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Embracing Your Child’s Silliness

Written by Denise A. Somsak MD

Photo Credit - peasap

Every household and every child has a silly meter, funny bone, goofy factor. At five years old, our daughter’s understanding of language has taken off. She knows what sarcasm is. She is conversational about a variety of topics.

She knows how to make rhymes. She has a preference for stories about magic and happy endings. She likes simple poetry. She knows the words to songs from Mary Poppins and Sound of Music. She can even sing in Spanish: La Bamba.

The downside of this mastery of language is her attempt at humor. She tells knock knock jokes without quite understanding the punch lines and riddles without getting the solutions. She loves to say things like poopy face, booty, and booger sandwich.

If we do not laugh at her verbal antics, she moves on to physical comedy. She imitates the odd noises her autistic brother sometimes makes and does a dance with them which cracks up our toddler.

She will crawl under our legs and yes sometimes chew our socks. The other day I told her, “Keep your teeth off my feet. No mother should have to say that to her five year old.”

She giggled so hard she lost her grip on my socks. She laughed at her own ridiculous behavior repeating, “Keep your teeth off my feet.”

We probably allow more silliness than most families. On good days we meet challenges with humor not anger. Our son is sweet, but he is odd. When our daughter tries to give him a drawing or share a piece of candy, he usually drops it on the ground and walks away sometimes departing with a thank you.

While of course we are working on his communication skills, we also feel the need to rescue her self esteem after this type of interchange. Most of the time we do this with humor. Over time, her story telling skills have embellished her brother’s actions.

“Mommy David looked at my picture and then dropped it to see if it would blow in the wind.”

We embrace our daughter’s silliness. We see it as a sign of normal development. We rejoice that she understands humor and language in a way her autistic brother never will.

Check out the National Institute on Deafness and Communication Disorders or the American Speech-Language-Hearing Association for language milestones at various ages to see how your child is developing and things you can do to foster communication skills.

Dr. Somsak was born and raised in the heartland. She recently joined Pediatric Associates of Cincinnati. She’s a no frills, practical gal. Dr. Somsak blogs regularly at Pensive Pediatrician 

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To Teen Guys: Yes, We Really Need To Check ‘Em

Recently, I was called to our community hospital to consult on a teenager with severe lower abdominal pain. The young man, whom I’ll call Dan (not his real name), lived outside of our community, and I’d never met him before. I arrived in Dan’s hospital room, introduced myself, and started talking to him and his mom about his symptoms. After reviewing his chart and getting his history, I proceeded to examine his heart, lungs, and belly. Then I told him, “OK, I need to check your privates, to make sure everything looks healthy and normal. Is that OK?” I was unprepared for Dan’s surprised, negative, very forceful reaction: “NO WAY!” and his mother’s simultaneous exclamation, “No, you DON’T need to do that!”

I asked permission, as I always do, and he definitely hadn’t given it! So I backed up a little bit. “I know it’s embarrassing to have your privates checked. But we don’t have a good explanation yet for the pain you’re having, and if it’s related to something going on with your genitals or your bottom, I definitely don’t want to miss that.”

Dan was still pleasant, but I could see in his eyes he was definitely not buying my explanation. “If you would feel more comfortable with a man doctor, or without your mom in the room, we can definitely do that.” His horrified expression spoke volumes; I think he would have preferred a spinal tap without anesthetic.

His mom said, “Why do you have to do that? The emergency room doctor and the surgeon who’ve seen him today didn’t feel that was necessary.” I explained, in that case, if no one else had checked “down there,” I felt even worse about blowing off that part of the exam. Dan, still with the deer-in-the-headlights look, volunteered, “I had it checked at the clinic where I got my sports physical done. Can we count that?”

We talked about it some more, but Dan stood firmly to his position: “My genitals are not your business, doc!” In the end, I never did perform this important exam.

