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 They were originally made of bone or rock, but in the past one hundred years mostly rubber or silicone.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