Common Medical Conditions

Common Infections and Need For Antibiotics
There are two common types of infections in children: viral and bacterial. Most infections in children are viral. These include cold viruses (runny nose, fever, cough, achiness) and "stomach flu viruses" (vomiting, diarrhea, fever, achiness). These viral infections get better by themselves and do not require antibiotic medicines.

Bacterial infections in children are also very common and consist of the following: ear infections, strep throat, pneumonia, bacterial sinusitis, some types of bronchitis, some types of skin infections, and urinary infections. If your child has a bacterial infection, then an antibiotic will be recommended.

If your child has a viral infection, then an antibiotic would not help.

If you suspect a bacterial infection, then it is best to have your child seen by a physician to make a proper diagnosis and prescribe the antibiotic of choice for your child's condition. Prescribing over the phone should be avoided most of the time, except in certain situations.

Listed below are some tips that may be helpful when planning babysitting for your children.

• Make sure your sitter knows where you are going, what time you are returning, and how to reach you.
• Tell your sitter that friends are not to visit, and that attention is made primarily to the children, not talking on the phone, watching TV, or doing homework.
• Provide phone answering advice- it is best for the sitter not to tell the caller when you will be coming home or where you are. It is OK for the sitter to tell the caller that the parents are not available right now and offer to take a message.
• No other person beside the children or the sitter should be allowed in the house while you are away. Inform the sitter if you are expecting any kind of delivery or visit.
• Ideally, the sitter can first meet the children on a day prior to the sitting time so that the children can meet and get to know the sitter first. Also, the sitter can then learn all about the children's routines at home, such as feeding practices, favorite games or activities, and bedtime routine. This would avoid trying to rush through all of this information while you're trying to leave and provide transportation for the sitter.
• It is a good idea to call home and check in with the sitter to answer any questions that may come up. This will provide reassurance to both the sitter and the parents.
• Review the basic developmental abilities for your children's ages so that the babysitter has reasonable expectations for the children.

Calcium needs in children and adults are indicated below. The best source of calcium is through dairy, particularly milk. Calcium sources are summarized below. Most children and adults who do not consume at least three dairy servings per day are most likely not getting enough calcium. For some kids, milk or other dairy products are not well tolerated or they may be simply disliked by the child. Rather than try to force feed milk to a reluctant child, it is better to let the child have control over their food choices as long as other nutritious choices are eaten. Relying strictly on non-dairy food sources of calcium to provide a child's daily needs is not a good idea. Rather, it is best to provide over the counter calcium supplements. There are many different calcium products available, including hard chewable tablets, tootsie roll like chewables, and plain tablets. The milligram amounts vary in these products so check the label closely. Also, "calcium carbonate" is only 40% actual calcium, so a "750mg tablet of calcium carbonate" is actually only 300mg of elemental calcium. The calcium recommendations and food composition as indicated in the tables below refer to elemental calcium.

To figure what your child's calcium needs are, follow this process: First, check the table below and figure your child's daily needs based on age. Second, figure that each dairy serving is about 300 mg calcium. Third, estimate non-dairy food sources at about 200 mg per day. Fourth, you can figure the calcium deficit and provide the rest in supplement form. For example, a 10 year old boy would need 1300 mg per day. If he drinks one cup of milk per day, he gets 300 mg from milk and 200 mg from non-dairy. This boy would need about 800 mg per day from chewable calcium supplements. In this case, four 200 mg tablets per day, two in the morning and two at night, would be appropriate.

We advise that children also get a multiple vitamin supplement, one per day, as well. Avoid calcium products that are combined with Vitamin A or D, because these vitamins are provided in a daily multiple vitamin and giving more of these with calcium products may result in overdosing on vitamin A or D. If any questions, please feel free to contact our office for more information.

Recommended Calorie Intake

Motor vehicle crashes are the leading cause of death in children between the ages of 6 years and 14 years. When used correctly, child restraint devices and safety belts are 50% to 70% effective in reducing fatalities and serious injury. Below is an overview of tips and guidelines. Violations of the safety restraint law can result in a $50 fine. Studies have shown that up to 80% of car seats are not properly buckled in. Common mistakes include: seat not tightly secured, harness straps too loose, inappropriate car seat size for weight, air bag placement, car seat facing the wrong direction, and seat belt not properly latched. Of course, the best strategy is prevention of accidents by staying alert and focused on the road, rather than the cell phone. For more information about these safety modifications, you can contact a toll-free hotline: 1-866-SEAT-CHECK or on the net at www.seatcheck.org.

The most common symptoms that bother a child with a cold virus are:

• runny nose or nasal congestion,
• cough,
• fever,
• pain, achiness, irritability, or headache.

Some medications combine many ingredients to treat several symptoms simultaneously, while others rely on single symptom, single item type medications. The major drug categories include these 5 items:

• antihistamines,
• decongestants,
• expectorants,
• cough suppressants,
• fever and pain reducers.

Parents should become familiar with looking at the labels of the cold medications that they buy so they are familiar with what ingredients are being used. When you do this, you will see that many different cold medicines are actually using the same ingredients.

For primarily runny nose or congestion, without much cough, try a combination AH/DC such as dimetapp plain, triam orange, or pediacare allergy.

For runny nose, congestion, and lots of coughing, try a combination AH/DC/CS such as Triaminic Nighttime, or Pediacare Nightrest. These are especially useful for bedtime since they have a sedative effect and may help the child fall asleep. In these situations, it may be best to avoid cold medicines during the day since it may be best for the child to let the nose run and cough up the mucous. However, at bedtime, it is best to help the child sleep if he/she is having a difficult time sleeping at night. For the child who has mild cold symptoms, but is sleeping well, it is not necessary to use any cold medicines.

For Fever, use acetaminophen first. Ibuprofen is an option if the acetaminophen is not helping. Do not use combination drugs that mix acetaminophen with AH's, DC's, EX's or CS's. These combination drugs are confusing and lead to the administration of unnecessary drugs. For high fevers, avoid cold medicines, since they can lead to increased sleepiness or vomiting. Please refer to our "treatment of fever" chart for further fever instructions.

For very thick phlegm type symptoms with cough, use an EX alone or a combination EX/CS or EX/DC.

If one medication is not helping, then try switching to another category drug. For example, if an AH/DC/CS is not helping a cough, you can try using an EX/CS type medication.

For infants below 6 months of age who are congested, use cold medicines very sparingly. The best treatment for stuffy noses in infants under 6 months is to instill 2-3 drops of saline solution in each nostril every 3-4 hours as needed, followed by suctioning the mucous with a bulb syringe. Avoid being too rough with the bulb syringe. Salt solution can be made by mixing 1/4 tsp salt in 8 ounces of water. If salt drops and suctioning does not help, you can try a plain DC infant drop such as Triam infant drops or Pediacare infant drops. See chart for dosing.

If wheezing or difficulty breathing, avoid cold medicines and contact the physicians.

There are so many common cold and allergy type medications available, it can be very confusing for parents to decide what, if anything, to use when your child has cold symptoms. At Pediatric Care Associates, we believe that cold medicines should be used very sparingly for these reasons. First, the use of cold medicines will never make the cold go away faster than it is pre-destined to last. This is because the body fights off cold viruses with its own immune system at its own pace and cold medicines will not change that at all. Second, cold medicines can have some side-effects like irritability, drowsiness, or upset stomach. Since we believe in the body's own natural healing powers, we discourage the use of foreign chemicals unless there is a good reason to treat.