Clearly, I failed Communication 101 with Dan at explaining the importance of a complete body check, especially in a kid who’s sick enough to be in the hospital. I suspect if I’d known Dan better, he might not have felt so awkward. What I really wanted to communicate was this:

  • It needn’t take very long. A comprehensive external genital exam takes under a minute in boys.
  • We can do whatever it takes to satisfy modesty and cultural appropriateness. It’s OK to kick your mom out and have your dad come in. Or vice versa. It’s OK to request a male doctor. Or vice versa. It’s OK to have a chaperone — in fact, I prefer it that way.
  • We do find problems “down there.” Honestly, most doctors are in such a hurry – we wouldn’t waste time doing something if we never found a problem. In Dan, a rectal exam for his kind of pain would have helped reduce his need for expensive, high-radiation tests. From time to time, either as part of a problem check or as part of a checkup, we’ll find hernias, hormone problems, cancer, eczema, abnormal birthmarks, ulcers, urinary issues, and infections of many kinds (not just STDs). Many years ago, a wise pediatric infectious disease physician taught me to check the whole body – even the unmentionables – for clues to “mystery patients.” He was right, and since then I’ve diagnosed herpes encephalitis, Behcet’s disease, and Crohn’s disease – based primarily on what I found in the genitals and rectal area.
  • Parents, assume nothing. You may think your child has no concerns about his genitals because he’s never mentioned them to you. You may think your son could never have an STD. You may think your son would notice if he had a small amount of blood in his stool. You may think he knows what a hernia or testicular mass feels like. And all these things might be completely true. But they might not.
  • Getting it all “out in the open” makes it easier for a child to bring up a concern. Let’s say a young man discovers a small lump on his genitals, and it’s worrisome to him. When I’m doing a genital exam and already have things uncovered, it seems easier for a concerned teen to “casually” point to the spot and say, “Hey, [indicating] is this OK?” I can easily say, “Oh yes, that’s a ______ and lots of guys have those. They’re normal and won’t interfere with peeing or sex or anything. I have a great handout about that for more information.” It’s harder for a kid to bring up issues “down there” if he thinks that a genital exam isn’t part of the equation. Will I think he’s a pervert or weird for asking: “So… doc…. I have this… thing… on my… privates?”
  • Your female counterparts seem to have gotten over this. I’ve noticed (and I’m not sure why – maybe because I’m a woman) that I rarely have girls or their parents look horrified or surprised when I ask to check a girl’s breasts or pubic area. Much more frequently, I have mothers ask me, “Are you sure 13-year-old Kathy doesn’t need a complete pelvic exam, now that she’s having periods?” Sometimes this is a subtle hint to check for pregnancy or STDs; sometimes parents are trolling for information about their child’s sexual activity, or lack thereof. But much of the time, parents know that ensuring “the lady parts” are important to keep healthy, just like everything else.

So: It’s OK to be embarrassed. It’s OK to sigh, blush, groan, and/or roll your eyes at the doctor. But guys, yes, we really need to check ’em.

Suzanne Berman is a general pediatrician in rural Tennessee. She tries to minimize embarrassment to her husband and son, too.

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How to get your child to eat vegetables

Written by Jesse Hackell MD

Let me start by saying that I am not of the belief that the job of a parent is to FORCE a child to eat any particular food. Attempts to do so usually result in mealtimes which are unpleasant and stressful for both parents and children, and negate any attempts to have family meal times as a time of sharing and interaction.

That said, we all know that children are often picky in their accepted food choices, and that they do not always cooperate in eating the variety and selection of foods which we, as parents and physicians, would like. There is no dispute that a child’s diet should include fruits and vegetables, for many reasons: These foods provide vitamins lacking in other foods, they contain fiber which is needed for normal intestinal function, and they are generally lower in calories than processed foods, while still providing the same feelings of fullness, and thus may help to change the continuing trend towards childhood obesity.

Getting your child to accept and eat vegetables is a lifelong process, starting when the very first foods other than breast milk or formula are presented (it could even be suggested that breast-fed infants are introduced to vegetables through the maternal diet, knowing as we do that maternal intake does contribute to the taste and quality of the milk, but that is a different topic.)

There has recently been a change in what is recommended as first foods for infants. In the past, processed single grain cereals were the starting food, followed by the addition of vegetables and fruits. Now, however, researchers believe that the order in which foods are introduced to an infant makes little difference in eventual food tolerance. Thus it would make sense to introduce a child to foods such as vegetables which are both less processed and less sweet than other foods, and to let the child learn that these tastes (and some vegetables certainly do have strong flavors!) are just a natural part of eating. Adding whole grain baby cereals, as opposed to processed white cereals, further introduces stronger flavors, and makes them a part of the child’s diet from the start, and might well lead to better acceptance in the future.

As your child gets older, individual preferences become stronger. We can hope that early exposure might make this transition a non-issue, but that is not always the case. So we need to have techniques to make vegetables more palatable to toddlers and older children as well.

