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Heather Joyce, MD
Rachel Brewer, MD

Ped For Parents

Breastfeeding - Is it Safe to Exercise?

So ... you've decided to breastfeed.  You also want to get back in shape following your baby.  While breastfeeding is a huge topic of conversation, there's not as much talk about breastfeeding and exercise.   Here's a few questions you may be asking ...

Will baby refuse the breast after exercise?  You may have heard that babies don't accept breast milk as readily after mom has exercised because of a buildup of lactic acid.  However, most studies have found no difference in acceptance of the breast, even after maximum intensity exercise.  Research has also not shown a noticeable increase in lactic acid buildup after moderate exercise.  Even with maximum intensity exercise where there is a minimal increase in lactic acid in breast milk, there are no harmful effects for the baby.  While there may be a change in taste of breast milk from lactic acid, babies will not subsequently refuse to breastfeed because of it.  More plausible reasons for why your baby may refuse to breastfeed after you exercise are issues such as the salty taste of sweat on your breast post-workout.


Is the composition of antibodies of breast milk affected by exercise?  Exhaustive exercise does cause IgA levels (a type of antibody) to decrease for a short amount of time.  However, these levels return to normal within an hour - a decrease in IgA levels in one feeding per day is not likely to be significant.  Moreover, moderate exercise does not affect antibody levels.


Is your milk supply affected?  In short, no.  In fact, some studies have shown that women who exercise regularly had a slight increase in milk supply.  However, if you exercise to the point of exhaustion, or train for an event such as an Ironman, your body may be depleted to the point where producing milk is its last priority.  Bottom line - moderate, regular exercise should not affect your milk supply.


What types of exercise are best?  There really is no "best" type of exercise for breastfeeding moms.  It's really more about what you enjoy and what makes you feel good.  Because breastfeeding moms are a bit more top heavy, things like running may be more uncomfortable, but it can still be done with the right type of support/attire.

What attire provides the most support for breastfeeding moms?  The key to being comfortable while exercising is finding a good supportive bra that fits you.  I would suggest getting measured at a sports specialty store for women (e.g. Athleta, Title Nine, etc) so that you know exactly what you need.  It really does make a huge difference.  You can avoid the two sports bra routine if you find the right bra that fits you :)


Other tips ...  Definitely try to breastfeed right before a session of exercise.  Clearly, this is more comfortable, especially for weight bearing activity like running.  You may develop plugged ducts if you  lift weights involving repetitive upper arm strengthening (if that happens, start with lower weight/reps).  And make sure you drink and stay well hydrated!!

Rachel Brewer, MD

Breastfeeding - The Initiation

I have been asked by several friends and patients to write a blog about breastfeeding. Turns out, I can go on  FOREVER about this subject, so I am going to break it up into topics, starting with the initiation of breastfeeding. My experience comes not only from working with mothers and newborns in the NICU, nursery, hospital and clinic, but also from having spent two years of my life breastfeeding/pumping. During pregnancy, you will develop your own opinion about breastfeeding, every person has a different goal in mind, from formula feeding only, to extended exclusive breastfeeding. Research has shown that most mothers in America set a goal of breastfeeding for at least 3 months, though less than 30% reach that goal. If you decide that breastfeeding is best for you and your infant, I would like to provide my support by answering questions and sharing information to help you be successful in reaching your goal.


Once you have made the decision to breastfeed, you will hear differing advice from EVERYONE - your relatives, friends, co-workers, doctors and lactation consultants. You will hear about how natural, beautiful, and rewarding breastfeeding is, but few people will admit how difficult, painful, and anxiety provoking it can be. During my course of breastfeeding, I have felt all of these emotions and more. In the end, listen to all the advice offered and use only what works for you. Not every breastfed infant is fed the same way, some breastfeed exclusively, some take pumped milk from a bottle, and others take a combination of breastmilk and formula. Infants benefit from any amount of breastmilk, however, it is best if they get at least half of their milk as breastmilk. In the end, the most import part of breastfeeding is the health of your infant, so if there are medical complications, like prematurity, poor weight gain, or jaundice, your infant my need to supplement with formula or pumped milk for a short period of time. 


The best time to start breastfeeding is within the first hour after delivery. After an uncomplicated vaginal delivery, most infants are awake and alert for about an hour and will latch and start to suck right away. Not all infants are able to go to the breast immediately and it is OK to wait until you and your infant are ready. Some have problems with blood sugar after birth and need a small amount of formula or sugar water to keep them safe - this is common practice in most hospitals. These infants will not have the energy to breastfeed if they do not get their blood sugar into the normal range. If your infant requires supplementation in the hospital, I recommend pumping every time this occurs, even if you don't produce any milk - this will let your body know that your infant needs more milk and will help your supply.

During the first days of breastfeeding, most mothers produce a small amount (5-10 ml) of colostrum with each feed. You will feel tugging and pulling, but should not feel severe pain. If you do, then your infant's latch may need to be adjusted. Take advantage of the nurses, doctors and lactation consultants in the hospital - they will have lots of advice and can provide hands-on help. You will also feel uterine cramping with each feed, this the due to hormonal contraction of the uterus - it hurts, but is good for your body. The more often your baby breastfeeds, the more milk you will produce, the more contacted your uterus will become, and the more experienced you and your infant will be prior to going home.

