severe or includes the face, you should consult your doctor.

Treatment:

• Remove and wash contaminated clothing immediately.
• Wash affected skin with soap and water.
• Topical agents such as calamine lotion and oatmeal baths can be used to control the itch. Do not use topical products that contain benadryl (diphenhydramine). Cool wet compresses with Burow solution can soothe the skin. Placing cold compresses of whole milk on the face is also very soothing.
• Oral antihistamines (e.g. Benadryl) can be used to control the itch.

What to do in case of poisoning or accidental ingestion

Call POISON CONTROL or us IMMEDIATELY!!!

DO NOT TRY TO MAKE YOUR CHILD VOMIT!

Information that you should have available when you call include:

• Container with label
• Name of substance
• Manufacturer’s name
• Contents (if available) on label
• Time of ingestion
• Approximate amount of ingestion
• Any signs or symptoms

Please note that Syrup of Ipecac is no longer recommended.

The telephone number of the Poison Control Center is:

1-800-222-1222

Respiratory Syncytial Virus (RSV) is a major cause of respiratory tract illness across all ages. The virus is generally present between October and April. In adults and older children, RSV causes nothing more than common cold symptoms. In infants, however, RSV can spread to the lower respiratory tract and cause bronchiolitis (infection of the lower airways) and pneumonia. While only a fraction of infants with RSV will develop lower respiratory tract disease, the symptoms may be severe enough to cause trouble breathing, poor feeding, and dehydration. The younger the infant is, the higher the likelihood that bronchiolitis will develop, and the more severe the symptoms can be. It is unusual to see bronchiolitis above two years of age.

In all children, RSV starts out with common cold symptoms, including congestion, cough, and a possible fever. Infants that develop bronchiolitis will begin to wheeze after a few days of congestion. The signs and symptoms you may see include labored and fast breathing, worsening cough, and poor feeding. The wheezing episode is at its worst by 2-3 days and generally subsides by 4-5 days, although wheezing may be prolonged in very young infants.

Your child can be tested for RSV with a nasal washing that can be run at a laboratory station. The test detects the presence of RSV proteins within one hour. However, we can usually diagnose RSV clinically and we rarely send a child for testing.

Like any virus that causes a common cold, there is no medicine that will cure RSV. Antibiotics are not effective because RSV is a viral illness. If your child has nothing more than common cold symptoms, you should treat your child accordingly. If your child is wheezing, you should watch your child’s breathing and fluid intake carefully. We occasionally will try a nebulized Albuterol treatment in the office, and we may also send your child home with a nebulizer. Albuterol is a bronchodilator (opens airways up) that is used in children who have asthma. However, Albuterol has been shown to help RSV bronchiolitis only about 20% of the time. Steroids, which are used regularly in severe wheezing caused by asthma, have no effect with RSV bronchiolitis.

Children who were born prematurely with immature lungs, have chronic lung disease, or chronic heart disease are at particular risk for severe RSV bronchiolitis. Some infants born prematurely, and some infants with chronic lung or heart ailments, are eligible to receive a monthly injection of an RSV antibody preparation called Synagis. Synagis does not prevent RSV, but it will make the course of the illness considerably less severe. We usually identify our children who are eligible for Synagis before the start of the RSV season, but you may contact us if you have questions about your child’s eligibility.

Rotavirus is a virus that is the most common cause of severe diarrhea in children younger than 2 years of age. Affected children can have diarrhea accompanied by fever and vomiting. On occasion the vomiting and diarrhea becomes so severe, especially in young infants, that dehydration and electrolyte abnormalities can quickly occur. The hospitalization rate is as high as 2.5%. The symptoms can last for several days and on occasion the stools will not return to normal for 1 to 2 weeks. Rotavirus is mostly a serious nuisance in the United States, but it continues to be a major cause of severe dehydration and death in developing countries.