COLD MEDICINE COMMON INGREDIENT CHART

DOSING CHART FOR COMMON COLD MEDICINES

**Dosing is every 4-6 hours for non-Nighttime liquids.

**Dosing is every 6-8 hours for Pediacare Nightrest, Triam NightTime, or Maximum Strength Medicines.

Constipation affects children of all ages, occuring commonly in infants and toddlers. Constipation is defined as having hard, difficult to pass stools. Some infants may stool once every 3-4 days, but this can be normal if the stools are soft. However, if the stools are hard and difficult to pass, then that infant has constipation. Toddlers should stool at least once every other day. A toddler who is stooling every 3-4 days is probably “stool holding” and you should discuss this with us. Many toddlers begin “stool holding” around toilet training time. If you are concerned about your child’s stooling, please call during regular hours and schedule an appointment so we can review your child’s history and arrive at the proper treatment plan.

When is my Child Contagious?
Actually, it is impossible to know exactly when many viruses stop being contagious. Most children can go back to the sitter or school once there is no fever for 24 hours and they feel better, although some symptoms such as cough, runny nose, or diarrhea can last for up to two weeks. Strep throat and pink eye are considered most contagious until the child has been treated with antibiotics for 24 hours.

Most coughs in children represent common colds and do not require treatment. Signs that there might be a problematic cough include a cough that has been there for more than two weeks and is not getting better, a cough associated with a fever for more than 2-3 days, or a cough associated with difficulty breathing. Any child with difficulty breathing needs to be assessed immediately either in the office or in the ER.

The most important aspect of child development is that each infant and child develop at their own pace with large variations. Therefore, it is not good to compare your child to a friend’s child, but rather to compare your child to normative expectations for all children when looking at your own child’s progress. Below are some good basic milestones that most children will achieve by the ages listed. If you have any concerns that your infant or child is not achieving these milestones, then you should talk to us about your concerns at your child’s well visit. We will also start handing out developmental screening questionnaires at a few specified appointment times to help us identify any concerns. One final important note is to remember that the more time parents can spend playing with their infant and child, reading to them, providing affection to them, and encouraging them to explore their world in a free and safe environment, the more likely the child will not only achieve normal developmental milestones, but it is likely they will sail right past them. These milestones are orientated to children without special needs. The lack of achieving these milestones may help identify those who may have special needs, but not always. Many children who do not achieve some of these milestones are very normal in their development overall.

Diarrhea is a very common condition in infants and children of all ages. It is not usually indicative of a major problem, but is most often due to common viral infections. During the first 24-72 hours of a diarrhea illness, it is best to offer a graduated diet, starting with clear liquids the first 24 hours, then starchy-bland foods the second day, then adding cooked foods the third day. Milk is usually added on the fourth day. Please ask about our diet guidelines handout for diarrhea. If your child continues to have diarrhea beyong 3-4 days, DO NOT RESTRICT FEEDINGS. Instead, offer all the usual foods that he/she enjoys. Recovery from diarrhea is enhanced by establishing a normal diet as soon as possible.

Often, diarrhea can last for several weeks in infants and toddlers following common viral infections. Prolonged diarrhea as the only symptom does not require any special treatment and the child should be offered a full diet. However, if the diarrhea is associated with blood in the stool, fever, vomiting, excessive tiredness, pale appearance, or significant weight loss, then further evaluation is necessary and you should call the office for an exam.

We usually prefer to examine all children with ear pain rather than prescribe over the phone. However, there are different and various circumstances that may lead us to prescribe medication before seeing a child with a possible ear infection. Most important is the follow-up exam, since that is when we diagnose an ear infection that may have failed to resolve or a persistent middle ear fluid collection. Recurrent ear infections and persistent fluid collections are very common. Appropriate follow-up exams allow the physicians to make more rational decisions regarding treatment options. Follow-up exams are usually done two to four weeks after the start of treatment.

BREAST FEEDING

1. Water/Pacifiers
   Breast-fed infants normally do not need additional water. It’s okay to offer plain water between feedings, although this is not necessary. It may be best to avoid water in a bottle in the first few weeks in order to avoid nipple confusion. For the same reason, we suggest that pacifiers be delayed until the breast feeding process is well established.
2. Vitamins
   Breast-fed babies should be supplemented with Vitamin D, since breast milk does not supply adequate Vitamin D to the infant. Typically, infant vitamin products include vitamins A, D, and C, but several products that contain just Vitamin D are also available. These vitamins are continued until the infant is done breast feeding and taking adequate amounts of a Vitamin D containing milk/beverage source.
3. Flouride
   Flouride supplements are not recommended until age 6 months in infants whose water supplies are deficient in fluoride.
4. Weaning
   Weaning from the breast can be done at any time. The decision when to wean is a personal and individualized decision, based on many factors. These decisions may revolve around a mom returning back to work, although most working moms can figure out ways to breast feed and pump while at work so that breastfeeding can continue. By age 1 year, most moms have weaned off the breast. However, there are some moms who continue to breast feed after age 1 year.

BOTTLE FEEDING

1. Water/Pacifiers
   Water can be offered between formula feedings but is not necessary. This should be non-sweetened water. Water can be offered between feedings if the infant is fussy in order to buy some time between feedings.
2. Vitamins
   Vitamin supplements are not necessary for healthy formula fed infants.
3. Weaning Formula and Bottle
   Formula is usually changed over to cow’s milk at about 12 months of age. Whole milk is usually preferred beginning at age 1 year. We strongly urge parents to eliminate infant bottles and change over to sippy cups by 1 year of age. Infants will protest for a few days and then they will adapt without any problem.

JUICES
Juice should generally be avoided in infants, since the sugar component provides empty calories and will interfere with the infant’s appetite for other more healthy food choices.

SOLIDS
Solids in the form of cereals, fruits and vegetables are not started until age 4 months. Some parents elect to defer starting solids until age 6 months. More information on this issue is forthcoming in our 4-6 month feeding handout provided later.

STARTING SOLIDS: FULL-TERM INFANTS
Solids are begun at 4-6 months of age. Most infants are ready by age 4 months, but some parents choose to wait until age 6 months. Although some experts recommend starting solids at age 6 months for all infants, there is controversy as to the validity of claims that starting solids earlier causes increased incidence of allergies or other health problems. Again, most infants are ready and interested in solids by age 4 months. Only in rare circumstances are solids such as cereals begun earlier than 4 months. Please call our office to discuss this if you feel that your infant should start solids earlier than 4 months.

STARTING SOLIDS: PREMATURE INFANTS
Infants who are very premature(Less than 35 weeks) may not be ready for solids at age 4 months and may be more ready at 5 or 6 months of age depending on their degree of prematurity and other circumstances. We will normally discuss this with you at the well child routine visits.