You will not "know" how much milk your infant is getting, but if they are waking to feed every 1-3 hours, having wet diapers and clearing their meconium, they are getting enough. All infants loose weight after delivery, but should start gaining it back after 5-7 days. Your infant should see the pediatrician for a jaundice and weight check within 3 days after discharge from the hospital.

Breastfeeding for the first time will be uncomforable and sometimes stressful for the fist couple of weeks, but it gets easier. If if continues to hurt or your infant is not getting enough milk to gain weight, then find support. Most hospitals, doctors offices, and specialty baby stores have lactation consultants available. You can also talk with an experienced breastfeeding mother, who may have some great tips for you. Just remember, for every person who tells you that breastfeeding was the easiest, most natural part of motherhood...there are 10 others who will give you a different story.

Next up...the first days home and pumping (aka The Milk Machine).

Heather Joyce, MD

It is Safe to Play Outside in this Heat?

We all know about the scorching temperatures across the country. Even here in Denver where it's relatively mild until August, we've already been dealing with 100 degree heat!

Every year there are heat-related deaths on the sports field.  This happens particularly in August when the heat is at its worst and fall related sports are getting into full swing.  How does this keep happening you ask?  Well ... state high school sports associations have been slow to adopt rules to make practices safe in extreme heat (although things are dramatically better than they used to be).  And of course, kids sports prior to high school age are often not legislated at all in terms of rules regarding practicing/playing in the heat.

So when does it become unsafe to practice outside?  And what precautions should be taken? Generally, when the heat index (which takes into account relative humidity) climbs above 100, practicing and playing outside assumes a much larger risk of dehydration, heat illness, and heat stroke.  When the heat index is 90-100, ample water should be provided, and athletes should have unrestricted access to it (for example, there shouldn't only be one water break per practice).  And the heat index should be re-checked one or more times during a practice or game if the heat index is approaching 100.

If the heat index is 100-104, you should begin to think about canceling outdoor activities.  Water breaks should be mandatory every 30 minutes, and toweling down with ice cold towels should be encouraged.  And when the heat index is 105 or above, play or practice should be stopped and moved inside.  Two-a-day practices (common practice in fall sports like football) should be reconsidered when the heat becomes an issue, and certainly, practicing when it is cooler earlier in the morning is a smart idea.

What are the consequences or the heat and how do athletes get in trouble?  Severity of heat related medical problems ranges from dehydration, to muscle cramps, to heat exhaustion, to heat stroke.  With each step, an athlete gets progressively sicker and important attention needs to be paid to an athlete progressing towards heat stroke.  The biggest indicator that an athlete is headed toward trouble is if he or she starts acting abnormal (aka altered mental status). They may become combative, aggressive, and clearly not act like themselves.  If medical personnel are available at that point, the athletes temperature should be taken and they should be immediate immersed in an ice bath if possible.  And call 911!

The heat shouldn't be ignored when your child is playing a sport outside. As a parent, you definitely have a role if you think limits are being pushed in play or practice!

Rachel Brewer, MD

Poison Ivy

A huge part of summertime fun is playing outside. Naturally curious, most children love to explore overgrown areas of the yard or park. Unfortunately, poison ivy thrives in these areas. The rash that develops after exposure to poison ivy is a contact dermatitis to the chemical urushiol and can usually be treated symptomatically with home remedies.

Prior to summertime excursions, look at pictures of poison ivy and teach children to avoid it. Tell your children to count the leaves on plants and look for the "three, almond shaped, sharp-teeth leaves" that are classic for poison ivy. Dress your child in protective clothing - long pants, shirts, and shoes with socks for outdoor adventures.

If  your child comes into contact with the plant and you notice prior to the rash appearing, wash the area well with soap and water. Remove the clothing that your child was wearing and wash it in hot water.

If the urushiol absorbs into the skin, a red, itchy, blistering rash may appear. It usually appears in straight lines because of the way the plant comes into contact with the skin, but may be diffuse and appear spreading. The rash does not spread with itching or breaking the blisters, but if your child's skin comes into contact with urushiol again (from clothes/pets/repeat exposure), it will continue to spread. Urushiol will continue to occupy any surface if it is not washed off, including dead poison ivy plants.

Home remedies to try if your child develops a rash:
1) Cool oatmeal baths
2) Calamine lotion
3) Vaseline
4) Cool compresses

If itching is severe and keeping your child from sleeping you may try diphenhydramine (Benadryl) or 1% hydrocortisone cream to the red areas.

The rash typically lasts 1-2 weeks, but may last as long as 8 weeks, depending on how your child's skin absorbs the urushiol and reacts to it.            
                                                                                                       
The rash may become infected with bacteria if you child is itching it, so seek medical care if they develop fever, yellow or white drainage, yellow crusting, severe swelling or warmth to the area. Also, your child may require strong antihistamines or oral steroids if the rash spreads to the face, mouth, eyes, genitals or involves the entire body.

Heather Joyce, MD

Bike Safety

Did you know that more children are seen in emergency departments for injuries related to biking than any other sport?  On average, over 500 kids a day are injured due to cycling related crashes!  Bike safety is something the whole family needs to learn about to avoid potentially serious injuries.

This first and cardinal rule of bike safety is obvious.  Every time you and your child ride a bike, wear a helmet.  It's that simple.  Younger kids are more apt to make this a habit, while older kids tend to steer away from helmets because of the "cool factor."  But don't let this rule slide ... it is clearly shown to save lives.

