While starting your child on solid food isn’t always “love at first bite” it also does not have to be complicated or stressful.

Here are some overriding principles to keep in mind when feeding your baby:

1)      It’s not just about the food. It’s about teaching your child to eat when hungry and to stop when full.

2)      Eating a meal with family is social as well as nutritious. Keep eating pleasant and relaxed and never force feed or trick your child into eating.

3)      Babies start out with pureed foods in a spoon between 4-6 months and progress to finger foods when physically capable, usually between 7-9 months. Teeth are not required; hand to mouth coordination is required.

Start with food on a spoon at 4-6 months. Before this age, babies don’t really digest solids. Also it’s hard to feed a baby who still slumps when propped in a sitting position. In addition, the normal “tongue thrust” reflex is less pronounced after 4 months of age. Putting cereal into a bottle doesn’t count as “eating” and is not necessary.

Timing is important when offering solid food for the first time. Babies learn to expect a breast or a bottle when hungry. So make sure your baby is happy and awake but NOT hungry the first time you feed her solid food because at first, she is learning a skill, not eating for nutrition. You should wait about an hour after a milk feeding when she is playful and ready to try something new. Keep a camera nearby because babies make great faces when eating food for the first time.  Start a new food in the morning so that you have the entire day to make sure it agrees with your baby. Watch for rash or stomach upset. Once you know the food agrees with your baby, that food can be fed at night if you prefer.

Traditional first food in the USA is single grain rice cereal because it is easy to digest and most kids are not allergic to it. This is the one food I suggest keeping store bought rather than home made because this cereal is fortified with iron which is important for your baby’s growth. Mix the cereal with breast milk or formula so it smells familiar to your baby and because it adds calories (vs. mixing with water).  Don’t worry about measuring. This is not an exact science. Just mix up a small amount to the consistency that you would likely eat oatmeal. Then put a small amount in a spoon and Go For It.

Some babies take one feeding to “figure it out.” They learn quickly to swallow without gagging and open their mouths when they see the spoon coming. Other babies need more time. They may tongue thrust the food back out, cough when trying to swallow, cry, or seem clueless when the spoon comes back to them. Don’t worry and go back to the above ground rules. Quit and try again another day. Some babies take several weeks to catch on to the idea of eating solids.

It is ok to try another single-ingredient food such as fruit or vegetable or another kind of cereal such as oatmeal if you think your baby does not like rice cereal. The overriding principal is to try one new food at a time so that if your baby has a reaction to the food, you know what to blame.

Stage 1 vs. Stage 2 baby food: The only difference is the size of jars. The consistency of the food is the same. Some stage 2 foods combine ingredients. Combinations are fine as long as you know your baby already tolerates each individual ingredient ( i.e. “peas and carrots” are fine if they’ve already had each one). Avoid the “dessert” jar foods. Your baby does not need fillers such as cornstarch or concentrated sweets. You could also make your own baby food by making a puree with cooked vegetables or soft fruits. Again, avoid introducing many new ingredients at once and avoid added salt and sugar.

Not all kids like all foods. Don’t worry if they hate carrots or green beans or apples. Many other choices are available. At the same time, don’t forget to offer a previously rejected food multiple times because taste buds change.

Be forewarned: poop changes with solid foods. Usually it gets more firm or has more odor. Food is not always fully digested at this age and thus shows up in the poop. Wait until you see a sweet potato poop!

By six months, babies replace one milk feeding with a solid food meal. Some babies are up to three meals a day by 6 months but should be receiving more calories from breast milk or formula than from solids. Also at six months you can offer a cup with water at meals. Juice is not necessary to give if your child eats fruit.

Sample menu by 6-7 months:  breakfast: cereal mixed with formula/breast milk and fruit, lunch: fruit and vegetable, dinner: cereal and vegetable. Cereal has the highest calories and best nutritional content and should be offered at least twice daily. Jar baby food meats can be omitted: most kids don’t like them and cereal and breast milk/formula have plenty of protein. You can wait with meat until offering finger foods.

Finger foods can be given when your baby can sit alone and manipulate a toy without falling over, usually between 7-9 months. Even with no teeth your baby is able to gum a variety of finger foods. Examples include “Toasted Oats” (Cheerios), which are low in sugar and dissolve in your mouth eventually without any chewing, ½ cheerio-sized cooked vegetable, soft fruit, ground meat or pieces of baked chicken, beans, tofu, egg yolk, soft cheese, small pieces of pasta. Start by putting a finger food on the tray while you are spoon feeding and see what your child does. They often do better feeding themselves finger foods rather than having someone else “dump the lump” into their mouths.

Children should always eat sitting down and not while crawling or walking in order to AVOID CHOKING.  Feed them while other family members are also eating. Babies imitate at this age and learn how to eat by watching others.

