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Here's a question more and more parents seem to be asking themselves: should I buy a nutritional supplement drink for my child?
I am seeing it often in my practice: concerned because a child isn't eating as well as they think he should, parents are buying nutritional supplement drinks like Pediasure or Boost.
I wish they would ask me instead of themselves. Chances are, I'd tell them not to do it.
I totally get why they do it. It's one of our most primal needs as parents to be sure that our children are getting enough nutrition. And the ads for these products are really effective: they market themselves as the solution for the picky eater problem.
The problem is, they can make the picky eater problem worse.
Think about it. What would you rather have: a plate of chicken, whole grain pasta and broccoli, or a chocolate milkshake? Because that's what these things taste like: milkshakes. They are thick and really sweet. And if not eating dinner meant you'd get one of those yummy drinks, well, there's an incentive to refuse dinner if ever there was one. The drinks are very filling, too (and full of calories)--so once you've had one, you really don't feel like eating.
Now, I definitely have patients who need these drinks to improve or maintain their weight, often because of medical problems. But those patients are relatively rare.
So, please--before you throw that pack of chocolate nutritional supplement drinks into your grocery cart, give your doctor a call. Talk about why you are thinking of doing it--and talk together about whether it's the best idea.
There may be other, healthier ideas.
Your child has an earache. You are worried it is an ear infection. You call the doctor and make an appointment. After all, he needs antibiotics, right?
We have a real problem of antibiotic overuse in our country--and because we are overusing our antibiotics, many bacteria are getting smarter and stronger. Because ear infections is the diagnosis that kids in the United States are most commonly prescribed antibiotics for, the American Academy of Pediatrics (AAP) tried in 2004 to encourage doctors to rethink their prescribing habits.
The thing is, it turns out that ear infections don't necessarily need antibiotics. Many are caused by viruses. Many will get better by themselves.And not only does overuse of antibiotics cause resistance, antibiotics can have side effects. The guidelines were supposed to help doctors make better decisions--the problem is, many doctors don't follow them. So the AAP is trying again; they have reissued guidelines, with some clarifications and additions.
Here is what your doctor is supposed to do when you bring your child in with that earache:
Check to see if it's really an infection. Not only can the common cold or tooth problems cause earaches, you can also get pain from having fluid in the middle ear, something called Otitis Media with Effusion (OME). OME can look like an infection, but it's not--so it doesn't need antibiotics. Your doctor is supposed to look for the signs of a true infection: ear pain that comes on suddenly and persists, and an eardrum that is full or bulging with pus behind it, one that doesn't move when you blow air into it--or an eardrum that is draining pus.
Ask about and treat pain. This sounds obvious, but sometimes we doctors get so caught up in the diagnosing and antibiotic stuff that we forget to really talk about pain--and it's pain that brings parents in the first place. Whether or not there is an infection that needs antibiotics, there is an earache that needs soothing--so your doctor should be talking to you about how you can help your child's pain.
If there really is an infection, figure out if it's severe. Again, sounds obvious--but it's important for deciding if antibiotics are needed. A severe infection is one where there is a lot of pain, the child seems ill, or there is a fever of 39 degrees Celsius (102.2 degrees Fahrenheit) or higher.
Decide if antibiotics are necessary. Here is who should definitely get antibiotics:
- Anybody with a severe infection
- Anybody with other health problems that put them at risk of complications
- Children under 6 months old
- Children 6-23 months who have infections in both ears
If antibiotics aren't definitely needed, talk with parents about waiting and watching for 48-72 hours. I do this a lot. I give parents a prescription, but I tell them not to fill it unless the child either gets worse or doesn't get better in 2-3 days. In my experience, most don't need to fill the prescription. Pain medication and some patience very often do the trick.
To make this work, parents need to understand exactly what they are looking for, need to be able to get the prescription if needed, need to be able to reach the doctor easily if they have any questions--and the doctor needs to be able to reach them easily to check on the child. These are not gimmes in life sometimes--sometimes, to be on the safe side, we need to just go ahead and give antibiotics. But when we can wait, we should wait.