Helmet fit is crucial.  A helmet should sit on top of the head in a level position, and shouldn't be loose enough to rock side to side or forward and backward.  It must always be buckled, but not to the point where your child can't breath or feels like her or she is going to choke.  Don't forget - helmets aren't just for biking.  It is just as effective for preventing injuries in activities like riding a scooter, roller blading, skateboarding, and riding an ATV.

I like the "eyes, ears, and mouth test."  This is a good test for helmet fit:

Eyes:  Look up and you should see the bottom rim of the helmet.  It should be 1-2 finger widths above the eyebrows.

Ears:  The straps of the helmet should form a "V" under your ears when buckled.  Remember, it should be snug and comfortable.

Mouth:  When you open your mouth as wee as you can, the helmet should hug your head.  If not, tighten the straps.

Click here for a video of a demonstration showing proper helmet fit.

Just like for adults, making sure the bike actually fits the child helps avoid injury.  When sitting on the seat, the child's feet should be able to touch the ground.  Of course, it's helpful if the gears, brakes, and bike components work properly.

Adult supervision and modeling bike safety will help your child learn to ride safely from an early age.  Riding as a family can be very fun and enjoyable - obey the rules of the road (ride on the right side of the road, use hand signals when applicable, and stop before entering an intersection, etc), and your child will understand how to ride a bike safely!

Rachel Brewer, MD

Hives

Hives are very common in children. The rash is itchy, red, raised welts that often move from one location to the next within minutes. If you are like most parents, your first thought is an allergic reaction and you rack your brain trying to figure out what your child may have eaten or touched. However, hives have many different causes, the most common in children being illness, either viral or bacteria. Allergen exposure is second on the list. Allergens may be food, medications, lotions, insect bites, soaps, detergents, fabric softener, clothing ...just to name a few. In many cases, it is difficult to figure out the exact cause.

Hives may last for hours to weeks, but most often 1-2 days. If they are due to an allergen exposure and the substance is taken away, the hives usually resolved within 24 hours with treatment. However, with illness, you may have to wait until the illness resolves for the hives to fully go away.

Most often, symptomatic treatment for hives is the best course of action. Antihistamines, like diphenhydramine  (Benadryl) are very effective at treating hives, however this medications may make your child drowsy or hyperactive. Your doctor may recommend a long acting antihistamine like loratadine (Claritin), fexofenadin (Allegra), certirizine (Zyrtec), or desloratadine (Clarinex) if the hives last longer than 2-3 days.

Home remedies to make your child more comfortable include placing your child in a cool bath (with or without oatmeal to sooth the skin) and dressing your child in light, airy clothing. Do your best to try and keep them from itching!

If your child develops swelling of the face, tongue, lips, or joints they need to be seen by a physician. If they develop difficulty swallowing or breathing, vomiting, abdominal pain, or pass out with hives - it is a medical emergency and can be a sign of a severe allergic reaction.

*Above is a picture of my son with hives due to a viral illness

Heather Joyce, MD

The Ins and Outs of Pacifier Use

The decision to use a pacifier is very personal. After one night of my newborn screaming in the hospital, I popped in a pacifier (Binky at my house) and never looked back. Both of my sons took a Binky without hesitation, but letting it go was not so easy - for both me and my children.

Sucking is a soothing reflex for all infants, whether they suck on breasts, nipples, fingers or pacifiers...they find a way. Pacifiers have been used for hundreds (but probably thousands) of years. They were originally made of bone or rock, but in the past one hundred years mostly rubber or silicone. Recently, studies have shown the pacifier use while sleeping decreases the risk of SIDS and while some professionals believe that pacifier use interrupts breastfeeding, recently studies have shown pacifiers can support breastfeeding. I also feel that pacifiers help keep infants from overfeeding, which can cause reflux, gassiness and discomfort.

If you want your infant to take a pacifier, but they seem reluctant. Here are few tricks:

1) Place the pacifier in your infant's mouth immediately after feeding. If breastfeeding, continue to hold the infant close to you as if you are feeding while offering the pacifier.
2) Gently rub the pacifier along the roof of your infant's mouth, until he or she starts sucking.
3) Try a couple of different brands.

Though some infants never take a pacifier, starting it is usually the easy part, breaking the habit can be much trickier. My advice is to go in with a plan to take it away (timing and method). You may not meet the goal, but at least you have one to work towards. Few infants or toddlers will walk up to you and hand it back. In my opinion, there are a couple of easy transition times that are good for taking it away.

• 1 year when you are making the bottle to sippy cup transition. Your child will cry for a few days, but will not try to manipulate or bargain for it. Also, you are already dealing with the loss of the bottle, so the pacifier may not be the bigger deal. 
• 18-24 months, if your infant still seems very attached to the pacifier and seems to need it to calm down, then wait until this time period. Much later and you will be pleading for your child to give it up. 

My method of choice for taking it away, is just that...cold turkey. Find them all and throw them away. There may be a couple of sleepless nights/naps, but most toddlers give up by 2-3 days and learn to sooth themselves in other ways. You may also want to offer a new transition object (stuffed animal, lovey, pillow pet) at this time. I have heard of several other methods that work, especially for older children, including:

• Cutting the tops of the nipple off and saying they are broken 
• Having the child throw them away and offer a "prize" in return
• The pacifier fairy (comes and takes them away during sleep, but leaves a "prize" in return)
• Using it only for sleep and gently weaning. However, you will still have to deal with the day that you don't give it at night. 