Finger food sample meals: Breakfast: cereal, pieces of fruit. Lunch: pasta or rice, lentils or beans, cooked vegetables in pieces, pieces of cheese. Dinner: soft meat such as chicken or ground beef, cooked veggies and/or fruit, bits of potato, or cereal.  By nine months, kids can eat most of the adult meal at the table, just avoid these choking hazards: raw vegetables, chewy meats, nuts, hot dogs.  You can use breast feedings or formula bottles as snacks between meals or with some meals. By this age, it is normal for babies to average 16-24oz of formula daily or 3-4 breast feedings daily.

Avoid fried foods and highly processed foods. Do not buy “toddler meals” which are small versions of adult TV dinners and very high in salt and “fillers.” Lastly, do not give honey before one year of age because honey can cause botulism in infants.

A word about food allergies: Even the allergists lack a definitive answer of what makes a child allergic to a food. A general rule of thumb is that if there is a known food allergy in a family, avoid THAT food as long as you can. If no food allergies run in the family, focus more on avoiding choking hazards (see above) than on potentially allergenic foods. Please refer to our blog post on food allergies for more information.

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Why the recent American media hub-bub over “the flu” and “the swine flu”?  Both are forms of the same virus called influenza.  Usually known as “the flu,” this year, “the flu” is called the seasonal flu in order to distinguish it from “the swine flu,” properly known as the 2009 H1N1 flu.  Getting hit by any form of influenza can feel like being hit by a ton of bricks.  Just ask my husband.  Last winter, the same man who ran his first Marathon in the fall, couldn’t run 500 feet for nearly a month after his bout with the seasonal flu.   Complications from either form of influenza include sinus infections, pneumonia and even death.  Influenza   infections in the States occur mainly from October to April each year.  Usually, only the  seasonal strain is of concern, but this season there is the added concern that the 2009 H1N1 strain, which first leaped into the spotlight this past spring, will also add to the total number of people affected by influenza.


Both influenza forms are viral illnesses which predominantly cause airway symptoms.  Classic flu symptoms are sudden onset of nasal discharge, cough, high fever, headache and achiness.  A virus is a category of germs which are named for the way they reproduce.  Examples of viruses vary wildly.  Chicken pox, the common cold, and Human Immunodeficiency Virus (HIV) are all caused by viruses.  Whether an illness is caused by either a virus or a bacterial germ does not necessarily reflect the severity of an illness.  To add to the confusion, people sometimes call any viral illness which causes stomach upset “the stomach flu.”  “The Stomach flu” is not caused by an influenza virus.  If your child has diarrhea and vomiting alone with no stuffy nose or cough, they are not likely to have a form of influenza.


 
How do I protect my kids against either the Seasonal Flu or H1N1?


Wash, wash, wash. 


Hand washing with soap and water for 15 seconds has been proven to decrease germs.  For young (or impatient) children , have them sing the Happy Birthday Song until they are done.  One note- alcohol containing hand sanitizers do kill germs; however, most brands contain a greater percentage of ethylene alcohol than distilled drinks. Hand sanitizers contain over 60 percent alcohol versus 30-40 percent alcohol in liquor. According to my sister, Melisa Lai, MD, a Boston area toxicologist, toddlers have ended up in comas from alcohol poisoning after drinking hand sanitizer.


No nose-to-nose. 


Both forms of influenza are spread through air via coughing and sneezing. Tell your kids that they don’t want boogies from other kid’s noses to go into their nose.  If their noses can touch the noses of other children, then they are too close.  Cough away from other kid’s faces.  If we use national standards for spacing between sleeping cots in daycares (Caring For Our Children Health and Safety Standards, 2nd edition), children are ideally kept two feet apart.


Keep ‘em away from crowded places. 

Any parent knows, keeping playing children two feet apart from each other is near impossible.  If your child is sick, keep them away from crowded places such as birthday parties, school and daycare.  If your child is already ill, you do not want them to catch a secondary illness on top of their current illness.  For the protection of your child and others, keep your child at home until  he/she is 24 hours fever free.  This school and daycare exclusion criteria is already recommended not only for influenza by the American Academy of Pediatrics, but for all illnesses (www.AAP.org).  A few days ago, the Centers for Disease Control http://www.cdc.gov/h1n1flu/schools/  published the same guidelines for influenza.


 


Immunize.

There are two types of immunizations against the seasonal flu.  Because the seasonal influenza strains change from year to year, the vaccine changes and need to be given yearly.  One is a nasal spray for children two years old and up.  The other type is injected into muscle and is approved for those six months and above.  Because the vaccines are made up in eggs, children with egg allergies cannot receive the vaccine.   Under nine years of age, the first year a child receives the seasonal flu vaccine, two doses are required.  If only one immunization was given the first year, the child will require two the second year.  If your child is ill or had a reaction to the seasonal vaccine in the past, ask your doctor about administration of the vaccine.  