If an antibiotic is prescribed, it should be Amoxicillin. To fight antibiotic resistance, it's important to use just the right antibiotic--the one that will kill only the bacteria likely to cause the infection. For ear infections, that's Amoxicillin, unless the child's allergic, just had Amoxicillin in the past month (which might mean Amoxicillin isn't strong enough), has conjunctivitis too (which can be a sign of bacteria that Amoxicillin doesn't kill), or doesn't get better in 48-72 hours. The guidelines tell doctors what to do in those situations.
There are a few more things in the guidelines, such as discouraging prescribing antibiotics for prevention of infections in kids who get them a lot, and advice as to when it's a good idea to send kids to get ear tubes. To prevent ear infections from happening in the first place, the AAP suggests immunizing kids against pneumococcus and influenza, encouraging breastfeeding for the first six months of life, and keeping kids away from tobacco smoke.
So...the next time your child has an earache, check to see if your doctor does these things--if not, ask why. And--this is just as important--if your doctor suggests waiting instead of giving antibiotics, don't freak out. It may really be the better choice.
To read more about the right way to treat ear infections, check out the article I wrote for Parents magazine on this topic.
We've all been hearing about the cool app Snapchat, which allows people to send pictures and videos that only last a few seconds before disappearing. Because of the disappearing thing, the worry that I keep reading about is that teens will use it for sexting, figuring that it's no problem if they take sexy pictures or videos, because they won't last.
Now I worry about sexting as much as anybody else (although a 2011 study suggests that not that many teenagers actually do it). Sexting can glamorize and normalize sex in a way that might cause some teenagers to start having sex earlier, or in unhealthy ways. And legally, sexting can possibly be considered sexual harassment--or worse, distributing pornography.
But that's not my biggest worry about Snapchat.
Here's the thing: the pictures and videos don't necessarily disappear. The way the app is set up, someone can take a screen shot. While theoretically the sender should be notified if a screen shot gets taken, it only took me a couple of minutes on Google to find hacks that would allow me to take screen shots or save video without the sender knowing.
I worry about Snapchat because it creates the illusion that something can disappear from social media--and that is really dangerous. The biggest two lessons that youth need to learn--actually, that everybody needs to learn--about social media are: 1. Nothing is private and 2. Anything you do on social media can last forever.
We keep hearing about people losing their chances at jobs or school admission because their prospective employers or admissions officers go online and check them out. They look at publicly available stuff--tweets, Facebook posts, etc--and they don't like what they find. We are all doing it, actually: making judgments about people based on what they post.
The other day, my 15-year-old daughter got mad that I looked at her blog. She saw it as an invasion of her privacy. Um...sweetie? The entire world can look at it. But I'm asking you not to, she said. It doesn't work that way, hon. You don't pick who looks at what you put online.
We just don't think about this stuff as we are posting and tweeting and sending photos and texts. A couple of days ago my 20-year-old son took a screen shot of a text conversation we'd had and posted it on Facebook. I didn't really mind, but it was definitely one of those note-to-self moments. Anything we email or post or text or send can go anywhere. Literally.
This is a really important, and yet really hard, lesson to learn. And apps like Snapchat make it harder by making it seem like it's possible that social media could actually be ephemeral or private.
I love social media, and think that it has tremendous potential to help us in so many ways. But it isn't ephemeral or private. At all. The sooner everyone learns and lives that, the better.
Recently I've been wondering if pediatricians are out of touch when it comes to media and kids.
Our messaging is pretty straightforward: turn it off. The recommendation of the American Academy of Pediatrics is that children under the age of 2 should not watch TV at all, and everyone else should watch no more than 2 hours a day. And when we talk about TV, we are really talking about "screens" in general, including video games and media on the Internet.
We have good reasons for our messaging. Kids who watch a lot of media are more likely to be overweight. Violent programming and games can lead to aggressive behavior, and watching media involving sex can make kids more likely to start having sex earlier. Watching fast-paced cartoons like Sponge Bob Squarepants can cause behavioral and learning problems in preschoolers--and lots of television and video games are linked to behavioral problems in older kids, too.
The problem is that people aren't listening to our messaging. And not only is it a real conversation-stopper (especially when parents aren't following our advice), we are missing an opportunity to help kids and families when it's our only message.