Many vegetables benefit from brief cooking, which softens them and make them more readily manageable by toddlers. Offering cooked or frozen and reheated pieces of many vegetables, such as carrots, will make them easy to handle for your children from their first attempts at self-feeding. And the nutritional value of these vegetables is far greater than the ubiquitous “puffs” of carbohydrates so often given to young children. Later, cooked and cooled broccoli spears, asparagus and carrots can be offered as a snack. Some children like to “dip” their vegetables in some sort of sauce, and I would suggest the use of plain balsamic vinegar as opposed to the common ranch dressing, which has far more fat and calories. For a child who will not eat a traditional tossed salad, vegetables and dip is a good prelude to dinner, and often can satisfy a hungry child home from school or play for long enough to enable the entire family to eat dinner together.

I do not believe that we need to “trick” our children, or disguise vegetables so they do not know that they are eating them, as so many people (such as “The Sneaky Chef”) are advocating. Nonetheless, common foods can and should be made with added vegetables, to benefit every member of the family. One favorite includes the use of vegetables in any dish made from ground meat—meat loaf, burgers, tacos or meatballs, for example. Using one pound of any ground meat (beef, veal, pork or turkey), take one cup of shredded carrots, one cup of shredded broccoli stalks (having steamed and cooled the florets for use with a dip), and one cup of shredded onion. Saute these in a little olive oil til soft, and mix with the meat, adding an egg if desired to hold things together. Add some bread crumbs, or even better, some rolled oats (not the instant variety), to add soluble fiber and beta glucans, which are thought to help control cholesterol, and form into a loaf, patties or balls, and cook as usual. The vegetables add moisture to the meat, as well as fiber to the diet, and they make the meat stretch further. You can also use chopped spinach or chopped artichoke hearts, which do not even need sautéing. Top with a tomato sauce, also prepared with added vegetables, for even more benefits.

I think the key here is to start doing this from the very first time your child eats these foods. Get them used to the fact that meatloaf simply has these flecks of orange and green in it, and they will not question the presence of the vegetables when they find them. If it becomes second nature for you to incorporate vegetables in everything you prepare, it will become second nature for your children to eat them as well.

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Potty Training: Reward Chart Glory

Written by Wendy Sue Swanson MD

Maaaaaaajor milestone in our house today. O filled up his first reward chart for potting training. Even bigger, last night just before he went to bed, O and I discussed that he only had two spaces left on the chart. Once filled, he gets a special trip to the toy store. Although seemingly unclear about the rules and benefits of the chart last night, he told me he would wait until morning to pee.

Thing is, he did.

He awoke with a dry diaper. We felt like lottery winners! O went to the bathroom, peed in the toilet, and then came to find me this morning. His 4 1/2 year old brother did the reporting:

O peed much more than we thought he could this morning, Mommy.

I was astonished. I went to the toilet to see the evidence. Dark yellow bowl of pee. Immense pride….I think my heart pushed out a double-beat.

This has never happened; we’ve just started trying with underwear this week. These little people in our lives astonish…

I’m doubtful this will last into perpetuity at this point, and I understand the potty training road, like most roads, is very bumpy. But I do know this: reward charts really can help motivate potty-trainers.

Click on the link to continue reading…

 

Dr. Swanson practicing pediatrician and the mother of two young boys.  She is passionate about improving the way media discusses pediatric health news and influences parents’ decisions when caring for their children. Dr. Swanson blogs regularly at SeattleMamaDoc.com

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Fly the Contagious Skies

Written by Herschel Lessin MD

As a practicing pediatrician and co-lead author of the American Academy of Pediatrics’ national vaccine policy statement, I was horrified when I saw the news that Delta Airlines had accepted an ad broadcast during their in-flight entertainment that was sponsored by the National Vaccine Information Center.

This notorious anti-vaccine group with the deliberately misleading name, paid for a three minute “public service announcement” that is anything but “public service”.

In this commercial, the group tries to hide its virulent anti-vaccine positions behind comments that there are better ways to prevent the flu than a flu vaccine. They grossly misrepresent the results of a recent study on the efficacy of influenza vaccine, making it sound almost worthless, which was clearly not the case nor the conclusion of the authors of the study.

I wonder if anyone asked them why you cannot do both?? That thought would, of course, never cross their minds because it contradicts their scientifically unsupportable and dangerous position that vaccines are bad.

The President of the American Academy of Pediatrics, Dr. Robert Block, has written Delta a strongly worded letter, as have other reputable scientific and medical organizations. Block wrote: Displaying NVIC’s message on Delta flights is, “putting the lives of children at risk, leaving them unprotected from vaccine-preventable diseases.”