PROCESS OF STARTING SOLIDS AND FEEDING PRACTICES DURING THE FIRST YEAR OF LIFE:

1. Begin with rice cereal on days 1,2 and 3, offering it twice daily at breakfast and dinnertime. Rice cereal can be mixed with water or milk(breast or formula) to make a thin oatmeal like consistency. The infant should be offered a rubberized spoon. During these first three days, offer 3-4 tablespoons at a time but be flexible. Some infants will be very hungry and want more- that's OK. Offer as much as the infant wants until he/she loses interest or spits the food out or pushes the spoon away. Parents should learn to use the infant's own cues of hunger and satiety to guide the amount of food that is offered. Never force feed a stubborn infant; just wait for the next mealtime. If the infant only wants 2 tablespoons- that's OK too.
2. Add a single fruit on days 4,5, and 6. Continue twice a day feeds. The fruit can be mixed in with the cereal in one big bowl of mush and offered that way or given separately. Offer 2-4 ounces at each sitting. (Again, some infants will take more and some will take less, some may not want any-that's OK too,). Common starter fruits include apple sauce, pears, bananas, and peaches. Prunes are especially helpful for constipated infants.
3. On day 7, add a single vegetable and change to three meals a day. Some of the popular starter vegetables include carrots, peas, squash, green beans, and sweet potatoes. One popular feeding schedule at this time is cereal and fruit for breakfast, fruit and vegetable for lunch, and fruit and vegetable again for dinner. Notice that we usually drop cereal down to once per day at this time. Some parents may elect to continue to offer cereal twice a day at either lunch, dinner, or bedtime "snack", but we prefer to emphasize fruits and vegetables.
4. Every 3 days, add a new food- alternate between fruits and vegetables so the infant learns to appreciate the tastes of both right from the start. You can offer multiple foods on any given day, but only offer one new food every 3 days. This helps to identify a food allergy or intolerance by not offering two new foods at the same time.
5. STAGED FOOD JARS- What To Do?
   With this schedule, it takes roughly 3-4 weeks to work through all the common starter fruits and vegetables. Therefore, at 3-4 weeks after starting solids, you can move from single stage 1 food jars to stage 2 jars of fruits and vegetables, mixed fruits, mixed vegetables or mixed cereal with fruit jars. Usually, the only difference between stage 1 and 2 is that the jars are bigger, the consistency is a little thicker and there are combination items. Stage 2 jars remains pureed and easy for infants to handle with the rubberized spoon by age 5-6 months . Animal foods like meats and chicken are usually begun at 6-7 months of age. Stage 3 jars are also deferred until after 6 months of age.
6. How Much To Feed?
   We prefer parents to use the infant's hunger cues as a guide to how much to feed, since the infant's appetite will vary from meal to meal. A rough estimate is as follows: Age 4 mon-offer 2-4 total ounces per feed, Age 5 mon-offer 4-8 ounces total per meal, Age 6 mon-offer 6-12 ounces total per meal.
7. Remember To Be Flexible!
   Don't get caught up in rigid feeding practices. Mealtimes may change once in a while and the infant may not be hungry from time to time. A good method is to start with a vegetable at a meal, then when the infant gets bored of the vegetable, move on to some fruit. On the other hand, if he is enjoying the vegetable and eats 6 ounces, he/she may not be interested in the fruit, so then you can start at the next meal by offering a fruit first.
8. How do I Schedule Milk Feedings and Solids Throughout the Day?
   Breast milk or formula intake remains quite high even after solids are begun. We prefer to offer the breast milk or formula either roughly 1 hour before the solid meal or 1 hour after the solid meal so the infant's stomach has time to empty. This means that you might be spending a lot more time feeding your infant. Again, be flexible and create a schedule that works best for you. Here is an example of a typical schedule:
   
   

   Early AM (6-7AM):	Milk feeding
   Breakfast (8-9 AM):	Solids
   Mid-Morning (10-11 AM):	Milk feeding
   Lunch (12-1 PM):	Solids
   Early Afternoon (1-2 PM):	Milk Feeding (optional)
   Late Afternoon (4-5 PM):	Milk Feeding
   Dinner (6-7 PM):	Solids
   Evening (9-10 PM):	Milk Feeding

   
   
   The above schedule provides for 4-5 milk feedings and 3 solid feedings per day all between 6 AM and 10 PM. Notice the optional early afternoon milk feeding allows for 5 milk feedings per day. Some infants may do well with milk and solid feedings right after one another which may allow for more of a time break between feeding times. By 4 months of age, parents should stop middle of the night milk feedings and encourage the infant to sleep a good 8 hours without any food or drink. Good Luck!
9. Are There Any Brand Preferences?
   We do not have strong brand preferences for infant foods. We prefer brands that have the least amount of preservatives and additives, including salt or sugar. The major brands are usually fine. Frozen infant solids are probably better since the food is preserved better, but there is the inconvenience of thawing the food before feeding time. Beware that microwaves may cause the food to be very hot in some places and not in others. Many parents make their own infant pureed solids by storing portions in ice cube trays for individual servings.
10. What About Juices?
    Try to avoid juices for both infants and older children. The reason is that juices contain mostly sugar and water, but lack the quality aspects of the fruit such as complex carbohydrate, active vitamins, antioxidants and fiber that can be obtained only by eating the whole fruit. Also, the vitamin quality in juice may be less active due to processing when compared to eating the fresh whole fruit.
11. When Are Other Cereals Started, Such As Barley Or Oatmeal?
    We usually begin first with rice cereal because it is very well tolerated, mixes well with other foods, and has very minimal adverse effects. After going through all the single ingredient fruits and vegetables(usually by 3-4 weeks of starting solids), then you can offer the infant oatmeal cereals followed by barley and wheat cereals. Remember to add only one new food every 3 days. Some infants may get constipated on rice cereal and may do better with oatmeal cereal earlier on.
12. What About Water And Flouride Needs?
    Infants do not need additional water prior to 4 months of age. After 4 months, it is OK to offer infants water once in a while but it does not need to be a regular item. Infants can drink faucet water starting at age 2 to 3 months if your water supply is clean and reliable. Generally, if it is good enough for adults to drink, it should be good enough for infants after age 2 to 3 months. Most infants will get flouride in their drinking water once they begin taking water if your water is flouridated. Even if your infant is not getting much water to drink or your water is not flouridated, we do not recommend flouride supplements prior to age 6 months. If you do not have flouride in your water supply, please discuss possible flouride supplementation with us at the 6 month routine exam.
13. What Feeding Practices Are Recommended After Age 6 Months?
    Excellent question. Please see our feeding guideline handout for infants age 6 to 12 months!!

ANIMAL PROTEINS
At about 6 months of age, most infants can be started on the major animal protein food groups, including meats, chicken, turkey, and pork products. Typically, these foods are given at dinner. The plain meats or chicken in the jars have a less than terrific taste and many people prefer to use the combination meat-vegetable, chicken-vegetable or other combination products.

FINGER FOODS
At 6-7 months of age, most infants are ready to start finger foods in addition to the jar foods. Although many infants do not have teeth yet at 6 months of age, teeth are not necessary for infants to begin small pieces of soft finger foods since the gums are hard and very good at chewing up many different food items. Examples of starter finger foods include banana, soft canned fruit like peaches, pears, or fruit cocktails canned in water. Vegetables that are cooked extensively in water such as canned soft peas or green beans. Cheerios are OK because they become very mushy as soon as they get wet in the mouth. Small pieces of bread and some noodles are good starter items. Remember to cut pieces into small 1/4 inch pea size pieces and give only a little at a time so that the infant does not put too many pieces in his mouth at once. Of course, foods such as banana that are very easy to mush up can be offered in slightly larger size pieces. Keep offering more and more finger foods so that by 9 months, the infant has tried many different foods. Over time small pieces of ground beef and shredded tiny pieces of chicken or turkey can also be offered. By 9 months of age, many infants are eating a large variety of finger foods and most foods that adults eat, excluding the obvious foods that can cause choking as discussed later in this handout.

FEEDING METHODS AND SCHEDULE
There may be hundreds of different methods of feeding infants and you will find a convenient method that works well for your infant. One popular method is to first sit the infant in a high chair, then put a few cut-up pieces of finger foods on the tray. Give the infant some time(5-10 minutes) to explore with the finger foods first, then begin offering some of the usual pureed jar foods of cereal, fruits, vegetables, or meats/chicken/turkey/ham, depending on the meal. The usual feeding schedule is fruit and cereal for breakfast, fruits and vegetables for lunch, and meat/chicken/turkey combined with vegetables for dinner. This provides a good mix of cereals once/day, fruits twice/day, vegetables twice/day, and meat-chicken type foods once per day.