The reality is that screens are increasingly part of life. TV is part of life--for most kids, it's either on in front of them or in the background for many more hours than we recommend. Video games are part of life, too--and I find that lots of parents don't even think about them as screen time. The Internet has made media always available and integrated into our days in ways we sometimes don't even realize.
So...as I wrote in a commentary in the journal Pediatrics, maybe it's time we changed to a "if you can't beat 'em, join 'em" way of looking at things.
I wrote the commentary about a really interesting study by Dr. Dmitri Christakis from Seattle. In it, his team of researchers worked with parents of preschoolers. Instead of talking to them about how much TV and other media their kids watched, they educated them about the kind of media they should and shouldn't watch. They encouraged shows that modeled good behavior, like Dora the Explorer and Sesame Street.
You know what happened? Not only did the kids watch more shows that were appropriate for them, their social behavior improved. As Christakis wrote in the study, "Although television is frequently implicated as a cause of many problems in children, our research indicates that it may also be part of the solution."
Now I'm not saying that we should entirely ditch the "turn it off" message. I want kids playing, exercising, reading, drawing, using their imagination and doing all those other things that they don't do when they are sitting in front of a screen. I'm still going to talk about turning it off.
But these days I'm talking more about what kids are watching. I think lots of parents not only don't understand how different kinds of media content affect their kids, but are also really open to ideas about what kinds of media are better for their kids--and might even help them.
I am sending more families to Common Sense Media, a fantastic website that has reviews of all different kinds of media, from movies to TV shows to apps (and books and music, too!). It helps parents make the best choices, in a very non-judgmental way. It also has information on teaching children how to navigate the world of media and be good digital citizens. This is something we really need to be teaching our children--and because it's not something we needed to learn as children, it may not occur to parents to teach it. The Center on Media and Child Health at Boston Children's Hospital has lots of great information too.
I also think that pediatricians, teachers, parents and all those who work with and care about children need to do a better job of helping create good content for children to watch. I think we need to be building partnerships with the media. We aren't going to get rid of all the sex and violence, because sex and violence sell. But we could work with media to give them information and messages that they can include in their scripts, give them ideas for movies and characters and plots of TV shows...instead of complaining, we could try to make things better. As one of my favorite sayings goes: if you're not part of the solution, you are part of the problem.
Let's all be part of the solution when it comes to media and our kids.
Recently I've been doing a lot of talking about fluoride. We give toothbrushes and toothpaste out in our practice, and it seems like all the parents of babies and toddlers are really surprised when I hand them toothpaste with fluoride in it.
"But we're not supposed to use fluoride toothpaste now," they say. Some of them hand it back to me, nicely pointing out that I goofed up.
Actually, you can use it--and you probably should.
As soon as babies get teeth, you should start brushing them, using a toothbrush designed for their age (brushes come labeled with age recommendations). As for what to put on that brush...
Kids older than 2 definitely should use fluoride toothpaste (although from ages 2-5, a pea-sized amount is fine). Any child under the age of two who might be at higher risk for cavities (because they carry a juice cup around, for example, or because cavities run in the family) should use it too--but just a smear across the bristles.
But honestly, there really isn't a significant downside to using fluoride toothpaste, as long as you are careful to just use that smear across the bristles. That's why the dentists at Boston Children's, where I work, recommend that all parents use it as soon as their kids get teeth.
The worry with fluoride is something called fluorosis--if you get too much fluoride (like by eating the yummy kids' toothpaste, which little kids are likely to do) you might end up with defects in the enamel of the teeth. But the vast majority of cases of fluorosis are really mild--just little white specks that are really hard to see--and can be avoided if, like I said, parents are careful to only use that smear.
That smear, which kids usually do end up swallowing, is probably all the fluoride kids need, according to the chief of the dental department at Boston Children's, Dr. Man Wei Ng. So while supplementation with fluoride is still recommended if your local water supply doesn't have fluoride (or if you are giving your child only bottled water, which a lot of parents do even though it's not necessary), you may be just fine with fluoride toothpaste. Check with your doctor to be sure. To get the most out of the toothpaste, Dr. Ng recommends not rinsing after brushing.
Here are some other tips to keep your child's teeth healthy:
- Have a dental home! Your children should see a dentist every 6 months starting at a year of age (or sooner, if teeth come early).