Pacifier use beyond the age of 2 or 3 can interfere with speech development and tooth positioning, so as hard as it may be, it is important to take it away at some point before this happens. My husband and I chose the age of 18 months with both boys and neither seemed to miss the Binky once it was out of site (and mind).

Heather Joyce, MD

Don't Forget the Sunscreen!

This blog post is brought to you by guest blogger Dr. Elizabeth Miller.  Dr. Miller received her medical degree from the University of Missouri-Columbia, and completed her residency in dermatology at the Medical College of Wisconsin in Milwaukee.  She now works in a multi-specialty group in Austin, Texas, and sees patients of all ages.

Summer is quickly approaching and now is a good time to think about how you can protect your child’s skin from sun damage. We know that the sun damage accumulated as a child and young adult is an important risk factor for several types of skin cancer like basal cell carcinoma, squamous cell carcinoma, and melanoma in their adult life.  It’s never too early to start teaching your child about sun safety!

Here are a few tips for sun safety:

*Seek shade, especially between the hours of 10am-4pm when the sun’s rays are the strongest

 *Look for a sunscreen with an SPF 30-50

 *Look for “broad spectrum” on sunscreen labels (equal UVB and UVA protection)

 *Reapply every 2 hours-even the best sunscreen wears off and loses its effectiveness over time

 *Use sunscreen even on cloudy days. Up to 80% of the sun’s UV rays are transmitted through clouds!

 *There is no such thing as a “waterproof” sunscreen-reapply after swimming or toweling off

*Wear “rash guards” or other long sleeved swim tops. Broad brimmed hats are also a great way to block the sun, especially on kids with light colored or fine hair. These are becoming easier and easier to find at local stores like Target, but you can also buy them online from companies such as Coolibar. Don’t forget the sunglasses and lip balm with SPF!

 *There are many good brands and types of sunscreen are available, find one that you and your children like best. Spray sunscreens are especially good for kids, but make sure you apply enough—the skin should look wet when you spray it on and then you need to rub it in to make sure you have even coverage. If using a spray sunscreen on your child’s face, spray it on to your hand first and then rub on to your child’s face, never spray directly on their face. Avoid inhaling the sunscreen.

A bit of technical information on the two different types of sunscreens available:

Chemical sunscreens

 * These absorb the sun’s rays in the top layer of skin, preventing damage to the underlying skin

 *Advantages: rubs in easily, most common type of sunscreen available, good sun protection

 *Disadvantages: some people with very sensitive skin develop skin irritation with this type of sunscreen

 *Read the label, the “active ingredients” will have one or more of these sunscreen chemical
   -Avobenzone
   -Oxybenzone-->rarely people can become allergic to this sunscreen ingredient and develop an itchy or painful rash (although this is not a dangerous rash)
   -Octisalate
   -Octocrylene
   -Oxtinoxate
   -Homosalate

Physical sunscreens

* These sit on top of the skin and reflect the sun’s rays

 *Advantages: good for people with very sensitive skin, good sun protection

 *Disadvantages: a little more opaque, harder to rub in

 *Physical blocker active ingredients
   -Titanium dioxide
   -Zinc oxide

The dangers of tanning bed use:

* Talk to your child about the dangers of tanning bed use. It is NEVER ok to use a tanning bed, even for special events or vacations

 *The World Health Organization (WHO) has classified tanning beds to be as carcinogenic (cancer causing) as cigarette smoking

 *There is a 75% increased risk of developing melanoma with tanning bed use
   -Even just 4 tanning bed sessions a year increases the risk of skin cancer by 11-15.  Melanoma is the second most common cancer in women between the ages of 20 and 35, and the leading cause of cancer death in women ages 25 to 30

      

      Elizabeth Miller, MD

  

Water Safety Tips

Summer is almost here!  Once Memorial Day hits, pools around the country will be filled with young children.  The number of children drowning skyrockets during the warmer months.  Since the beginning of the decade, an average of more than 800 children 14 years and younger have died as a result of unintentional drowning each year.  Also, during that time span an average of nearly 4000 children sustained near drowning-related injuries each year.  Follow these tips to keep your kids safe around water.

*In-ground public pools are not the only places that drownings tend to occur.  Pools that pose the greatest risk of entrapment are children's public wading pools, hot tubs, or other pools that have flat drain grates or a single main drain system.  Teach your kids never to play or swim near drains or suction outlets.  Install protection to prevent entrapment if you own a pool or hot tub.

*Actively supervise your kids around water at all time.  Even if it is just a small wading pool in your backyard.  Have your cell phone nearby to call for help in an emergency.

*If you own a pool, make sure it has a four-sided fence and a child-proof gate to prevent a child from wandering into the pool area unsupervised.  Hot tubs should be covered and locked at all times when not in use.

*A door alarm to a pool area comes in handy to alert you if a child does wander into a pool area unsupervised.

*Teach your children never to go near a pool or body of water without you or an adult present.

*Teach your children how to swim ... whether this is through swimming lessons or you showing them skills, it's important to teach kids how to tread water, float, and swim to shore or the edge of the pool if needed.

*Learn CPR.  If you learn it and are prepared, you'll likely never need it.  Don't find yourself unprepared in an emergency situation.

*If you are gearing up to head out to the lake or another body of open water, always have your child wear a life jacket approved by the US Coast Guard.  The life jacket should fit snugly and not allow the child's chin or ears to slip through the neck opening.

And here is a great resource of water safety and tips on preventing all types of injuries in kids.  Be safe this summer, have fun ... and enjoy the water!!