Rotavirus occurs in epidemics every winter and usually begins to circulate in the northeast United States during the middle of winter. The virus is transmitted from person to person by the fecal-oral route, but it can survive on surfaces and toys for periods of time. Rotavirus is present in stool before the onset of diarrhea and can persist for 10 to 12 days after the onset of symptoms. Widespread outbreaks in households, child care centers, and hospitals are common. Virtually all children have been infected at least once by 3 years of age; reinfections are common, but tend to be milder. The incubation period is 1 to 3 days.

The treatment for rotavirus is strictly supportive. There is no cure for rotavirus other than time. A laboratory can confirm the presence of rotavirus in a stool sample, but most of the time we will clinically diagnose your child with rotavirus based on the symptoms and the time of year. If you feel that your child has a rotavirus infection, follow our vomiting and diarrhea instructions carefully and call us if you are concerned that your child may be becoming dehydrated.

The best method of preventing rotavirus infection is to wash your hands routinely and carefully, especially after changing diapers. If your child wears diapers and has a rotavirus infection, he or she must be excluded from child care until the diarrhea no longer spills over the edge of the diaper.

Rotateq is an oral vaccine that helps to protects against the most common types of rotavirus. We have seen a dramatic decrease in the number of children experiencing infection since the introduction of the vaccine. It is given at the 2 month, 4 month and 6 month old visit.

A severe allergic reaction is called an anaphylactic reaction. Symptoms of an anaphylactic reaction begin within 30 to 60 minutes of exposure to a bee sting, drug, food, or other allergen. The symptoms to watch for are:

• Wheezing, croupy cough, or difficulty breathing.
• Tightness in chest or throat
• Dizziness or passing out
• Widespread hives, swelling, or itching (only considered part of a severe reaction when present along with other above symptoms)

What to do when the above symptoms are present:

1. Use your epinephrine pen! Time is of the essence during a severe allergic reaction. If your child is having the above symptoms, use the epinephrine pen immediately. Also, if your child has had a severe reaction in the past and has been exposed again, give the epinephrine pen BEFORE any symptoms start.
2. Call 911! If your child has these severe symptoms and was given epinephrine, this is of vital importance. Even though your child’s symptoms may improve quickly after getting the medication, he will need to be monitored for the next several hours for a couple of reasons. Epinephrine is a quick-acting medication, but it does not last very long. Your child may still be having a reaction, and may need another dose of epinephrine. Also, anaphylactic reactions sometimes come in two phases, with the second one coming between 2 and 4 hours later. Therefore, it is very important that your child be seen and monitored in an ER.
3. Give an antihistamine. If you have Benadryl or another antihistamine at home, give a dose in addition to the epinephrine.

Using your epinephrine pen

Review the instructions included with your pen and know it well BEFORE an emergency happens and you need to use it. All epinephrine pens require the injection be on the outer thigh and it be held there for 10 seconds. If you are unclear on how to use your pen, please come in to our office, and one of our nurses will teach you on a demonstration pen.

Emergency kits containing epinephrine should be kept at home, school, and in a backpack or other personal bag. As well, your child should have a medical ID necklace or bracelet with the stated allergy on it.

Websites for more information:

www.aaaai.org
The American Academy of Allergy, Asthma, and Immunology

www.aafa.org
The Asthma and Allergy Foundation of America

www.foodallergy.org
The Food Allergy and Anaphylaxis Network

“Strep throat” is the commonly used term to describe an infection of the throat with Group A Streptococcus. The classic presentation of strep throat occurs in a school-age child with a sore throat that appears bright red on examination. Fever, headache, abdominal pain, enlarged lymph nodes, and vomiting may accompany strep throat. Some children will have a pink sandpaper-like rash on the face, trunk, arms and groin; this is called “scarlet fever”. Strep throat is unusual under three years of age and does not cause congestion or cough.

If your doctor has a strong suspicion that your child has strep throat, a “rapid” strep test will be done. This test consists of a chemical reaction that detects the presence of Streptococcus. It is approximately 96% accurate in detecting the presence of the bacteria. Since 3-5% of strep throat will be missed by the rapid test, all children with negative rapid tests automatically have throat cultures performed.