 As of this writing, vaccines for the H1N1 flu are still not available.  Vaccines are expected to be available in the late fall.  Uncertainties about the H1N1 formulations, side effects and distribution still persist.  


 The priority groups for the seasonal flu immunization and the 2009 H1N1 flu immunization are slightly different.  The main difference between the set of recommendations is that those over 65 years of age are not a target groups for the 2009 HINI vaccine but a target for the seasonal flu vaccine.  Also, college aged (19-24 years) adults are part of the 2009 H1N1 target group but not of the seasonal flu vaccine target group.


 According to the Advisory Committee on Immunization Practices, a working group of the Centers for Disease Control which meets to review infectious disease  data and recommends national guidelines for immunizations, the following groups are the priority groups for influenza vaccination:


Priority groups for the seasonal influenza vaccine:


1.       Children aged 6 months up to their 19th birthday


2.       People 50 years of age and older


3.       People of any age with certain chronic medical conditions


4.       People who live in nursing homes and other long-term care facilities


5.       People who live with or care for those at high risk for complications from flu, – includes Health care workers, Household contacts of persons at high risk for complications from the flu, Household contacts and out of home caregivers of children less than 6 months of age (children too young to be vaccinated)


6.       Pregnant women


 


Priority groups for the 2009 H1N1 influenza vaccine:


1. All people from 6 months through 24 years of age
2. Household contacts and caregivers for children younger than 6 months of age
3. People aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
4. Healthcare and emergency medical services personnel
5. Pregnant women  

Is there treatment?


Treatment is generally supportive.  Have your child drink plenty of fluids and get as much rest as possible.  Fever reducers such as ibuprofen (i.e. Morin, Advil) and acetaminophen (i.e. Tylenol) may help keep children comfortable enough to do the things such as drink and sleep that will make them better.  Outpatient antiviral does exist but the strains of flu can morph, thus rendering them sometimes ineffective.   Antiviral medications are for children whose illness is moderate or severe or if they are at high risk of complications.  Generally antivirals work best within the first 48 hours after onset of symptoms.  Antibiotics such as Amoxicillin and a “Z-pack “will not kill influenza viruses.  Antibiotics are prescribed if there is bacterial infection overlying the influenza infection.


This winter, although your family may escape both strains of influenza, remember, there are plenty of “flu-like” illnesses out there which can also wreck havoc on your child’s health.  Hopefully, if the threat of the seasonal and 2009 H1N1 flu forces us to pay attention to good hygiene habits, we may overall end up with a healthier winter.


For the most up to date information on influenza: www.CDC.gov


Naline Lai, MD


 

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Okay, admit it.


Before you became a parent, you never really gave much thought to poop.


Now you are captivated and can even discuss it over meal time: your child’s poop with its changing colors and consistency. Your vocabulary for poop has likely also changed as you are now parents. Before your baby’s birth, you probably used some grown-up word like “bowel movement” or “stool” or perhaps some “R” rated term not appropriate to this pediatric site. But now, all that has changed.


As a pediatrician I have many conversations with new parents, and some not-so-new parents, about poop. Mostly this topic is of real interest to parents with newborns, but poop issues come out at other milestones in a child’s life, namely starting solid foods and potty training. So I present to you the scoop on poop.


Poop comes in three basic colors that are all equal signs of normal health: brown, yellow, and green. Newborn poop, while typically yellow and mustard like, can occasionally come out in the two other colors, even if what goes in, namely breast milk or formula, stays the same. The color change is more a reflection of how long the milk takes to pass through the intestines and how much bile acid gets mixed in with the developing poop.


Bad colors of poop are: red (blood), white (complete absence of color), and tarry black. Only the first poop that babies pass on the first day of life, called meconium, is always tarry black and is normal. At any other time of life, black tarry stools are abnormal and are a sign of potential internal bleeding and should always be discussed with your child’s health care provider, as should blood in poop (also not normal) and white poop (which could indicate a liver problem).


Normal pooping behavior for a newborn can be grunting, turning red, crying, and generally appearing as if an explosion is about to occur. As long as what comes out after all this effort is a soft poop (and normal poop should always be soft), then this behavior is normal. Other babies poop effortlessly and this, too, is normal.


Besides its color, another topic of intense fascination to many parents is the frequency and consistency of poop. This aspect is often tied in with questions about diarrhea and constipation. Here is the scoop:


It is normal for newborns to poop during or after every feeding, although not all babies poop this often. This means that if your baby feeds 8-12 times a day, then she can have 8-12 poops a day. One reason that newborns are seen every few weeks in the pediatric office is to check that they are gaining weight normally: that calories taken in are enough for growth and are not just being pooped out. While normal poop can be very soft and mushy, diarrhea is watery and prevents normal weight gain.