- Brush twice a day (with fluoride toothpaste). Even if your child likes to do it alone, do it with him (or after him) until he's really able to do it well himself, which is probably somewhere around first grade.
- Floss between teeth that are in contact. Start when kids are young, to get in the habit.
- Candy isn't great for teeth--but what's really bad for teeth is frequent candy, or any frequent snack--especially gummies and fruit roll-ups that get stuck in and around teeth. Because that's what causes cavities: when the sugars and starches hang out in the mouth and are broken down by bacteria into acid. Limit snacks and sugary things, and brush afterward.
- For the same reason, juice (especially sugar-sweetened, but any kind, really) is bad news for teeth, especially when carried around in a sippy cup all day (diluting it may cut the calories, but it doesn't help with preventing cavities). Drink water and plain milk instead.
- Don't let your baby or toddler sleep with a bottle.
- Consider xylitol-containing candies and chewing gum--they may help.
When you're pregnant, what you want to think about is choosing a name and planning the baby's room. You don't want to think about the possibility that something could be wrong with your baby--especially with your baby's heart.
Luckily, most babies are born with healthy hearts--but heart defects are the most common type of birth defects. And with some heart defects, knowing ahead of time can make all the difference.
It can make all the difference for a baby's health. With some of the more serious defects, babies need special treatment and medications, and even surgery, shortly after birth. When parents know that their child has one of these defects, they can talk with their doctor about the best hospital to deliver the baby, and a team can be ready to take care of the baby as soon as she is born.
It can also make all the difference when it comes to preparation. Whether it's meeting doctors, learning about the condition and about surgery, touring a hospital or making child care plans for other children, knowing ahead of time allows parents to do all the things they might need or want to do to get ready.
The American College of Obstetricians and Gynecologists recommends that all pregnant women get an ultrasound at 18-20 weeks to check the baby out from head to toe, and parents should be sure they get one--but even with this ultrasound, heart defects can be missed. There's a lot to look at, and some facilities and technicians are more skilled and experienced than others. That's why Dr. Tworetzky at Boston Children's Hospital developed this list of questions parents should ask during their ultrasound:
Do you see four chambers in the baby's heart?
Are there two upper chambers (left and right atria), each with a valve controlling blood flow out of them?
Are there two lower chambers (left and right ventricles), each with a valve controlling blood flow out of them?
Do the two vessels leaving the heart (aorta and pulmonary artery) cross each other as they exit?
Is the wall between the two lower chambers intact, without any holes?
Is everything else in the baby's heart normal?
If the answer to any of the questions is no, you should see a specialist like the ones at Boston Children's Advanced Fetal Care Center, to find out more and see if your baby will need any special treatment.
This is not meant to freak you out, although I understand that it might. It's true that some people might prefer not to know about these things ahead of time, because of the anxiety and upset it would bring. Ignorance can be bliss--but for some babies it can be dangerous. Talk with your doctor about what is best for you, your pregnancy, and your baby.
Here's a video to check out--and you can also download a pdf of the questions.
In the wake of the Newtown shootings, as a country we are all taking a step back, looking at our laws and our policies and thinking about what we can do to prevent unspeakable tragedies like the deaths of those children from happening again.
I am not a gun owner and never will be, but I am not advocating getting rid of all the guns. I totally get that there are responsible gun owners out there, people who use them for hunting and sport, keep their guns safely stored, and would never think of using them (or allowing them to be used) to hurt anyone (or at least anyone who wasn't in the act of attacking them). Those are the people I'd really like to help me understand a few things.
First of all, can you help me understand the problem with universal background checks? In his senate testimony, Wayne LaPierre of the NRA said that they will never be universal because criminals will never submit to them. That's true, of course. But I can't understand how one gets from there to saying that it's okay that 40 percent of gun sales happen without background checks. I know that bureaucracy is a hassle and background checks can miss things. But I don't get why saving some lives isn't worth a hassle--and why we shouldn't make at least the basic attempt to stop people with mental health problems or a criminal background from buying guns. Am I missing something?