If the rapid strep test or the throat culture is positive, your child will be placed on ten days of antibiotics. We do not routinely place children with negative rapid strep tests on antibiotics before the culture results are available. If your child’s throat culture is positive, you will be called by our office staff between 9 and 11 am on the day the results are available. You will not be called if the culture is negative.

A child with strep throat is contagious until he or she has been on antibiotics for a minimum of 24 hours. Before returning to school, a child should be fever free and on antibiotics for 24 hours.

If your child has a persistent fever and/or continues to complain of a sore throat after 72 hours of antibiotics, you should contact our office. A rash, if present, may persist for days. If after ten days of medication and being off antibiotics for more than 48 hours, your child has a recurrence of symptoms, you should have him or her rechecked in our office. Research has shown that in almost all cases a relapse of symptoms represents a newly acquired strep infection, not treatment failure.

Household contacts of a child with strep throat need to be examined and cultured only if they have symptoms of strep throat.

The Academy of Dermatology and the American Academy of Pediatrics both endorse the use of sunscreens and feel that they are an important part of a total sun protection program that also includes sun avoidance and sun protective clothing. We now know that exposure to the sun is bad for children’s health, leading to sunburn, premature skin aging, cataracts, and skin cancer.

Tips for sun protection:

• Keep infants out of the sun.
• Cover your baby with a long shirt and a wide brimmed hat.
• Place your baby under a sun umbrella at the beach.
• For kids over six months, select a sunscreen with a minimum SPF of 15 and UVA/UVB protection. An SPF of 15 allows only 1/15 (7%) of the sun’s rays to get through and therefore extends safe sun exposure from 20 minutes to 5 hours. A higher SPF is rarely needed because sun exposure beyond 5 hours is unusual. Most sunscreens need to be reapplied in 3 to 4 hours as well as immediately after swimming or profuse sweating. “Waterproof” sunscreens generally stay on for 30 minutes in water.
• For infants under six months, the safety of sunscreens have not been extensively studied. We recommend keeping your child out of the sun as much as possible, but if a sunscreen is necessary, use one that contains titanium dioxide and is PABA free.
• Protect your child’s eyes to lower the risk of developing cataracts when older. Buy sunglasses with 99% to 100% of UVA/UVB protection.

Swimmer’s Ear is an infection of the outer ear, or ear canal. The introduction of excess moisture in the ear canal allows bacteria to grow, causing swelling and inflammation of the canal. Compared to a middle ear infection (“otitis media”), where symptoms such as malaise, fever, runny nose and eye discharge commonly accompany the painful ear, the presentation of Swimmer’s Ear is generally localized to pain and tenderness of the affected ear(s). This discomfort can be elicited by tugging gently on the earlobe or pressing over the entrance to the ear canal.

Swimmer’s Ear is treated by ear drops that contain an antibiotic and a topical anti-inflammatory steroid. Occasionally if the infection is severe oral antibiotics are given as well. If the pain is severe, a warm wet compress behind the ear as well as an analgesic (Tylenol or ibuprofen) may be helpful.

While swimming is the most common cause of otitis externa, an outer ear infection can also be caused by a middle ear infection that drains through a hole in the eardrum. It is important for us to distinguish between the two causes because if your child has a middle ear infection (otitis media) as well as an otitis externa, he or she will need oral antibiotics.

We recommend that your child not immerse his/her head under water until he/she has had 5 days of medication and is symptom free.

Since certain individuals are susceptible to recurrences (especially those who swim frequently), the most effect practice is instillation of 50/50 alcohol-peroxide mix immediately after swimming. Over-the-counter preparations such as “Swim Ear” may be used as well. These solutions dry the ear canal and keep the acid-base balance at a level that inhibits bacterial overgrowth.

Tick-borne diseases, such as Lyme Disease, are largely preventable. If you live in a tick-infested area, or are visiting an area inhabited by ticks, you can minimize your child’s exposure by taking a few simple precautions.