Rachel Brewer, MD

Tricks of the Trade: Giving Medications

I have two boys, one who asks for medication whenever he thinks he might need it, the other who spits it back at us like we are giving him poison. As a health care provider for children, giving medication and helping parents give medication to their children is a big part of my job. Some children need medication only intermittently for fever or pain, others daily for chronic illnesses or infections. It is important that parents find the best way to give medication to each of their children for the times when it is important. Thankfully, medications come in a variety of forms, including pills, capsules, chewables, powder, granules, and liquids. Unfortunately, not all children's liquids taste good (even after flavoring).

The most important step in giving medication to children is making sure you are giving the correct medication and dosage. Most children will be prescribed liquid, so your job is to measure the medication correctly and make sure your child swallows it. Infants and toddlers will usually take medication measured in a syringe (1 ml, 5 ml or 10 ml). However, they do make special nipples that hold medication, which some infants prefer. Older toddlers and children will drink medication from a measuring spoon or cup, they can also take chewable medication. Once your child is big enough to take a pill (5-7 years old for most children), you can start teaching them to swallow pills/capsules.

Tips for getting your child to take medication:
1) Give it slowly in their cheek
2) Offer a tasty bribe for after they take the medication or in between squirts - juice, popsicle, sucker
3) Get the pill form, crush it and put in apple sauce/pudding - this only works if it is not a long acting medication
4) Get the capsule form and open into apple sauce/pudding
5) Give a very small amount of medication in between screams/crying, most children will swallow it with their saliva
6) Get the rectal suppository form (acetaminophen) and place it gently into your child's bottom

Giving medication to your child is not always easy, so if you are having trouble, ask for advice from your doctor or nurse. They may be able to prescribe a different form of the medication or offer other ideas for getting your child to take the medication.

Heather Joyce, MD

A Potty Training Strategy

Potty training can be a very exciting or a very frustrating time for both parents and children. Making potty training stress-free is an exercise of patience for a parent, but does make the process easier in the long run. There are many options for potty training your child, but the real secret is consistency and perseverance. That being said, I do have a favorite method that stresses positive reinforcement with relatively quick results.

Step #1: Introduce the potty early (12-14 months). Let your curious toddler explore the bathroom, watch you or other siblings use the potty and get them a small potty to experiment with. Every time your toddler shows interest in the potty, give positive feedback with smiling, clapping, hugs/kisses (whatever makes you look silly and gets your child excited)!

Step #2: Start encouraging your toddler to sit on the potty without a diaper on. I do this before or after bath time, when they are already comfortable being naked. If they are resistant, then wait longer and try again. When they do sit on the potty or actually pee, increase the positive reaction to a full on party! Continue this step until they make the connection between the potty and peeing/pooping. Your child is physically ready to move on to Step #3 when they can go 2-3 hours with a dry diaper and they know (and can tell you) when their diaper is soiled.

Step #3: When you and your child are ready - meaning you have a few days at home, your child has made the pee/poop/potty connection, and is physically ready - you can start the real potty training process. Prepare to stay at home for 2-3 days and take away the diapers. You can keep your child naked or in "big boy/girl underwear" during the day. I suggest staying in a room with floors that are easy to clean during this time and only giving drinks with meals and snacks. Put your child on the potty every 1-2 hours and 10-20 minutes after eating or drinking. If they do go pee or poop on the potty, do the same as before and have a huge party or reward them with something they like, IMMEDIATELY. The first day, they will most likely have several "accidents". When they do, calmly clean it up and take them to the potty. You will notice less "accidents" as the days go on and on the 3rd-4th day, most people can attempt outings without diapers. They do make plastic covers for carseats, which I suggest investing in!

Most children are not ready for naptime/nighttime potty training when they start daytime potty training. It is normal for some children to have nighttime accidents until late childhood. Make sure to explain to your child that diapers and/or pull ups are only for sleeping and underwear is for the daytime. I do suggest putting a waterproof mattress cover on their bed at this time, because some are ready and willing to try nighttime training out. You will know they are ready when they wake up dry most mornings. Make sure not to sabotage their efforts by giving drinks before bed! 

If potty training is not going well and either you or your child is frustrated, buy another box of diapers and try again in 1-2 months. Do not pressure your child during this time and go back to positive reinforcement for exploring the potty. Make sure to save the real parties for the fantastic moments that they do go pee or poop on the potty!

Heather Joyce, MD

Sports Physicals

Its that time of year again.  It's time to fill in the checkmarks on those many questions and take your child to get a physical so that he or she can participate in sports the upcoming year.  You're thinking, "why do I have to schlep my kid to the doctor every year for this?"

There has been a lot of collaboration among sports medicine pediatricians over the last several years to make sports physicals worth your time and effort.  The questions we asked have changed and the focus on the physical has also changed so that we can save lives.  Sure, we can pick up and treat any joint pain or problems during a sports physical, but the true purpose of doing them year in and year out is so that sports related deaths can be avoided.

One of the most common causes of non-traumatic sports related deaths (vs traumatic deaths due to things like collisions) in youth sports is cardiac - meaning that there are a handful of congenital heart problems that can lead to sudden death while being physically active.  You hear about these every year on Sportscenter ... for example, it's the basketball player that suddenly collapses after shooting a lay-up.  It's scary stuff.