If the infant begins throwing the finger foods on the floor, then that means he is not interested in those foods at that time. If the infant rejects both the finger foods and spoon fed pureed foods, then you should end the meal. The infant will learn that throwing food on the floor will result in ending the finger foods for that meal or ending the meal altogether.

How do I know if he/she is eating enough food or formula? When do I stop spoon-feeding?
Each infant has their own appetite control center that guides them to ingest the right amount of calories that their body will need. A young infant has the same type of appetite center that adults have. This appetite center does not let a healthy infant undereat. Therefore, the parents need not concern themselves with how much the infant is eating. On some days it may seem that very little is eaten, but over the course of several days, the infant will eat adequate calories. The parents should offer a wide variety of foods from all the major food groups(grains, fruits, vegetables, proteins(animals, fish)) over the course of several days and allow the infant to take whatever quantities of each that he/she is interested in.

Sometime between 9 and 12 months most infants will begin to reject the spoon and only want to finger feed. They will indicate this by pushing the spoon away or turning their head away from the spoon. When this occurs, you know that it is time to stop spoon-feeding and let the child strictly finger feed. When infants switch over to all finger foods, most parents worry that the child is not getting enough food, because he/she appears to take very small amounts of solids. There is no reason, however, to be concerned about this since no child will undereat as long as edible foods are being offered throughout the day. This would typically include at least 4-5 meal times when the infant is seated at the table in a high-chair. Sometimes, he/she will want to eat and sometimes he/she will not want to eat. This is fine since the child knows exactly how much he/she needs and will not let him/herself go hungry or thirsty for any prolonged period. It does not happen! (Exceptions to this rule occur in certain medical conditions and developmental disorders that can be readily identified at the well exam physicals.)

Which Jar Stage is best? When are Jar foods stopped?
At 6 months, most infants are taking their spoon fed foods from stage 2 jar foods, which are pureed foods and include fruits, vegetables, cereals, and animal proteins(meat, chicken, turkey, etc.). At 6 months, stage 3 foods can be offered, which include single item foods and mixed meals with a wide variety of foods such as noodle-meat combinations. Strained type foods can be offered gradually between the ages of 6-9 months. "Graduate" type foods include foods that are precut in small bite size pieces that are used for finger feeding foods. These are finger foods in jars that offer some convenience but are relatively bland in taste and not as fresh as freshly prepared "real people" foods that can be cut up in small pieces. When finger foods are offered, it seems tastier to offer foods that adults would typically eat then the foods pre-cut, processed and placed in jars.

What about Cow's Milk and dairy products?
Dairy products such as cheese, ice cream, yogurt, and cottage cheese can begin to be offered at 6 months of age without any problem in most infants. Of course, if your infant is milk allergic, then please contact the physicians before offering any milk products. We recommend that breast milk or infant formula be offered as the primary beverage up until age 1 year. At age 1 year, most children can be placed on whole milk. “Next Step” type toddler formulas are marketed to toddlers through age 2 years, but are not necessary and may cost more money than whole milk.

What about Vitamins?
We are learning more and more about vitamins and how important all the vitamins and minerals are. We are also learning that our typical American diets are probably deficient in some vitamins and minerals. At age 6 months, infants who are receiving infant formula do not need additional vitamins, since the formula contains adequate amounts of vitamins. If your infant is getting breast milk and a variety of solids(cereals, fruits, vegetables, and animal proteins), then vitamins may not be "necessary" but offering a vitamin product with Vitamin D may be a good idea since breast milk is deficient in Vitamin D. At age 1 year, routine multiple vitamin supplements offer advantages of improved vitamin and mineral intake, including iron, and is generally advised.

What about Fluids (MILK OR FORMULA)?
At 6 months of age, most infants are taking an average of about 20-24 ounces of breast milk or formula a day, usually in 4-5 feedings per day. Some infants, however, may take less and some more since there is a lot of individual variability. Your infant will know how much he/she needs to drink and will take in the right amount based on his/her appetite and internal hunger/thirst controls, and this can vary from day to day.

At 6 months of age, infants will get most of their fluids from breast milk or formula. Additional water can be offered via bottle or sipper cup, but this is not a necessity. The decision to give additional water will depend on individual circumstances. Between 6-9 months, infants can be offered a sipper cup to explore with. I usually put just water in the cup so the mess is not too bad as the infant shakes the sipper cup about. Between the ages of 9-12 months, the infant may actually start drinking a little from the sipper cup. At age 1 year, you should completely eliminate the bottle and switch over to all sipper cup beverages- milk and water. It is OK if the child reduces his/her fluid intake during the first 2-3 months after switching off the breast or bottle onto sipper cup. The child will not allow him/herself to get dehydrated no matter how little he/she appears to drink.

We recommend offering little or no fruit juice beverages, Kool-aid, sugared soft-drinks or lemonade type beverages. All these products, including 100% natural juices, are very high in simple sugar content and are not good choices for your child's eating habits. Fruit juices are made after most of the healthy elements of the fruit(fiber, complex carbohydrate, antioxidants) are processed out and mostly the sugar component remains. Then water is added and the product is put in a bottle and labeled 100% natural. Also, the vitamins in fruit juices are processed and not as active as in the whole fruit. Therefore, we recommend avoiding juices on a regular basis and offering more fresh fruit products instead. Beverages can be limited to just milk and water. This may sound boring, but it is quite healthy.

Soda-pop drinks have no place in an infant's diet or any child under age 2 years. For older toddlers(over age 2 years), it is difficult to avoid the Soda-pop culture at least once in a while. For these older kids, I still advise that parents eliminate soft drinks. If this is not possible then diet pop is preferred since regular pop fills up the body with empty calories and leads to poor nutritional habits and weight gain.

What about eggs AND FISH products?
Generally, egg products are usually offered at 7-9 months. When egg products are first offered, give egg white alone for the first week, then give whole egg products thereafter(scrambled eggs, pancakes, etc.). The reason why egg products are seperated during the first week is that if your infant has an allergic reaction to the egg, then it will be easy to determine what part of the egg(white or yolk) is the culprit. Although egg allergy is not common, it does occur from time to time. Symptoms will usually involve hives all over the body. Difficulty breathing, wheezing, or swelling may be signs of a serious allergic reaction and you should call 911 for immediate assistance if these symptoms develop.

Fish products can also be offered at about 7-9 months. Most infants will do fine with fish products. Allergic reactions are more likely with shellfish products so these should be watched closely when they are first offered. Shellfish products are usually first offered at around 9 months of age. Fish products should be limited to two servings per week in order to prevent excess mercury exposure.

What about Desserts?
No problem. Some modest amounts of dessert items can be offered from time to time, such as ice cream, or cakes, but these should be kept to a minimum(1-2 times per week) so the infant does not become too familiar or fixated with them.

CHOKING AND ASPIRATION
Choking and aspiration of food is, fortunately, a rare occurence. Avoid foods like peanuts, hard candy, large pieces of bread, steak, and raw vegetables since these can lead to choking or present more trouble for the infant to chew and swallow. Hotdogs should be cut in small pieces both ways. Some gagging is not uncommon when infants begin finger foods, but the infant will get better at handling different textures as time goes by. The infant should be positioned upright. Never allow an infant or young child to eat while lying down or leaning the head back. If the infant is gagging but has good color and shows forceful gag-coughing effort, then he/she will usually expel the food without any outside assistance, so it is best to allow some time for the infant to cough up the food on his/her own. If more difficulty is noted or any color changes are seen, then call 911 and proceed to anti-choking CPR methods summarized below:

1. If you can see the object in the mouth, then sweep it out with your finger.
2. If you cannot see the object or a finger sweep does not work, then turn the baby on his stomach over your arm with your   hand supporting the jaw and neck and give him 5 back blows to the midback. At the same time, have someone call the paramedics.
3. If the infant continues to have difficulty, lay him/her on the back and provide 5 upper abdominal thrusts under the rib cage area then repeat step 2. Keep doing this until help arrives. It is essential to call for help even if you are alone with the child.