He asked Delta to remove it. (This is the same group that put a huge billboard opposing vaccines in Times Square, which was taken down after widespread outrage at its misleading and false statements.)

Air travel in winter, with its increased risk of confinement in a closed space with hundreds of people and their illnesses, using a recycled air supply, is hardly the place I would want to place my children and myself at risk.

Here is the note that I wrote to Delta Customer Service on their website. I encourage everyone who cares about the health and safety of children to do the same.

As a pediatrician and Platinum Delta member, I am utterly appalled by your company’s poor judgment in running an anti-vaccine ad by the National Vaccine Information Center. This group is part of the anti-vaccine fringe who ignore all scientific evidence and promote fear about the totally unsupportable and disproven alleged risks of vaccines. This group and its ilk are responsible for putting countless children at risk for death and damages from vaccine preventable diseases due to their persistent and unsupported opinions about the risks of vaccines. This ad should be removed immediately. You should be ashamed of yourselves for spreading the distortions and mistruths promoted by the zealots running this group.

If you would like to protest Delta Airlines decision to run these ads, take a moment to sign this online petition by clicking on the link below

http://www.change.org/petitions/tell-delta-to-stop-putting-their-passengers-health-at-risk

Dr. Lessin has been a practicing pediatrician in the Hudson Valley since 1982. He is a founding partner and serves as both Medical Director and Director of Clinical Research at the Children’s Medical Group

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In Defense of Cough

Written by Nelson Branco MD

 

There are always coughing kids, but this time of year the number of visits to pediatricians for “cough” begin to outnumber almost everything else. Once the kids have been back in school for a few weeks, and they’ve had a chance to cough and sneeze all over each other, the cough season has begun.

Most parents worry that their child might have asthma, pneumonia or some other infection causing the cough. Your doctor will be running through a much longer list of possible reasons for cough – pneumonia, wheezing, croup, asthma, bronchitis, congestive heart failure, viral upper respiratory illness, bronchiolitis, reflux, post nasal drip due to allergies or sinus infection, habit cough, aspirated foreign body and a few others. It usually takes only a few questions to narrow down the possibilities, but sometimes it takes a bit more work, especially if the cough has been going on for some time or has not responded to treatment.

Obviously, many of these causes will have a specific treatment – antibiotics for pneumonia or sinusitis, steroids and albuterol for asthma, antihistamines or nasal steroids for allergies, antacids for acid reflux. But how about if your child has a viral illness? These illnesses – upper respiratory infections (the common cold), tracheitis, bronchitis, and bronchiolitis, are usually self-limited and don’t need any specific treatment.

Cough is a protective reflex that keeps the lungs clear of mucous, irritants and infection. Cough is usually involuntary, and it’s difficult to suppress a cough when your brain says it’s necessary. Cough can interrupt sleep, be disruptive at school or irritating to your child, and cough is a very efficient way to pass infections to others (Cover That Cough!). So, given all this, why don’t we generally prescribe cough suppressants? The first reason is that most don’t work. Even codeine, when studied in large groups of children, doesn’t work well at suppressing cough. Over-the-counter medications don’t work too well either, though there are many available and lots of people use them.

Another reason not to suppress all coughing is to prevent pneumonia or lung infection. Cough is a helpful reflex – it keeps mucus from the throat and upper airway out of the lung, and helps move mucus up and out of the lung. Most of this mucus is swallowed; this is fine. The lungs are lined with cells that have tiny hair-like projections called cilia. These cilia all beat in one direction to help move mucus and debris out of the lungs, like an escalator. The cough helps move things along even faster.

One of the biggest problem with cough is that it can interrupt sleep. Because sleep and rest is important to help fight off any virus or other infection, we often recommend treatments that will help with sleep. A teaspoon of honey given at bedtime has been proven to be just as effective as an over the counter cough syrup. You can also use herbal tea with lemon and honey, and vaporizers/humidifiers, steamy bathrooms, and saline nose drops can help to thin the mucous so that it’s easier to cough up.

Remember – not all cough is bad. Sometimes cough is a sign that there is a problem that you need to talk to your doctor about. Most of the time, though, cough is just doing its job to keep the lungs clean. Teach your kids to wash their hands frequently, cough into their elbow instead of onto surfaces or their hand, make sure to get a flu shot and, as much as possible, avoid people who are obviously sick.

 

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP.