So, questions on your child's sports physical form are directly related to figuring out if he or she may have a cardiac problem.  We pay careful attention to any family history of heart-related death at a young age, or symptoms like dizziness, chest pain, or palpitations (funny heart rhythm) with exercise.  It's important that you don't run through the questions on the form marking "no," but to carefully review them with your child.

If we suspect that your child has a heart condition based on family history or symptoms experienced during exercise, he or she would then likely undergo a series of tests and consultation with a pediatric cardiologist to make sure that it is ok to participate in sports.

Sports physicals are also a great environment to talk about how to avoid another common cause of catastrophe on the sports field, which is heat related deaths.  And some of the questions on the sports physical form in your state may examine your child's vulnerability to heat illness asking about things such as prior issues with heat illness.  There has also been a lot of dialogue between sports physicians and state high school athletic associations about measures to avoid heat related death.  For example, during high school football season, there is a limit on two-a-day practices, and practice times may be limited depending on the ambient temperature.

Again, sports physicals are also a good time to review aches and pains that may be occurring during athletic activity, but make sure not to speed through the questionnaire and review it carefully with your child.  It could definitely save his or her life!

Rachel Brewer, MD

Hip Pain

Hip pain can be a tricky thing in kids.  Sometimes it's hard for them to actually point to their hip and say "this hurts," so they may point to their groin, thigh, or even knee, even though the problem arises from the hip.

One of the most common cause of hip pain in kids is synovitis (otherwise known as transient synovitis), which may come in combination with a viral illness and/or fever.  The pain comes from inflammation inside the hip joint.  This problem is not caused by a fall or trauma.  These kids are usually less than 10 years of age, and complain of hip pain, difficulty walking, and they also tend to walk with a limp.  The condition is self-limiting, meaning that it goes away on it's own.

Even though synovitis is self-limiting, it is necessary for kids with this problem to be evaluated to make sure that they don't have more serious hip problems that can be detrimental long term.  This means that they need an x-ray of their hip and pelvis.  Again, x-rays in kids with synovitis are normal, but they help make sure that other treatment is not needed.  Treatment is non-weightbearing (rest) and medicines like tylenol or ibuprofen until the pain resolves.

Some hip problems in kids affect their bones and may need surgery.  In older kids (around adolescence), the growth plate in the ball of the hips joint can actually slip and cause long term damage if surgery is not done immediately.  This problem is called slipped femoral capital epiphysis (or SCFE).   In young children (usually before school age) there is a condition called Perthes disease where blood flow to the hip is compromised and the ball of the hip joint is affected.

Hip pain can of course also occur with falls or trauma.  But sometimes kids aren't the best historians and you may not witness the fall, so it could be difficult to determine if a fall or injury is causing their pain or limp.

So .... if your child limps, regardless of his or her age, make sure that they are evaluated by a pediatrician or orthopedic doctor.  If not, they could sustain long term damage and arthritis in their hip!

Rachel Brewer, MD

Hand, Foot, and Mouth Disease

Just so we are clear, I am not talking about foot and mouth or hoof and mouth disease in farm animals, but a mild virus in children that causes fever, mouth sores, and rash. Hand, foot, and mouth disease is caused by a virus that likes warm weather, so it is most common spring through fall in my neck of the woods (Middle America), but can occur any time of year in tropical locations. The illness is very common in young children because it is spread by direct contact with saliva and stool - think lots of drooling, diaper changing and hands in the mouth. It starts with fever and is followed by sore throat, drooling, and rash. The rash is characterized by red, raised bumps or blisters on the hands and feet. In my opinion, it should be called hand, foot, mouth and bottom disease, because I see diaper rash as a symptoms just as commonly as the rash on the hands and feet. Your child may also get fatigue, fussiness, runny nose, vomiting and diarrhea. Often, little children refuse to eat and drink. The illness typically lasts 7-10 days, with fever for 2-3 days. The most important part of hand, foot, and mouth disease for a parent, is keeping your child from getting dehydrated. Below are my tips for keeping your child comfortable and hydrated during this common illness:

• Ibuprofen or acetaminophen - give an appropriate dose for your child's weight as needed for fever and pain (including feeding refusal). If your child will not swallow medicine by mouth, there is a rectal form of acetaminophen that works well. 
• Offer fluids at all times - this includes breastmilk, formula, milk, Pedialyte, Gatorade, water, popsicles, ice cubes, ice cream (basically anything they will drink!) 
• Avoid spicy and acidic foods/drinks 
• Offer soft, easy to swallow foods 

Home remedies:

• Salt water rinses for older children - 1/2 teaspoon of salt mixed with 1 cup of warm water, swish and spit as needed for pain 
• Magic mouth wash - Maalox (Aluminum Hydroxide and Magnesium Hydroxide) and Benadryl (diphenhydramine) mixed together 1:1 and dropped in or placed in the mouth with a Q-tip. The best way to make this is to mix 5 ml of Maalox with 5 ml of Benadryl. Use 1 ml on the sores every 6 hours. 
• Gly-Oxide is another over the counter product that works well to clean and coat the ulcers  

I do not recommend mouth numbing gels (like Orajel) during this illness, because of the large amount required to numb all of the sores and the short lived relief. There are rare, but serious side effects from using too much of this medication. Unfortunately, there is no antibiotic or medication to shorten the length of the illness. Seek medical care if your child is refusing to drink, has decreased urination or wet diapers, dry mouth or you are concerned about dehydration.  