FORMAL CPR TRAINING WHICH INCLUDES MORE IN DEPTH ANTI-CHOKING TRAINING IS HIGHLY RECOMMENDED FOR ALL PARENTS OF INFANTS AND YOUNG CHILDREN.

**PLEASE NOTE THAT THESE RECOMMENDATIONS ARE BASED ON HEALTHY INFANTS AND ILLNESSES SUCH AS STOMACH FLU WITH VOMITING WILL REQUIRE SPECIALIZED DIET INSTRUCTIONS.

**ALSO, PLEASE NOTE THAT THERE ARE MANY DIFFERENT OPINIONS REGARDING THESE FEEDING PRACTICES. WE HAVE PROVIDED SOME COMMON FEEDING GUIDELINES, BUT WE ALSO ADVOCATE FLEXIBILITY AND APPROACHING EACH CHILD WITH THEIR OWN INDIVIDUAL NEEDS.

Treating fever has become a little more complicated now that both acetminophen and ibuprofen are available. Both drugs are very effective at treating fever. A temperature > 100.4°F is considered a fever. We recommend always starting with acetaminophen, since it has fewer side effects than ibuprofen. If the fever remains greater than 102°F 1-2 hours after giving acetaminophen, then you can give ibuprofen. Acetaminophen is dosed every 4 hours. Ibuprofen is dosed every 6 hours. Sometimes doses of acetaminophen can be alternated with doses of ibuprofen every 3 hours in cases when the fever returns sooner than 4 hours from the last medicine dose. We DO NOT recommend giving alcohol baths. Luke warm water baths can help make a child more comfortable with fever that responds poorly to medication. Remember, the important thing is to make the child more comfortable. Fever, itself, does not cause brain damage or bodily harm. Fever indicates that the body is fighting off an infection. Therefore, we treat fever in order to make the child more comfortable, not because the fever is

Avoid drugs that combine acetaminophen with cold medicines such as antihistamines or decongestants in one bottle, since it is confusing to dose these combination drugs and you may be treating with more drugs than you need.

Please note: This chart does some approximating to simplify things, parents can calculate exact doses by using the child's weight in Kg.

Acetaminophen is dosed at 15mg/kg per dose every 4 hours, as needed.

Ibruprofen is dosed at 10mg/kg every 6 hours, as needed.

This handout should help our families manage their children's cold symptoms, viruses, and fevers. Dosing is provided for acetaminophen, ibuprofen and most cold medicines for all age groups, including infants.

COMMON QUESTIONS REGARDING GIVING FEVER AND COLD MEDICATIONS?

• Can I give medications at the same time? What about drug interactions?
  There are no significant drug interactions between acetaminophen, ibuprofen, any cold medication, or any antibiotic. Therefore, any of these drugs can be given together without any problem.
• What can I give for fever if my child is vomiting?
  The best fever reducing drug to give a child who is vomiting is acetominophen by RECTAL(suppository) route. This medicine is available over the counter and the dosing is the same as indicated in the dosing chart below.
• If the medicine bottle says, "Don't give until you call your physician", or "Don't give under age 2 years unless contacting your physician," then does this mean I should call the office or page the physician before giving the medicine?
  The answer is no. We have provided this handout with dosing recommendations for ibuprofen, acetaminophen, and cold medications for any age down to age 2 months. Therefore, you should not need to call us for dosing questions. However, please call us if you have other medical concerns or if you would like some reassurance.
• If a child has cold symptoms, when is it necessary to page the physician after hours?
  The physicians are always available for after-hours paging. Of course, most questions can probably be handled the following morning during regular office hours. Examples of these situations include stuffy noses, coughing without breathing distress, or fever without prominent lethargy.

There are some situations that should not wait until the following morning, but rather an urgent page is recommended. These URGENT situations are listed below:

• Any child who is very lethargic defined as not responding normally with little or no eye contact. A child who is able to point at objects, answer a question, and maintain good eye contact may be considered listless, but is not considered lethargic.
• Vomiting many times in a row (4-5 episodes) should prompt a page.
• A child who has severe, unremitting, and constant abdominal pain should prompt a page.
• Any type of significant breathing distress(not just a stuffy nose) should prompt a page.
• Obviously, an unconscious child should prompt a page.
• Seizure activity consisting of rythmic movements of the arms and legs associated with eyes rolling should prompt a page.

Nutrition and Health Concerns: Fish and Mercury

Is there anything out there that’s healthy to eat? Fish is recognized as a terrific source of protein and omega fatty acids that are believed to be a very healthy component of our diet. Unfortunately, fish also harbor mercury in the form methylmercury. This substance is known to be a developmental neurotoxin which can also pass into the fetus during pregnancy, and pass into breast milk. Recent recommendations by the EPA directed toward pregnant women, nursing mothers, and small children include:

(1) avoiding all shark, swordfish, and king mackerel,

(2) eating a variety of different fish in amounts up to 12oz a week(about 2-3 meals).

The EPA safe level of methylmercury is 0.1ug/kg weight/day. Considering tuna consumption, Albacore contains 0.32ug per gm tuna and light tuna contains 0.13ug per gm tuna. For a 25 pound child (typical 2 year old), this correlates to about 1 ounce of Albacore tuna per week or 2.3 ounces of light tuna a week. A 70kg adult would be allowed 49ug per week of methylmercury. A typical adult’s tuna sandwich contains 3 oz of tuna, which is 84 gm, and contains 28ug of methylmercury.

The mercury comes from coal-burning power plants and waste combusters which release mercury into the air. It then enters water where it is taken in by microorganisms, which are then eaten by small fish and then passed along the food chain into the fish we usually ingest. Environmental groups have been working hard to reduce these mercury emissions which, if supported by our legislators, may reduce the mercury load in our fish by nearly 90%.

Food allergies are commonly over-diagnosed. Parents may report that their child has a food allergy based on some questionable experience. In reality, however, for every 5 parents who report a food allergy, only one of those 5 children will actually have a food allergy. The consequence of this erroneous diagnosis places unnecessary food restrictions on children, including basic staples like milk, wheat or eggs, leaving these children vulnerable to inadequate nutrition. These food restrictions may also have a negative effect on their quality of life.

In the presence of a ‘true’ food allergy, the child will usually have typical symptoms of vomiting and hives all over the body. Other symptoms may include cramping, diarrhea or itching. More worrisome symptoms may be swelling of the face or lips, or difficulty breathing or wheezing. Symptoms of food allergy occur within seconds or minutes of exposure and are consistent with every exposure. Accordingly, if some symptoms are not seen every time the child is exposed to the suspected food, it is unlikely to be a food allergy. In the absence of hives, vomiting, swelling or breathing distress, food allergy is unlikely. The most common food allergies are cow’s milk, egg, soy, wheat, peanut, tree nuts, fish and shellfish. We do not advocate restricting foods because of a family history of food allergy or increased parental anxiety, since that would only cause undue restrictions on your child’s diet. Instead, during the first year of life, as more and more foods are added to your child’s diet, we recommend watching closely for any of these typical symptoms and then we can test for ‘true’ allergy if any symptoms are seen. Allergy tests are not very accurate. In fact, a positive test result does not mean that your child has a definite food allergy, but only means that your child may have a food allergy if symptoms occur with exposure. There are many children who have positive allergy tests to various food substances, but never have any symptoms when they eat those foods. Therefore, allergy testing is only recommended if there are symptoms with exposure.