After the first few weeks of life, a change in pooping frequency can occur. Some formula fed babies will continue their frequent pooping while others decrease to once a day or even once every 2-3 days. Some breastfed babies actually decrease their poop frequency to once a week! It turns out that breast milk can be very efficiently digested with little waste product. Again, as long as these babies are feeding well, not vomiting, acting well, have soft bellies rather than hard, distended bellies, and are growing normally, then you as parents can enjoy the less frequent diaper changes. Urine frequency should remain the same (at least 6 wet diapers every 24 hours, on average) and is a sign that your baby is adequately hydrated. Again, as long as what comes out in the end is soft, then your baby is not “constipated” but rather has “decreased poop frequency.”


True constipation is poop that is hard and comes out as either small hard pellets or a large hard poop mass. These poops are often painful to pass and can even cause small tears in the anus. You should discuss true constipation with your child’s health care provider. A typical remedy, assuming that everything else about your baby is normal, is adding a bit of prune or apple juice, generally ½ to 1 ounce, to the formula bottle once or twice daily. True constipation in general is more common in formula fed babies than breastfed babies.


Adding solid foods generally causes poop to become more firm or formed, but not always. It DOES always cause more odor and can also add color to poop. I still remember my husband’s and my surprise over our eldest’s first “sweet potato poop” as we asked each other, “Will you look at that? Isn’t this exactly how it looked when it went IN?” If constipation, again meaning hard poop that is painful to pass, occurs during solid food introductions, you can usually help by giving more prunes and oatmeal and less rice and bananas to help poop become softer and easier to pass.


Potty training can trigger constipation resulting from poop withholding. This poop withholding can result in backup of poop in the intestines which leads to pain and poor eating. Children withhold poop for one of three main reasons:


1.       They are afraid of the toilet or potty seat.


2.       They had one painful poop and they resolve never to repeat the experience by trying to never poop again.


3.       They are locked into a control issue with their parents. Recall the truism “You can lead a horse to water but you can’t make him drink.” This applies to potty training as well.


Treatment for this stool withholding is to QUIT potty training for at least a few weeks and to ADD as much stool softening foods and drinks as possible. Good-for-poop drinks and foods include prune juice, apple juice, pear juice, water, fiber-rich breads and cereals, beans, fresh fruits and vegetables. Sometimes, under the guidance of your child’s health care provider, medical stool softeners are needed until your child overcomes his fear of pooping and resolves his control issue. For more information about potty training I refer you to our podcast on this subject.


My goal with this blog post was to highlight some frequently asked-about poop topics and to reassure that most things come out okay in the end. And that’s the real scoop.


Julie Kardos, MD with Naline Lai, MD


©2009 Two Peds in a Pod®

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It is one week before the start of school and I watch as my daughter’s sixth grade teacher stabs an onion with a needle.  It’s a back to school ritual for my family.  Usually a piece of fruit is a proxy for my daughter’s thigh, and the needle contains epinephrine, a potentially life saving medication that my daughter would need if she were to eat a cashew. 



Two of my children are part of a growing number of people with food allergies.   According to the Food Allergy & Anaphylaxis Network, an estimated 11 million Americans have a food allergy.  Despite the numbers, the etiology of food allergies remains a mystery.  One of the most popular theories is that a child develops a sensitivity when the gut is exposed to a bit of the offending food during an unknown critical time in development–perhaps even in utero.  My son had an allergic reaction to peanuts at eight months of age without ever ingesting a peanut. He had been touched by an unwashed hand that had just handled peanuts.  To add to the confusion, experts wonder if there is a relationship between allergies and how food is processed.  In China, despite an abundance of peanut containing entrees, relatively few people are allergic to peanuts.  It is postulated that the smaller number is somehow connected to the fact that most peanuts are boiled not roasted.  Strangely, only eight categories of food:
milk, egg, soy, peanut, tree nut (i.e. cashews and pecans), fish, wheat and shellfish cause ninety percent of allergic reactions.



Reactions can range widely from a single, pesky, itchy welt to a choking off of all airway passages.  The type of suffocation that occurs can be impossible to ventilate, even with a respirator.  The medication  which can thwart allergic reactions, epinephrine, is available in a portable form.  Yet one study showed that even after medical evaluation, epinephrine was prescribed to only half of children and less than one quarter of adults with nut allergies.   More distressing, as a pediatrician, I find families fail to recognize the symptoms of respiratory distress and do not realize the urgency of the situation.  Even when respiratory symptoms are obvious, families are sometimes too panicked to think clearly.  I know of cases of parents who injected the medicine into their own fingers rather than into their child.