• Children and adults hiking in tick-infested areas should wear long clothing and tuck the end of their pants into their socks. Light colors are preferable so that ticks will be more visible.
• Apply an insect repellent with at least 20% DEET (e.g. Hour Guard 8, Deet Plus, Deep Woods Off!, Repel Classic Sportsman) or Permethrin (e.g. Permethrin Tick Repellent, outdoorsman Gear Guard, Repel Permanone) to clothing, shoes, and socks. Do not apply insect repellent with this concentration of DEET or Permethrin directly to the skin.
• At least once a day, carefully inspect the skin for ticks. Pay close attention to under the arms, in the groin, behind the ears, along the hairline, and on the legs, particularly the back of the knees.
• If you see a tick attached to the skin, remove it with a pair of tweezers. Grasp the tick as close as possible to the site of attachment, and pull up straight from the skin to avoid breaking the body and jaws. Always use gloves when handling a tick. After removing the tick, wash the bite site with soap and water. Never put alcohol on a tick during or after removal.

Ticks that carry the bacteria that causes Lyme Disease need to be feeding for well over 24 hours to transmit the bacteria. If the tick has been attached for over 24 hours, watch for a rash that may develop anytime between 3 and 31 days after the bite (usually 1-2 weeks). The Lyme Disease rash is red, circular, expands over a period of days to weeks, and clears centrally. The rash may be associated with fever, malaise, or flu-like illness.

At this time we do not recommend saving the tick for analysis because of the unreliability of the available testing.

Vomiting

• Nothing by mouth for 30-60 minutes
• Small frequent feedings of clear fluids (Pedialyte up to age 2; Gatorade after age 2) preferred for 12-24 hours. If these are refused, flattened soda is acceptable. DO NOT GIVE PLAIN WATER. If small sips of fluids are not staying down or are refused, try teaspoons or medicine droppers of the fluids every 5-10 minutes.
• If unable to keep fluids down, try Cola syrup or Emetrol, 1/2-1 teaspoon every 15 minutes until 1 dose stays down, with a maximum of 6 doses. Do not use under 6 months of age. Cola syrup and Emetrol are used as a coating for the stomach that may alleviate vomiting; they are not fluids to hydrate your child. Once a single dose stays down, discontinue the Cola syrup and proceed back to clear fluids.
• When small frequent feeding of clear fluids stay down for 2 or more hours, you may try larger amounts of fluids.
• When your child has not vomited for 12 hours and appears better, you may try half-strength formula in infants and solid food in older children. You should avoid giving Pedialyte alone for more than 24 hours. If half-strength milk-based formula causes more vomiting, or diarrhea begins, you may try half-strength soy formula instead.
• When ready to reintroduce solid foods, start with ripe bananas, applesauce, jello, clear broth, dry toast, dry crackers, baked potato, and rice.
• Avoid milk products.
• If vomiting recurs, do not give anything for 30-60 minutes and then restart clear fluids as above.

Diarrhea

For diarrhea, unlike vomiting, food (nutrition) is critical to heal the bowel and hasten recovery.

Foods to avoid: milk products, fruit juices, high fiber foods
Foods to encourage: rice, bananas, applesauce, jello, rice cereal, barley, dry toast, dry crackers, clear soup, baked potatoes.

Infants may be temporarily placed on a soy formula.

Occasionally, in cases of severe diarrhea, stool may not return to completely normal for several weeks. As long as the diarrhea slowly improves, your child is well appearing and has no fever, and there is no blood in the stool, there is no cause for alarm. Any baby under 6 months with prolonged diarrhea should be seen.

Call us if:

• Your child is unable to keep any fluids down for several hours.
• Your child is having severe abdominal pain.
• Your child has blood and mucus in the stools.
• Your child has has a high fever.
• Your child’s symptoms are prolonged.

Careful hand washing with soap and water after changing diapers or cleaning up vomitus or diarrhea is key in helping prevent the spread of gastroenteritis through your family.