Another confusing issue is the notion of a food ‘intolerance’. Food intolerance occurs when symptoms that are not ‘allergic’ develop after exposure to certain foods. One example is when people have lactose intolerance and develop diarrhea or bloating from drinking milk. This is not an allergy, but rather symptoms resulting from low levels of lactase enzyme. Many infants have intolerance to some formulas, resulting in crying or gas or loose stools, but do not have an actual ‘allergy’ to the formula. Lactose intolerance is very rare in infants and young children.

For those who are identified as having a significant food allergy with hives or breathing issues, treatment focuses on food avoidance, educating all caregivers and school personnel and keeping on hand epinephrine shots to use in case of emergency. Food allergy medical bracelet identifiers are also very helpful. Some food allergies will be lifelong while others may be outgrown within several years.

We would like to offer some eating tips that apply to kids of all ages. These recommendations are not based on weight control issues, but focus on healthy eating habits that apply to people of any size-thin, thick, or inbetween.

• Children generally ingest too much fat. Skim milk is recommended after age 2yr. When children change from fatty milk(1%, 2%, or whole) to skim milk, the decrease in fat intake will be offset by increased caloric intake of nonfat foods, such as complex carbohydrate(breads, starches), fruits and vegetables.
• Juice should be strongly discouraged as a regular food item, but only made available as a dessert. Juice is high in simple sugar. Eating whole fruits is much better than drinking fruit juice. One way to cut down on juice is to keep it out of the house.
• Avoid nutritional supplements like megavitamins, creatinine, or special protein milk shakes.
  Vitamins in the form of a "multiple vitamin" usually contain a wide array of vitamins and minerals and may be recommended for children who are very picky eaters with certain food groups. For typical children, vitamins would be "optional" and not essential.
• The best beverages to drink are water and milk.
• Children should be offered 4-5 meal times a day, so they have adequate opportunity to snack on healthy foods. This would include the three main mealtimes plus 1-2 short meal times. Fruits, vegetables, and grains should be emphasized at the short meal times.
• Desserts are fine, but limit them to no more than one item per day.
• Avoid "clean the plate" policies. Instead, allow the child to put more food on their plate if they finish and are still hungry. This puts the child "in control".
• Animal foods(cow meat, chicken, turkey, pig meat, etc) should be limited to no more than once a day. Substitute lean fish and non-animal items when possible. Non-animal items would include anything that grows from the ground, such as fruits, vegetables, and grains(cereal, breads, pasta).
• Emphasize lean cheeses when possible.
• Children may be "big" eaters or "little" eaters based on their own internal needs. Children know how much food they need to grow normally. Parents should not concern themselves with "how much" a child is eating, even if it seems like very little. Rather, parents should make easily available many different food items from all the major food groups over the course of a week and allow the child to decide how much of which food they want.
• Eating should not be a chore, responsibility, or something someone else tells you to do at home or on the TV. Rather, eating should be a response to one's internal cues of hunger and appetite, and should be a generally enjoyable experience.

Some common sense precautions will minimize a child's chance of getting insect bites. Avoid wearing flowery colors, perfumes or scented soaps. Stay away from flowery areas. Teach children not to bother bees or wasps. Stingers can be removed by horizontal stroking with a blade. Avoid squeezing the skin. Keep children well clothed and screened after dusk when mosquitos are at their worst. Local swelling and redness can be treated with cold compresses, topical Benadryl, pramoxide creams, or oral Benadryl. Insect repellants may be useful on occassion(e.g. Off®, Cutter's® ). Avoid insect repellants in infants under the age of 6 months and, instead, employ careful avoidance measures.

Ticks can be removed by using tweezers and pulling firmly upwards. Skeedadle® is a good tick repellant. If a rash or painful joints develop 2-3 weeks after the bite, we need to see the child. Most ticks in Illinois do not carry Lyme’s disease.

Bacterial meningitis is an infection of the central nervous system that is rare but can lead to death or severe neurologic damage in infected persons. The most typical presenting symptoms are fever, neck pain, and lethargy. The three most common causes of bacterial meningitis in children are Hemophilus influenza, Streptococcus pneumonia, and Neisseria meningitis(also known as Meningococcus). We currently have vaccines for all three of these bacterial infections. The Hib vaccine (for Hemophilus influenza) and Prevnar® vaccine(for Streptococcal pneumonia) are administered to infants beginning at age 2 months.

The first Meningococcus vaccine, known as Menomune®, has been offered to college entry teenagers for many years now as this age group is more susceptible to this infection. Recently, a newer Meningococcal vaccine, Menactra®, has been approved for use in children as young as 11 years of age and offers a longer duration of protection than the earlier vaccine.

Meningococcal disease from Neisseria meningitis is the leading cause of bacterial meningitis in children ages 2-18 years. Antibiotics can treat and cure the disease if treatment is begun early enough. Still, about 1 of ten people who get the disease will die from it. People at increased risk from this infection include college freshmen living in dormitories, Military recruits, anyone traveling to Africa, people with damaged or missing spleens, immune deficient individuals, or people exposed during an outbreak. Currently, it is thought that only one dose of vaccine will be necessary, even when given at age 11 years. The Menactra® vaccine does not cover all the serotypes of this infection and does not guarantee 100%protection, but the vaccine is considered to be about 80-90% effective in providing antibody response to those vaccinated. Side-effects are mild and similar to other vaccines, including soreness and redness for 1-2 days, and in few individuals, headache, fever, or chills.

This vaccine has now been recommended by the American Academy of Pediatrics for all children ages 11 and up. Unfortunately, the vaccine has been in such demand that there is already a shortage. Therefore, we are offering the vaccine to all college entry patients, but we will defer offering the vaccine to all children ages 11 and up until the shortage is resolved. We prefer to vaccinate children at the time of their annual well exam as this is most practical.

Mumps infection is caused by the mumps virus. The most specific symptom of mumps is swelling of the salivary glands, especially the parotid gland just in front of the ear. Other non-specific symptoms may include fever, muscle aches, headaches, tiredness, and poor appetite. Other less common symptoms may involve inflammation of the brain and inflammation of the testicles. There are other complications of mumps as well, but they are very rare. Mumps is spread from person to person by sharing saliva directly (kissing, utensils, food, cups), or by airborn droplets. Fortunately, most cases of infection resolve without any complications. In fact, one-third of people infected will have no symptoms at all. Treatment is supportive, including the usual complement of rest, fluids, and pain medications.

The mumps vaccine was first brought into wide circulation in 1967. Prior to that, there would be over 200,000 cases each year in the United States. Before this recent outbreak, mumps infection had decreased to fewer than 300 cases per year. Recently, there has been an outbreak of mumps in Iowa (815 cases) with some cases in other Midwest states, including Illinois. This current outbreak is affecting mostly people in their late teens and early 20's. It is possible that many of these individuals may not have received the recommended two doses of vaccine. It is also likely that some people don't get fully protected after getting both vaccine doses. It is not surprising that the vaccine's immunity may wane over time, as has been the case with Measles. The most important way to combat this infection is to encourage compliance with the recommended two doses of vaccine. There are no plans to add a third dose of vaccine at this time.