Unfortunately, even epinephrine can not always stop catastrophic consequences.  The only real treatment is avoidance.  This can be tough in a world where many confuse food allergies with a personal choice—like a person who chooses to be a vegetarian.  Adding to the confusion is the mistaken belief that food intolerance is synonymous with food allergy.  For instance, in milk intolerance, people have difficulty digesting the sugar in cow’s milk, whereas people with a milk allergy are reacting to the protein in cow’s milk. 



Watching an allergic person eat at a restaurant is like watching a person eat Japanese puffer fish- every bite could be lethal.  It took only one cashew to cause my daughter to break out in hives, vomit and experience a tightening of her throat.  During my first two weeks of college, I remember a  freshman at my college dying  because of peanut butter hidden as “the special thickening ingredient” in a restaurant’s chili.  Perils are everywhere.  A milk allergic person worries if a meat slicer has been previously used for cheese, the fish allergic individual needs to worry about Worcestershire sauce because it often contains anchovies and the egg allergic person needs to be suspicious of  foamy toppings on specialty drinks.   In my pediatric practice, one of my patients, a peanut-allergic girl, started wheezing simply because the child next to her in the car opened up a bag of peanut butter filled snacks.



Despite the sometimes small amount of an allergen required to set off an allergic reaction, one study showed that at least the major allergen in peanuts is relatively easy to clean from hands with simple soap and water.  Common household cleaning products remove the allergen from counter and table tops.  But kids, especially toddlers, are not known for their meticulous sanitation practices.  Schools and daycares often find keeping an entire classroom free of an offensive food easier than keeping kids from touching each other.



So when that letter comes home this fall identifying someone in your child’s class with a food allergy, don’t moan and groan.  Abstain from sending in potentially allergenic foods with your child.  Imagine sending your children to school knowing that a well meaning friend might try to share a deadly snack.  Like the millions of allergic Americans, your picky eater could learn to modify his or her diet.  Our family went from eating daily peanut butter and jelly sandwiches to becoming a nut free home.  What is an inconvenience to you may save a kid’s life.


 


 


Naline Lai, MD


 



For more info:
Food Allergy, Asthma and Anaphylaxis Network
www.foodallergy.org



 an online  resource and discussion group 



References:

Distribution of Peanut Allergen in the Environment


Perry TT et al.  J Allergy and Clinical Immunology.  2004;113:973-976


 


Prevalence of Peanut and Tree Nut allergy In the United States Determined By Means of A Random Digit Dial Telephone Survey: A 5 Year Follow-Up Study


Sicherer S. et al. Journal of Clinical Immunology 2003;112:203-1207

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With school starting in the next few weeks, many families will have to shift their children from “summer time sleep mode” to “school year sleep mode.” Your children will have an easier time if their bedtimes are shifted gradually over the period of a week or two toward the desired time period. Remember, the average school aged child needs 10-11 hours of sleep at night and even teenagers function optimally with at least 9-10 hours of slumber per night.


Here are some straight forward rules to follow to help ensure good quality sleep for your child:


1)      Keep sleep onset and wake up times as consistent as possible 7 days a week. If you allow your child to “sleep in” during the weekends, she will have difficulty falling asleep earlier on Sunday night, have difficulty waking up Monday morning, and start off her week over-tired, more cranky and less able to process new information—not good for learning.


2)      Limit or eliminate caffeine intake. Often teens who feel too sleepy from failing to follow rule number 1 from above may drink tea, coffee, “energy drinks” or other caffeine laden beverage in attempt to self-medicate in order to concentrate better. What many people don’t realize is that caffeine stays in your body for 24 hours so it is entirely possible that the caffeine ingested in the morning can be the reason your child can’t fall asleep later that night. Caffeine also has side effects of jitteriness, heart palpitations, increased blood pressure, and gastro-esophageal reflux (heartburn).


3)      Keep a good bedtime routine. Just as a soothing, predictable bedtime ritual can help babies and toddlers settle down for the night, so too can a bedtime routine help prepare the school aged child/teen for sleep.


4)      Avoid TV/computer/ screen time just before bed. Although your child may claim the contrary, watching TV is known to delay sleep onset. We highly recommend no TV in a child’s bedroom, and suggest that parents confiscate all cell phones and electronic toys, which kids may otherwise hide and use without parent knowledge, by one hour prior to bedtime. Quiet activities such as reading for pleasure, listening to music, and taking a bath, are all known to promote falling asleep.


5)      Encourage regular exercise. Kids who exercise daily have an easier time falling asleep at night than kids who don’t exercise. Gym class counts. So does playing outside, dancing, walking, and taking a bike ride. Of course, participating in a team sport with daily practices not only helps insure better sleep but also promotes social well being.