Heather Joyce, MD

Germ-Fest

So, I am going to digress from the usual sports medicine topics that I love, and talk a little about what to do when germs invade your house.  I mean when your kid gets sick, then you get sick, then maybe your husband, and then your kid again.  The whole process may last weeks (and feel like months).  I'm basing this on recent personal experience that included a nasty upper respiratory illness for my daughter, a GI illness and then pneumonia for my husband, and two nasty respiratory viruses for myself separated by a week. This house is ready for spring.

When one household member gets sick with a viral illness, containing it isn't easy.  If I could have replayed the last month in my house, I might have bought a hazmat suit to stop the spread of germs ... it takes a toll when the virus keeps steamrolling your family members (and the dog Daisy even got depressed - her number of walks/runs dropped dramatically).  Here are a few common sense tips to help prevent the spread of germs.  These steps may seem simple, but I know I skimp a lot on these things when I'm rushed.

Wash your own hands.  Don't get too focused on keeping the germs off of your kids.  If you're not washing your hands, you could be the one who infects your healthy child or spouse.


Make washing your kids hands routine.  Of course this seems obvious, but it can't be stressed enough. Nearly 80% of infectious diseases are spread by simple touch!  When you have a sick toddler or baby, germs get in every nook and cranny (literally).  And when your kids can wash their hands themselves, teach them to do it for at least 20 seconds (maybe sing the alphabet song or something similar).  If soap and water aren't available, use an alcohol based sanitizing gel until it evaporates.

Disinfect, and then do it again.  Wipe off surfaces that sick household members have touched - doors, tables, counters, handrails, etc.  You can even put some plastic toys in the dishwasher and stuffed animals and other toys in the washing machine.  If you're experiencing a GI illness in your house, be extra careful to disinfect the toilet, floor, and bathroom sink.

Don't change dirty diapers in the same place for two different children.  Enough said.  This is a great place to exchange germs.

Mealtime.  Don't share silverware, cups, plates, food, etc.  Germs love these methods of transportation.

Breastfeeding.  Don't stop breastfeeding if you get sick.  In fact, the antibodies you pass on might help protect your baby from getting sick.  And if your little one is sick and you are nursing, again, just practice good hygiene to avoid transmission to yourself.

Ok, I know these seem simple.  But take them seriously when a family member gets sick.  I know we will next time!

Rachel Brewer, MD

Allergies

It's that time of year again...itchy, red eyes, runny nose, sneezing and hives. Allergies make many children and parents miserable. The best treatment for allergies is allergen avoidance, so keep your children inside all spring, with the windows closed and the air conditioner on - IMPOSSIBLE! However, you can try reduce a child's time outside and make sure not to run an attic fan/house fan with the windows open. There are many other treatments, but they all involve using medications. Antihistamines are still the best medications we have available to treat allergies. There are several available over the counter now. I typically recommend a trial of diphenhydramine (Benadryl), which means giving an appropriate dose every 6-8 hours for a couple of days and monitor for symptom improvement. If symptoms are better, your child may benefit from a long acting antihistamine. I do not recommend long term therapy with diphenhydramine (Benadryl), because it can cause sleepiness and adverse behavior effects on children. Long acting antihistamines include loratadine (Claritin), fexofenadin (Allegra), certirizine (Zyrtec), desloratadine (Clarinex). See your doctor before starting a long acting antihistamine, because they all have different and specific dosing for children of different ages. If your child has allergies and asthma, there is another medication available called montelukast (Singulair) available by prescription.

Treatments for specific allergy symptoms include:

Watery, red, itchy eyes:
- Use a cool, wet washcloth to soothe your child's eyes and to keep them from rubbing
- Try an antihistamine eye drop, there are some available over the counter and others that are available by prescription
- Gently remind your children not to rub their eyes, this can lead to infection

Runny nose or congestion:
- Nasal saline several times per day
- Nasal steroid available by prescription

Rashes - hives or dermatitis:
- Cool bathes
- Cotton long sleeve clothing
- Vaseline or Aquaphor

Springtime is the best time to play outside. Allergies affect many children, but there are several treatments available to make life more tolerable when the plants and flowers are all blooming. Make sure to see a physician if your child develops difficulty breathing, wheezing, or severe eye swelling when their allergies flare.

Heather Joyce, MD

Confessions of a Modern "Crunchy" Mom - Cloth Diapers

Though I work as a pediatrician full time, vaccinate on schedule, and sometimes hit the closest drive-though for a quick meal, I am often called "crunchy" by my co-workers and friends. There are many aspects of "natural " parenting that feel right to me, including, cloth diapering, breastfeeding (or pumping) for as long as possible, homemade organic baby foods, and baby wearing. As a working parent, my life is an act of compromise, so I am flexible with my "crunchy" side.

The decision to use cloth diapers with our second child was not easy, but after reading many blogs and talking to parents who have used them, we decided it was worth a try. There are many pros to cloth diapering, including reduced cost, diaper rash, disposable diapers sitting in landfills (for who knows how long), plus they are so cute! We make it work by realizing that we don't have to use them all the time to reap the benefits. We have used several different brands, all with inserts and covers. We use a diaper sprayer on the toilet and we wash them ourselves. However, we don't take them on vacation or use them during diarrhea illnesses and when my son started daycare, we brought disposables to use there. As he gets closer to potty training, we have less diapers to wash and truthfully, I enjoy using them more!