Childhood obesity is becoming a national concern. Fifteen percent of school age children are overweight and another 15% are considered ‘at risk’. Pediatricians have traditionally focused their counseling on healthy eating choices, but more attention should also be directed to portion sizes as well. The following tips may help kids eat healthier and trim down a little:

• After age 2 years, beverages can be limited to water and skim milk. All other drinks should be calorie free such as ice tea or diet soda. Juices should be greatly limited or avoided; instead, use fresh whole fruits and water. Diet drinks with sugar substitutes can be avoided by simply drinking water instead.
• Portion sizes of carbohydrates, including potatoes, noodles, cereals, breads, rice should be limited to single portions at any given meal. “Second helpings” should be avoided.
• Avoid all fried foods, such as French fries and fried fish or chicken. Instead, use skinless grilled cuts of chicken or fish.
• Red meats should be offered in moderation, such as 3 times per week.
• Allow only one dessert item a day, such as a candy bar or piece of cake. It is unreasonable to expect kids not to eat these foods at all, just apply the “one a day” rule.
• Avoid snacking outside of the three main meals and two designated snack times. At snack times, offer fresh fruits and vegetables, thus avoiding the excessive intake of starches.
• Also, no snacking away from the kitchen table. Especially, avoid snacking while watching TV.
• Tell your kids they need to eat at least one fruit a day and one green vegetable a day. More, of course, is preferable.
• Never emphasize to a child that they must “clean their plate”, instead tell them to eat based on their hunger cues and when they feel full, stop. Put less food on their plate as a way to discourage food waste. Preferably, let the child take their own food portions.
• When the child has already eaten healthy portions of the basic staples and you hear the comment “But I’m still hungry,” offer more fruits or vegetables and that’s it.

Evidence has now accumulated to support a positive role for certain dietary oils, called Omega-3 fats, which provide significant health benefits. Beneficial Omega-3 dietary oils refer to three distinct dietary fats: (1) ALA- alpha-linolenic acid, (2) EPA-eicosapentaenoic acid, and (3) DHA- docosahexaenoic acid. EPA and DHA are marine in origin and considered ’Fish Oils’. Alpha-linolenic acid (ALA) is vegetable in origin (i.e. flaxseed oil, canola oil, and soybean oil). These dietary intakes of Omega-3 oils have been shown to decrease the risk of coronary heart disease in susceptible people. These oils have also demonstrated a beneficial effect on decreasing triglyceride serum levels in individuals who have abnormally high levels. Since coronary artery disease may begin as early as the 2nd decade of life, it is important to support healthy heart dietary practices during the pediatric and adolescent ages.

Current adult recommendations for ALA intake are about 2 gm per day. Adult recommendations for EPA and DHA combined are about 1 gm/day. For healthy children and young adults, it is recommended to ingest fish twice weekly. More fish ingestion than two servings per week may expose children and adults to excessive mercury intake and should be avoided. For those who do not eat fish, then it may be reasonable to take fish oil supplements. However, there is no current pediatric or adolescent recommendation on this issue either from the American Academy of Pediatrics or from the FDA. Exact recommended intake amounts for children have not been established yet. For children over 10 years of age who are not eating fish, it may be reasonable to offer one fish oil capsule (300mg) per day pending further studies on recommended daily intakes. These fish oil supplements should be well purified and free of contaminants such as mercury. The fish oil supplements available at the pharmacy typically contain about 300mg of DHA and EPA combined.

Dietary sources of omega-3 oils are indicated in the adjacent tables. Salmon, for example, contains about 0.6 to 1 gm omega-3 fats per 3 oz serving. ALA supplements are available, but it is preferable to focus on healthy dietary vegetable choices rather than take ALA supplements for children and adolescents. Looking at DHA and EPA content of various fish sources, it would be difficult to obtain 1 gm per day without eating fish everyday. Therefore, logic indicates that supplements may become common practice in the future. Our goal with health education is to be one step ahead of the future.

OMEGA-3 RELEVANCE TO PREGNANT WOMEN AND INFANTS:

Pioneer research by Mead-Johnson (makers of Enfamil formula products) determined that human breast milk contained significant amounts of DHA and another fat called ARA (Arachidonic acid) and that these fats were important in the developing brain of infants. These fats were then added to their infant formula products. Studies confirmed a positive role in brain development for those infants who were fed supplemented formula compared to non-supplemented formula and comparable to breast fed infants. Since then, other formula manufacturers have added these fats into their formulas. In addition, pregnant women and lactating women are recommended to take these oil supplements to ensure adequate amounts in their breast milk and for the developing fetus in utero. Since the fetus is at increased risk of mercury exposure, pregnant women must be careful to limit their dietary fish intake to no more than twice weekly.

Pertussis is also known as “whooping cough” and is caused by the bacteria Bordetella pertussis. Although all children are vaccinated beginning at age 2 months and ending at age 5 years, immunity wears off about 5 years after vaccination, which leaves children ages 10 and older, as well as adults, susceptible to this relatively common bacterial infection. Over the past several years, cases of pertussis has been increasing with several outbreaks occurring in our community.

Symptoms include three phases:
The first phase, called catarrhal, lasts 1-2 weeks and acts much like the common cold with runny nose, fever, sneezing and nasal congestion.

The second phase, called paroxysmal, lasts 2-4 weeks and is characterized by intense coughing spasms that may be associated with vomiting and a whoop sound from taking a deep inspiration after a coughing spell. The catarrhal phase is the time that pertussis is usually suspected and either tested for or treated.

The third phase is the convalescent phase and can last 1-2 weeks with gradually diminishing cough.

Defining pertussis infection requires that certain criteria are met. The cough must be present for at least 2 weeks with the presence of either (1)paroxysms of coughing spells, (2)inspiratory “whoop” sound, or (3)cough induced vomiting. These criteria help distinguish pertussis from other common conditions such as viral upper respiratory infections, sinus infections, allergies, or asthma, and many more conditions can cause a prolonged cough. Confirming the diagnosis with laboratory tests is difficult because these tests can be falsely negative and pertussis culture can take several weeks to grow positive. Still, obtaining confirmatory results may be important in some cases, such as newborns or very ill individuals, whereby a specific diagnosis is very important. In other cases, treatment empirically with antibiotics may be justified when laboratory testing becomes very difficult or inconvenient. Pertussis is most serious in the newborn and young infant because the pertussis illness can lead to a stoppage of breathing or severe pneumonia.

Treatment is with the antibiotics, erythromycin or azithromycin. Treatment may not necessarily reduce and shorten symptoms, but it will reduce the chance of transmission of infection to others. If your child has had a close contact with a known pertussis infected person, prophylactic treatment is indicated even if there are no symptoms. A close contact would be people living in the same household, same daycare room, or same classroom. More distant exposures should only be treated if symptoms develop.

There are efforts now to test and implement a vaccine that can be given to children beyond age 7, adolescents, and adults in order to provide more universal protection and limit the rise of pertussis. Such a vaccine would be a welcome addition in our efforts to control this disease.

This is a common problem and represents an infection of the white of the eye. Treatment requires antibiotic drops or ointment by prescription for 3-7 days. Most of the time, you can call us during regular office hours and we will phone in a prescription. If a child is in severe pain, history of trauma, or has blurry vision, then you should page us promptly. Also, if after 5 days of treatment, symptoms have not improved, then you should call and schedule an appointment.