Getting enough sleep is important for your child’s academic success as well as for their mental health. I have had parents ask me about evaluating their child for ADD or ADHD because of his inability to pay attention and then come to find out that their youngster fights bedtime and averages 7-8 hours of sleep per night when he really need 1-2 hours more, or their teen is so over-involved in activities that she averages 6 hours of sleep per night. Increasing the amount of sleep these kids get can alleviate their attention problems and resolve their hyperactivity. Additionally, sleep deprivation can cause symptoms of depression. Just recall the first few weeks of having a newborn:  maybe you didn’t think you were depressed but didn’t you cry from sheer exhaustion at least once?


Unfortunately for children, the older they get, their natural circadian rhythm shifts them toward the “night owl” mode of staying up later and sleeping later, and yet the higher up years in school start earlier so that teens in high school start school earliest at a time their bodies crave “sleeping in.” A few school districts in the country have experimented with starting high school later and Grade School earlier and have met with good success with less tired, more productive teens. Unless you live in one of these districts, however, your teens need to conform until they either go to college and can choose classes that start later in the day or choose a job that allows them to stay up later and sleep later in the day in order to be better in sync with their age specific body rhythms.


Some children seem to get plenty of sleep at night and are still tired during the day. Some medical conditions that interfere with sleep quality include but are not limited to:



  • Asthma: kids cough themselves awake multiple times during the night
  • Obstructive sleep apnea: children often are obese or have enlarged tonsils and adenoids or have anatomically “floppy” airways. These kids snore and pause their breathing, then rouse themselves in order to start breathing again, multiple times per night.
  • Medication side effects
  • Psychological conditions such as depression or anxiety
  • Illicit drug use

If your child seems to be sleeping enough but still seems excessively tired during and after school, you should consult with your child’s health care professional to look for medical and psychological causes of fatigue. It is always ok to ask your child/teen directly if they feel depressed or anxious. Even if they deny this, they will appreciate your concern and may come back to you later with a more truthful answer.  A night time ritual of “tell me about your day” can help kids decompress, help them fall asleep, and keep you connected with your child.


Julie Kardos, MD

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It’s that time of year again, supply #3 on my back-to-school shopping list, glue sticks, are sold out at the Target down the street.  At this time of year, I see many of my patients embarking on their next stage of schooling.  Kids I remember starting kindergarten are off to high school.  Babies are starting daycare and the teens are starting college.  With all of these transitions to independence, the basic rules of daycare drop off still hold:



  • Always convey to your child that the transition is a positive experience.  You give your child cues on how to act in any situation.  Better to convey optimism than anxiety. 
  • Take your child and place her into the arms of a loving adult- do not leave her alone in the middle of a room.
  • Do not linger.  Prolonging any tears, only prolongs tears. The faster you leave, the faster happiness will start.
  • It’s ok to go back and spy on them to reassure yourself that they have stopped crying- just don’t let them see you.

Now with that all being said, kick back late at night, after all the school forms have been put away.  Whether your child is off to college, off to daycare or off to kindergarten, take out a glass of wine and listen to the letter I wrote for one of my own children years ago…


My Child,


As we sit, the night before kindergarten, your toes peeking out from under the comforter, I notice that your toes are not so little anymore. 


Tomorrow those toes will step up onto to the bus and carry you away from me.   Another step towards independence.   Another step to a place where I can protect you less.  But I do notice that those toes have feet and legs which are getting stronger.   You’re not as wobbly as you used to be.  Each time you take a step you seem to go farther and farther. 


I  trust that you will remember what I’ve taught you.  Look both ways before you cross the street, chose friends who are nice to you, and whatever happens don’t eat yellow snow.   I also trust that there are other eyes and hearts who will watch and guide you. 


But that won’t stop me from worrying about each step you take. 


Won’t stop me from holding my breath­. 


Just like when you first started to walk, I’ll always worry when you falter. 


I smile because I know you’ll hop up onto the bus tomorrow, proud as punch, laughing and disappearing in a sea of waving hands.  I just hope that at some point, those independent feet will proudly walk back and stand beside me.   


Maybe it will be when you first gaze into your newborn’s eyes, or maybe it will be when your child climbs onto the bus. 


Until then,


I hold my breath each time you take a step.