Second: assault weapons. I need help with this one too. I need someone to explain to me why people feel so strongly about having them. The fact that they are flying off shelves is disturbing to me. I get that they are cool, that it could be exciting to own something so powerful. But they are guns designed for maximum carnage. They are meant for military use, not civilian use. I understand that the data suggests that the assault weapon ban didn't lower crime--but these are the guns that killed all those children in Newtown, that killed the people in Aurora....in the wrong hands, they can cause not just murder but devastation. There needs to be a really good reason to keep them available--can someone please tell me what that reason is?
Third: what's up with the marketing to children? I was so upset to read the article in the New York Times about the various efforts of the gun industry to recruit and engage children--even young children, younger than 12. It was absolutely chilling to read about marketing military-style rifles for "junior shooters" (who can't buy them legally, but whatever), the semiautomatic hand gun competitions for youth, and the other ways that gun manufacturers and gun organizations are targeting children. I understand that parents might want to pass on a hobby or tradition--that is their choice. But marketing, by definition, isn't about teaching values and safety--it's about selling things. Can someone explain to me why it's okay to market something to children that they can't buy legally and don't have the maturity to use responsibly, something that could literally kill them or someone else?
Watching Gabby Giffords struggle to speak at the hearings was heartbreaking. A gun did that to her. We have to do something, she said haltingly. It will be hard. I think she's right--I think it will be incredibly hard.
But we have to do something. Background checks, banning assault rifles, and looking honestly and critically at gun marketing seem like good places to start. If I'm wrong, can you please explain to me why?
I really missed my father yesterday.
It was his birthday, the eighth I've spent without him since his unexpected death. I keep thinking that it's going to get better, that the grief will dull and I will get used to living without him. But it's been harder than I expected. It hasn't gotten better.
It's just that there are so many things I need and want him for. A historian and writer, he was the parent who was around all the time when my sister and I were growing up. He was the one who brushed our hair, packed our lunches, picked us up from practice, showed up at school functions, listened to our drama and dried our tears. He was our cheerleader and sounding board, our companion, the one who made everything okay.
So I was cranky yesterday. I was cranky when I came home from work to take the kids to a learning event at church and 12-year-old Natasha said she had a stomachache. She didn't have a fever, the pain was really vague and her belly was soft. Fine, you don't have to go, I said. You can stay home with Elsa (who had a big test and was staying home to study). But you have to shower and go to bed. No TV. I don't want to do that, said Natasha, who is prone to exaggeration and occasional fibs. Which of course made me crankier.
There have been so many things I've wanted my dad's help with over the past 8 years. He used to do admissions work for his beloved alma mater and I always expected he'd be there to help me when it came time to go through the college application process with my kids--and yet I had to do it for Michaela and Zack without him. In these past eight years I've been doing so much writing--and he was my go-to person when it came to writing, my best critic and advisor. And all the time, all the time, there are things I want to tell him or ask him about. I know he didn't mean to abandon me, I know it's silly and unreasonable to feel that way, but it's how I've felt.
Liam and I went to church--but not long after we got there, Natasha was texting me. I have diarrhea. I feel sick. And then: Can u come home please? So Liam and I left and came home. She still didn't have a fever and didn't seem all that sick; my mood didn't exactly improve. I need to go to bed now, she said, climbing into the top bunk with her clothes on. Can you stay upstairs with me?
So I got Liam into his pajamas and we read books in my bed. I was not just cranky but close to tears, so full of missing Daddy, so sorry for myself. And then it came, that noise that all parents know and dread: the vomit noise.
I don't know what I was thinking, letting her get into the top bunk of a T-shaped bunk bed. She had vomited over the edge, onto Liam's bed, onto the floor, everywhere. I mean everywhere, and tons of it.
I wiped up the ladder and floor so that she could get down and out, made a place for her to lay down in Elsa's room, and started the cleanup. And somewhere in the midst of gathering up vomit-covered bedding and scooping up particulate matter with towels and finding clean blankets for Natasha and tucking her in, I got hit with a memory.
My father was the one who was with us when we got sick. He was the one who held back our hair when we threw up, wiped our mouths, and cleaned it up. He was so patient and sweet as he did; I don't ever remember him complaining. All I remember is that when he was there, I felt better. It wasn't until years later that I realized just how squeamish he was; he had the worst time with vomit and diarrhea and blood. But he never let on. Because when you love someone you do what you need to do to take care of them.