Building Self-Esteem
One of the most important and fundamental challenges of childrearing is building a sense of self-worth and self-esteem in your children. There are many things parents can do to promote self-esteem. Some of the key things are listed below:

• Positive Strokes - Catch your child being good, even if it’s an ordinary and “expected” behavior, and let him know with a hug, kiss, or comment how proud you are. Verbal praising should comment about the activity he is doing, like “That’s a wonderful drawing”, rather than blanket statements like “You are so good.” Children also love third-hand compliments like “Your daddy told me how well you did at soccer practice.” Try to stress personal achievement, rather than competitive achievement.
• Physical Contact - The more you can gently touch, hold hands, hug or kiss your children, the more you send a very concrete message of caring. This takes more effort as your kids grow older, but is equally as important.
• Encourage Self-Control - Children gain self-confidence by participating in decisions that guide their daily behavior. Give your children choices and make them feel llike they’re in control. Of course, this is not always possible.
• Limit Setting - Set reasonable and CONSISTENT limits for your children’s behavior. If children know what is expected of them, what is acceptable and unacceptable behavior, it makes their decisions much easier and contributes to self-confidence.
• The Two I’s - When children exceed their acceptable limits of behavior, be quick to institute the two I’s: (1) Isolate your child away from the problem area and away from the parents, and (2) Ignore your child until they settle down or for several minutes if they remain quiet. This is the most effective form of time-out. Don’t play games with your child by trying to get him/her to necessarily stay in a chair or corner. It’s more important that you just put the child somewhere and then ignore him/her no matter what they do after that. Pretend like the child is a ghost- you can’t see them, hear them, or feel them until they acquiesce and settle down.
• AVOID Lecturing, Yelling, and Nagging - Keep you comments short and constructive. Remember, with children of any age, your actions mean everything and your words mean very little.
• AVOID Back-Handed Compliments - Comments like “It was nice of you to share your toys today. At least you didn’t create a fight like you usually do.”
• AVOID hitting and spanking - All this does is send a message that it is OK to use violence as a means to resolve problems.

Strep Throat - Scheduling Throat Cultures
Strep infections are characterized by the symptoms of sore throat, fever, stomach ache, and headache in a child. Strep throat infections are treated with antibiotics. Most sore throats are not Strep infections, but caused by common viruses. Since viral infections do not require antibiotics, it is important to make a definite diagnosis of Strep throat by doing a throat culture. Certainly, if the child has a sore throat with other symptoms such as fever, headache, stomachache, or tender neck glands, the incidence of Strep is increased greatly. Strep is not common under the age of 3 years.

If you suspect that your child has a "STREP" throat infection, then you can schedule a nursing appointment that day to do a THROAT CULTURE. On weekdays, most throat cultures are done between 11:00 and 12:00 and then again between 3:00 and 4:00 pm. Please call our office to schedule throat cultures. Cultures can be done at other times if required by your schedule. Remember, when you call to schedule a throat culture, you will not be examined by a physician unless you schedule a doctor's appointment when you call. If a nursing appointment only was scheduled, but you change your mind and later request a physician's appointment, then the physician will examine your child after previously scheduled patients have been seen. You can avoid this situation if you schedule a physician's appointment to begin with.

Proper sun protection will help your children from getting painful sunburns. Infants and young children should wear cover shirts at all times, even in pools if their shoulders are out of the water. Sunscreens should have an SPF factor above 30. Remember, you may have to apply sunscreen several times during the day. Common brands include Johnson's Baby Sunblock®, Waterbabies®, and Sundown®.

Sunburns should be treated with cool tap water soaks or compresses to the burned areas for 10-15 minutes, 3-4 times a day. A bland emollient, such as Lubriderm®, Vaseline®, Nutraderm®, Eucerin®, Aloe preparations, or others can be applied topically. Use Acetaminophen for pain relief. If there are large blisters forming, leave them intact and seek medical attention if the burn is that severe.

Swimmer's ear is a common and painful condition that may develop in any child who swims a lot. If your child has a painful ear, usually worsened by moving the earlobe around, then he/she should be examined. If this occurs on the weekend or after hours, you should immediately restrict swimming. The child can be seen within the next 1-2 days and prescription medication started. In severe cases, a follow-up exam in 7-10 days may be necessary and swimming may need to be restricted for 7-14 days.

After the initial infection is treated, the child should be placed on drops to help prevent swimmer's ear from recurring later. These drops can be bought without prescription(i.e. Vosol), or they can be made by mixing a solution of white vinegar and rubbing alcohol in equal amounts(1/2 : 1/2). Use 2-4 drops in each ear canal after swimming.

Nothing creates more discussion and opinions than teething in children. Over the years, teething has been blamed for nearly every cold symptom, including runny nose, fever, cough, and diarrhea. We believe that teething causes some mild irritability and increased drooling with a desire to chew on things. The other symptoms, including fevers above 101, diarrhea, runny nose, or severe sleep difficulties, are not likely to be related to

Many infants begin drooling a lot and putting nearly everything in their mouths starting at age 3-4 months. This behavior reflects the infant's need to explore with their mouths, which subsequently induces more drooling. This is unlikely to be related to teething, since actual teething occurs a little later in most infants at age 6-8 months.

Please note the typical teething schedule described below. Also note that many children do not follow the typical teething schedule. This usually represents normal variation.

In our continuing series on nutrition, we hope to educate our families on all aspects of nutrition, featuring a different nutrient or nutritional subject with each newsletter. Now, we will discuss Vitamin B6, also known as Pyridoxine. B6 is involved in many functions of the body, including the immune system, nervous system, and basic metabolism or nutrient processing. Recommended RDA's are included in the table below. Deficiency of Vitamin B6 is very rare since most foods contain this vitamin. For those rare cases of B6 deficiency, symptoms may include skin irritation, inflamed tongue, confusion, depression, nervousness, fatigue, cracking of the lips, seizures, and anemia. Too much B6 intake can also result in toxicity with symptoms of muscle incoordination, numbness of hands or feet, and impaired reflexes. The upper limits of intake for vitamin B6 is 100mg per day.

Sources of vitamin B6 in foods are indicated in the table below. People who may require Vitamin supplementation of B6, include the elderly, cigarette smokers, and alcoholics.

More controversial claims that Vitamin B6 supplements may improve certain conditions, such as PMS, headache, depression, and carpal tunnel syndrome, have not been proven. Certainly, a multivitamin including B6 should be sufficient to prevent any chance of a deficiency without risk of toxicity. A typical adult multivitamin contains 6 mg of B6. Considering the RDA's as indicated below, this is more than enough for anyone. A Children's Complete vitamin may contain 2 mg, which is clearly more than adequate for a healthy child.

The West Nile Virus
Many questions have come up regarding the West Nile Virus(WNV). It should be emphasized that this is an uncommon condition that does not typically pose a serious problem to children. Even in high risk areas, less than 1% of mosquitos will be infected with the WNV. Of bites that occur from these 1% of infected mosquitos, less than 1% of those will result in a serious health problem, usually in the older population. The virus cannot be transmitted from person to person, only by mosquito bites.

West Nile Virus can cause an infection of the brain called encephalitis. The disease usually resolves on its own without any specific medication. In fact, there is no available specific medication for West Nile Virus. This means that treatment is based on supportive measures such as providing fluids, rest, fever medication, and pain medication. Most infected individuals will have a mild illness, with symptoms of fever, headache, and body aches. These are nonspecific symptoms seen with just about any common virus. The more concerning symptoms of severe infection include severe neck pain and headache, lethargy, disorientation, and seizures. These more severe symptoms can be seen with different causes of meningitis or encephalitis, including many different viruses and bacteria. Certainly, anyone with these more concerning symptoms should prompt an immediate call to the physician.

From a preventative standpoint, the best recommendation is to avoid mosquitos by keeping kids indoors at dusk and limit their exposure to environments where mosquitos are around and biting. Also, use insect repellants with DEET (over age 6 months) if you must be in exposed areas. Teach your children to avoid handling dead birds or any dead animal, even though transmission would still be unlikely from handling a dead bird or animal.