Cloth diapering tips:
1) Talk to other parents who have used them and people who work at local stores who sell them
2) Choose a style that works with your lifestyle
3) Make a washing schedule - we do ours every 2-3 days (buy enough to make it at least a couple of days)
4) Use newborn diapers until the umbilical cord falls off - I could not find a way to make the diaper fit without irritating the umbilical stump. Please comment below if you have the secret!
5) Buy a diaper sprayer for your toilet
6) Use extra inserts for overnight - we use hemp (they are thin, but absorbent)
7) Bleach, strip, and lay out in the sun to dry once in a while
8) Use essential oil in your dry bag to hide the smell

Once you figure out a routine and get used to washing poop, it really is doable for any parent who would like to give it a try.  Every cloth diaper that is used, means one less disposable diaper sitting in a landfill!

Heather Joyce, MD

Osgood What?

Many of you parents out there may be familiar with knee pain due to Osgood Schlatter's disease because your child is experiencing it, or you experienced in the past as a child.  It is definitely one of the most common causes of knee pain in kids (not due to falling or trauma).

I talked about what apophysitis is a few weeks ago, and Osgood Schlatter's is the most well known form of it.  Again, an apophysis is a growth plate that provides a point for a muscle/tendon to attach.  And apophysitis is due to chronic traction of a tendon at its origin or insertion.  Continuous stress at the apophyseal site leads to local swelling and pain.  Stress at the knee comes from things like running, jumping, or squatting.

When Osgood Schlatter's disease occurs, kids develop a bump that you can feel just below their kneecap. The bump is painful to touch.  Pain is worse with running and things like walking up stairs, hills, or any incline.  It is especially painful when a child with Osgood Schlatter's falls on his or her knee.

If you think your child has Osgood Schlatter's it is important for he or she to stretch, stretch, and stretch.  Specifically stretch the calf muscles, hamstrings, and quad muscles.  Icing the knee (right over the bump) at least two times a day and taking an age appropriate dose of ibuprofen is also helpful.  Sometimes kids with chronic or severe Osgood Schlatter's need formal physical therapy.

Bracing with a knee strap (which goes between the kneecap and the bump that forms with Osgood Schlatter's) can also be helpful.  The strap theoretically compresses the patellar tendon and lessens the traction on the apophysis where the pain is.

Osgood Schlatter's disease typically resolves when the apophysis (or growth plate) below the kneecap closes.  However, in some kids, the problem can become chronic and those kids require surgery.  This doesn't occur until high school age or beyond because you have to give the apophysis a chance to close.  There are also experimental treatments with injection for moderate to severe Osgood Sclatter's, which may become a more common treatment in the future.

It doesn't harm a kid to play with knee pain due to Osgood Schlatter's, but it may prolong the course of recovery.  The best thing to do is try a course of rest and rehab to try to eliminate the pain before going back to a sport 100%.

Rachel Brewer, MD

Ankle Sprains

Ankle sprains are one of the most frequent presenting problems that we see in kids and adolescents.  The important thing is to recognize when you should take your child to be evaluated if they experience an ankle injury and also understand how to treat and rehab the injury at home.

First, like I've said before .... young kids don't sprain stuff.  What does that mean?  It means that their bones are the weakest link since their growth plates are still open, and that the growth plates get injured with a joint injury, not the ligaments.  You can "sprain" a ligament, not a bone.  Once a child's growth plate closes, they are more apt to truly sprain a joint.  Ligaments get "sprained," and muscles get "strained."

Ok, so your kid twists his ankle at soccer practice.  Should you run to the ER?  If the foot or ankle appears deformed or pale, yes.  That means there likely is a serious fracture.  If your child has immediate swelling in his ankle and can't bear weight, it is also important to be seen.  However, call your pediatrician first if it is after-hours and they can determine if it is ok to treat the injury at home overnight and be seen the next day.

Bottom line is that most ankle injuries in kids warrant an x-ray - especially if they are young enough where there growth plates in the ankle are still open (prior to puberty).  

If your child is diagnosed with a true ankle sprain (again, this is likely in adolescence), then there are several things you can do at home to speed along recovery.  You may have heard of RICE therapy.  This stands for rest, ice, compression (with a brace or ace bandage), and elevation.  This also works for ankle sprains.  Swelling in ankle sprains can be very impressive, and RICE therapy helps swelling go away faster (anti-inflammatories like ibuprofen can also help).  If your child cannot bear weight because of pain, they may need crutches for a couple days.

Kids are generally pretty good at letting pain guide them in terms of being able to bear weight on their ankle if they experience a sprain.  Once they are able to bear weight (when pain has improved), it is ok to progressively start to walk normally again.  If you rest the ankle too long with non-weightbearing that can lead to stiffness and more pain. 

Rehab is key to getting through an ankle sprain.  Rehab means moving the ankle, getting the strength back, and also getting back your balance.  This handout shows some great things you can do at home.  Remember, flexibility, strength, and balance are all part of rehab.  Sometimes ankle sprains are severe enough that it working with a physical therapist is required (you can be referred by your pediatrician or sports medicine doctor).  

Experiencing an ankle sprain is the biggest risk factor for having another one in the future.  A brace called an ASO (a lace-up ankle brace) is very helpful at preventing ankle sprains.  It is important to wear the brace during any cutting/pivoting sports.  Once you "stretch" the ligaments during an ankle sprain they never "tighten" back up - that's why wearing a brace is very important!  You can get a lace-up brace from your pediatrician or sports medicine doctor.  

Rachel Brewer, MD