Love,
Mommy


Naline Lai, MD

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After completing my pediatric training, I worked for a couple of years in a large pediatric office before I had any children of my own. I was always struck by the Life Event of a child’s first birthday. This milestone carries so much meaning and emotion for families. My patients’ parents described huge birthday parties with characters such as Elmo walking around or Moon Bounces, large catered affairs with numerous friends and family members and entire neighborhoods. Often I would see a child sick in my office a few days before such an event with parents who were panicked that their child might be sick on his Big Day, or I would see a child for his one year well check and hear many details about the enormous party. Of course I also saw plenty of children a few days after their first birthday party who became ill, most likely, from a well-intentioned friend or relative who was already sick and passed the illness on to the birthday child at the party. I heard about the kids who clapped for the Happy Birthday song and kids who cried and one who vomited from excitement… all over the birthday cake. Many of my patients had their first full blown temper tantrum during their own over-stimulating first birthday party.


I remember not quite understanding why parents go through such effort and expense to throw a party that their child will never remember at a developmental stage where 99 percent of children are having stranger anxiety and separation anxiety, often forgoing daily routine to skip naps, eat at erratic times, and then expect their birthday child to perform in front of a large crowd singing loudly at them. “My husband and I will do it differently,” I would tell myself.


Now, three of my own children later, I must apologize for not quite understanding about that first birthday. I remember waking up on the day my oldest turned one year. My pediatrician brain first exclaimed “Hurray! No more SIDS risk!” Then my mommy brain took over, “Ohmygosh, I survived the first year of parenthood!” This day is about Celebration of the Parent. I finally understood completely why my patients’ parents needed all the hoopla.


Because I am actually a little uncomfortable in large crowds, my son’s first birthday party included all close relatives who lived nearby, people he was well familiarized with. Some pediatric tips I had picked up which I will pass on:


1)      Sing the Happy Birthday song, complete with clapping at the finale, for about one month straight leading up to the birthday. Children love music and hearing a very familiar song sung by a large group is not as overwhelming as hearing an unfamiliar song.


2)      Plan mealtime around your child, not the guests. If you are inviting people close to your heart, they will accommodate. Dinner can be at 5:00pm if that’s when your child usually eats, or have a lunch party that starts midmorning and then end the party in time to allow your child to have his regularly scheduled afternoon nap. Most one-year-olds are usually at their best in the morning anyway.


3)      If your child becomes sick, cancel the party. Your child will not be disappointed because he won’t understand what he is missing. You as parent would have a lousy time anyway because all of your attention will be on your ill child and you will be anxious. Your guests who are parents will appreciate your refraining from making them and their own children sick.


Recently while performing a one-year-old well child check I asked about my patient’s birthday party and her parent told me “Oh, we didn’t have a party. It was like any other day, although we did give her a cupcake for dessert.”


Now THIS is a pragmatic approach to parenting  because, again, no child will ever have memories of her own first birthday. However, I hope the parents did take time, at least with each other, to congratulate themselves and to feel really good about making it to that huge milestone in their parenting career. I hope they savored their accomplishment as much as their child savored the cupcake.


Julie Kardos, MD

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Ouch! Stung on the scalp.


Ouch! Stung on the hand.


Ouch! Stung on the leg.


Ouch! Ouch! Stung TWICE on the lips.


Those nasty, nasty hornets.  During the hot days of August, they become more and more territorial and attack anything near their nests.  Today, in my yard, hornets mercilessly chased and attacked a fourth grader named Dan.  As everyone knows, you’d rather have something happen to yourself than have something negative happen to a child who is under “your watch.” As I rolled out the Slip and Slide, I was relieved not to see any wasps hovering above nests buried in the lawn.  I was also falsely reassured by the fact that our lawn had been recently mowed.  I reasoned that anything lurking would have already attacked a lawn mower.  Unfortunately, I failed to see the basketball sized grey wasp nest dangling insidiously above our heads in a tree.  So, when a wayward ball shook the tree, the hornets found Dan.


What will you do in the same  situation?


Assess the airway- signs of impending airway compromise include hoarseness, wheezing (whistle like sounds on inhalation or expiration), difficulty swallowing, and inability to talk.  Ask if the child feels swelling, itchiness or burning (like hot peppers) in his or her mouth/throat.  Watch for labored breathing.  If you see the child’s ribs jut out with each breath, the child is struggling to pull air into his/her body.    If you have Epinephrine (Epi-Pen or Twin Jet)  inject  immediately- if you have to, you can inject  through clothing.  Call 911 immediately. 


Calm the panic- being chased by a hornet is frightening and the child is more agitated  over the disruption to his/her sense of security than over the pain of the sting.  Use pain control /self calming techniques such as having the child breath slowly in through the nose and out through the mouth.  Distract the child by having them “squeeze out” the pain out by squeezing your hand.


If the child was stung by a honey bee, if seen, scrape the stinger out with your fingernail or a credit card.  Do not squeeze or pull with tweezers to avoid injecting any remaining venom into the site.   Hornets, and other kinds of wasps, do not leave their stingers behind.  Hence the reason they can sting multiple times.