And in that moment, I realized that so much of what I do well as a parent I learned from him. He's not here anymore, and I will never get over that. But he gave me so much, and taught me so much, that I use every single day. I am a better and happier person because I had him as long as I did.
Instead of feeling sorry for myself, I felt grateful.
Happy Birthday, Daddy. Thank you. So much.
The other day I was seeing a 1-month-old. "He likes to suck his thumb," said his mother. "What can I do to stop it? I don't want him to get into the habit."
While most of the time when I hear that question the child is older, this is one of the most common--and tough--questions I hear. So when a reader asked if I could write about it, I thought it was a great idea.
While some parents worry about their child being teased for thumbsucking, parents mostly worry about what it will do to their teeth. So to make sure I was giving the best and most correct advice possible, I asked Dr. Man Wai Ng, the chief of the Department of Dentistry at Boston Children's Hospital, to help me out.
"Most children stop the habit on their own by age 4 years," says Dr. Ng. Which is good, because if kids stop by 3 or 4, it usually doesn't cause any problems with their teeth. So before then, it's fine not to bug your kid about it (and bugging is unlikely to do much anyway at that age).
Between 4 and 6 years, it's time to take action. Don't nag or punish, Dr. Ng says, because it may create more tension and make things worse. She suggests being positive instead, rewarding kids for not doing it. Catch them being good--when you notice they aren't sucking their thumb at a time they usually do, give lots of kudos--stickers and other little prizes go over well too. Set simple goals, like: if you don't suck your thumb for the next hour, we'll have an extra story before bed.
You can also try mittens or bandages, which make it harder and less comfortable to suck the thumb (this is particularly useful for those kids who suck while they sleep). Bitter-tasting stuff painted on the thumb can help too (Dr. Ng has had good luck with the brand Mavala Stop) although many of my patients either figure out how to wash it off--or just get used to it and keep sucking.
If your child is older than 6 and still sucking his thumb despite your best efforts, talk to your dentist; there are appliances that might help. And talk to your doctor--working as a team, there's always a solution.
Are you pregnant? Then you need a TdaP vaccine.
That's the biggest news in the immunizations changes just released by the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC). Every year around this time they update the schedule; while there are a few minor changes in some immunizations, and they've made the schedule easier to read and use (which I'm very grateful for!), the most important change is that they are recommending that pregnant women get a TdaP vaccine during pregnancy.
Why? To protect babies against pertussis, or whooping cough. They are the ones who are most likely to get very sick and die, both because of their age and because they are too young for the vaccine (we don't give the first dose until 2 months, and it takes more than one dose for protection).
Pertussis is on the rise. According to the CDC, preliminary reports from their surveillance systems show that more than 41,000 cases of pertussis were reported in 2012, up from 18,719 in 2011. There were 18 deaths, the majority of which were in infants less than three months old.
Some of these outbreaks have happened in communities where children don't have all their vaccines, like in Washington State where the rate of vaccine refusal is high. But some are happening because, quite simply, the protection of the vaccine has worn off, allowing the illness to spread throughout communities.
We give a booster dose in middle school, but it's becoming clear that sometimes the immunity wears off before that (after infants,we see the most pertussis in 7 to 10-year-olds). It's also clear that the middle school dose doesn't last forever either--so lots of adults aren't protected from the illness.
By immunizing during pregnancy (which is safe), we protect the primary caretaker of the baby--and since some of the mother's immunity can pass to the baby during pregnancy, we give the baby a head start too.
But although the recommendations are only for pregnant women (and pregnant adolescents), to really keep infants safe we need to surround them with immunized people. So I've been talking to families about being sure that fathers, grandparents, babysitters and daycare providers are all immunized.
My friend Dr. Wendy Sue Swanson, who lives in Washington State, blogged about this last April during an outbreak there. She included an email that parents can send to families and friends explaining that if they want to visit with their newborn, they need a pertussis shot (and a flu shot). She says that parents need to be Mama-Papa-Bear about it. "It only seems over-the-top-nuts," she writes, "until we lose another baby to pertussis."
It's hard to argue with that. Protect your baby and all the babies around you. Get a TdaP vaccine.