Relieve pain by administering Ibuprofen (Motrin,Advil) or Acetaminophen (Tylenol).


As  you would with any break in the skin, to prevent infection, wash the affected areas with mild soap and water.


Decrease the swelling.  Histamine produces redness, swelling and itch.  Counter any histamine release with an antihistamine such as Diphenhydramine (Benadryl).  Any antihistamine will be helpful, but generally the older ones like Diphenhydramine, tend to work the best in these instances.  Unfortunately, sleepiness is common side effect.


To decrease overall swelling elevate the affected area.


A topical steroid like hydrocortisone 1% will also help the itch and counter some of the swelling. 


And don’t forget, ice, ice and more ice.  Fifteen minutes of indirect ice on and fifteen minutes off.


Even if the child’s airway is okay, if the child is particularly swollen, or has numerous bites, a pediatrician may elect to add oral steroids to the child’s treatment


It is almost midnight as I write this blog post.  Now that I know all of my kids are safely tucked in their beds, and I know that Dan is fine, I turn my mind to one final matter:  Hornets beware – I know that at night you return to your nest.  My husband is going outside now with a can of insecticide.   Never, never mess with the mother bear…at least on my watch.


Naline Lai, MD

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Recently I received a phone call from a mom whose six-year-old son was afraid to go to sleep at night. For the past two months the child insisted on falling asleep in the parents’ room while holding one parent’s hand, and if the parent carried him to his room after he finally fell asleep, he would wake up every few hours to return to their room. No one was getting good sleep. In addition, his mom was concerned that he often seemed angry during the day.


Turns out that two months ago the boy’s grandfather died. The boy and his toddler-aged sister had attended the grandfather’s funeral and at the viewing his younger sister, upon seeing her dead grandfather in the coffin, kept saying, “Grandpa, wake up, you are missing your party! Why can’t Grandpa wake up?”


When children are confronted with the death of a family member, friend, or pet, it is very important to never refer to death as “sleeping. Children are very literal and so it is better to say something like, “When people are dead, their bodies do not work, they do not breathe or move,” but do NOT use any sleep analogy. This can cause them to be afraid to fall asleep and not be able to wake up.


This child’s mom was concerned that her son “seemed angry a lot of the time” and was difficult to get along with. This behavior change is very normal and was occurring for two reasons:


1)   When children feel sad, they often appear angry. The child is still mourning the loss of his grandfather. In addition, his parents also are grieving and children perceive their parents’ moods. The child misses his grandfather and it is normal for him to feel sad about this. Children often express sadness with anger, so the parents need to be sensitive to this.


2)   When children are sleep deprived, they become short tempered. This child was staying up until midnight or later before falling asleep in the parents’ room, waking up in the middle of the night, and waking up at 7:00 am for school. School aged children need on average about 9-10 hours of sleep or more to function optimally.


I advised the mom to have a casual conversation during the daytime about death. She could start by saying something like, “You know, I was thinking about Grandpa’s funeral. Remember how your sister kept saying “wake up, grandpa?” I wanted to make sure that you knew that Grandpa was not asleep. He was dead and his body wasn’t working anymore.” Then wait and see if he asked any more questions. If he asked why he died, the parent should give a simple but truthful answer. In this case, Grandpa had cancer, so parents could say, “he had an illness that his body was too old and weak to fight off.” It is also fine for the parent to say, “I am sad because I miss Grandpa.” Again, answer questions if they come up but be very concrete and simple in your answer. If the child says, “What if I get sick? Will I die?” the parent could answer, “No, you are young and strong.”


The other important part of helping this child is getting back to good sleep habits. (I refer you to our forthcoming podcasts on sleep for baseline good bedtime habits.) This child may have been afraid of dying in his sleep or just may have developed a bad association with sleep. He clearly associated his parents with safety. I recommended that a parent sit on his bed in his room until he fell asleep. The bedtime would be moved about 15 minutes earlier each night until they arrived at a more appropriate bedtime. They were to tell the child that they would not leave until he fell asleep. If he awoke during the night and came into their room or called out for his parents, one of them was to sit on his bed again until he fell asleep. The parent was not to talk or interact during this time of falling asleep. The goal was to create a positive, safe association with falling asleep.


After a few days of the child falling asleep within about 15 minutes of sitting on his bed, tell him that the new rule is that one parent would sit NEXT to his bed until he falls asleep. Keep repeating this and wean farther away every few days (ie sit in the middle of his room, sit in the doorway, etc) until he is able to fall asleep on his own. Remember to give lots of praise the next day, small tangible rewards are okay for each accomplishment. 


By acknowledging his grief and also by using behavior changes to help restore good sleep at night, this child’s daytime anger gradually resolved.


Julie Kardos, MD

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