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Mom and Dad, Did You Ever…

Written by Nelson Branco, MD, FAAP and Ellen I. Branco, MSW, MPH

Adolescence is filled with challenges – at school, at home, with friends, on stage and in sports.  Even their own body betrays them from time to time.  Acne, hair, changing bodies and voices, parents, siblings and friends are all possible sources of gut-wrenching shame for a normal teen.  Parents of teens have challenges too – and high on the list is the challenge of talking about important topics like sex, drugs and rock and roll.  The natural process of becoming independent, separating from parents and identifying with peers is difficult but ultimately rewarding.   Through it, teens need their parents to step back, set appropriate limits and be there when they fail or hit a bumpy patch.
This is also a time when experimentation with alcohol and other drugs often happens.

According to the 2009 Youth Risk Behavior Survey, 37% of high school students have tried marijuana and 73% have had a drink of alcohol at some time in their life.

Lots of teens will do this without their parents’ direct knowledge, but when parents learn about their child’s drug or alcohol use, it can be an opportunity to have an honest and frank talk about difficult subjects.  For the teen, there is often a mix of dread at being found out but also relief that they aren’t keeping a secret any longer.

Research shows that open talk about drugs or alcohol between parents and teens has a protective effect, and can lead to students waiting longer to experiment.

In this talk, parents need to be explicit about what they think, and not assume that their actions demonstrate their beliefs.  Teens are acutely aware when parents are saying one thing but actually feel differently, even if the difference is subtle. 

Students and parents alike have a lot of questions about marijuana.  They are surrounded by news stories about medical marijuana, the legalization debate, questions about enforcement of current laws, and almost constant references to marijuana and marijuana use in popular media.

For the teen, the question is: “How bad is it really? How seriously do I take this?”  The message is often not clear, even from their own and their friends’ parents.  Some parents say “I smoked pot, it wasn’t a big deal, and I turned out fine,” and others “My nephew smoked pot and everything went downhill from there.”  Adults understand that both can be true, but this can be difficult to communicate to a high school student. Younger adolescents see the world as black and white – marijuana, like other things, is an either/or – good or bad, which one is true?

As parents, you must be clear about what you want to communicate to your teen.  Here are five points that may be helpful.

1. Every person’s brain reacts differently to THC, the active drug in marijuana.  You have no idea how you are going to respond to a particular drug until after you have tried it.  Some of the factors that affect response to drugs are genetics, setting, mood and stress, but ultimately your brain is unique and will determine how you respond.  What is OK for a friend or sibling could create a very different reaction for you.  Even the same drug could be very different a month later in a different situation.

There is also research showing that a small percentage of teens with a predisposition to schizophrenia put themselves at risk of having a psychotic episode at a younger age if they become chronic users of marijuana.  More research is being done on this topic, as well as the connection between chronic marijuana use and other psychiatric disorders.  It’s critical to be honest with your teen about any family history of depression, schizophrenia, bipolar disorder, substance abuse or other mental health disorder.  This family history puts them at risk, especially if they become a chronic user of marijuana.

2. The marijuana that people smoked 25 years ago is different than what is available today.  There is a greater range of THC levels in marijuana, especially marijuana grown in Northern California. The average THC concentration 25 years ago was somewhere in the range of 3%.  Marijuana now has a THC concentration in a wide range from 3 to 15%.  In general, the marijuana available today is more potent that what was around in the past.

3. You can’t become addicted to marijuana, but you can become dependent. This means that chronic users of marijuana become dependent on this drug to help them cope with stress, failure, anxiety, boredom and any other uncomfortable emotion.  Chronic marijuana use can also lead to Amotivational Syndrome, which is very familiar to all of us who have laughed at the “stoner” character onTV or in the movies.

4. If you are going to smoke pot, it’s better to wait.  The latest research on teen brains shows that a teen’s brain is still in an intensive developmental phase, with lots of growth and pruning of connections in the frontal cortex.  THC is a potent chemical and affects the parts of the brain that control short term memory, learning, coordination, and problem solving.  The latest brain imaging tools have given us a new vantage point into the developing brain – stay tuned for more information on this in the years to come.

5. There are real legal repercussions to being caught with pot.  There could be repercussions at school, at home and with the police.  These repercussions can be harsh if a teen is caught with a large amount of marijuana, is driving while under the influence, or in a vehicle where pot is being smoked.  Legally, your teen may face anything from a fine to jail time, and any school disciplinary actions related to drug use may affect their chances for college admissions.

Many parents wonder how much to share of their own marijuana experience.  In general, it is best not to over-share.

You can tell your teen that you have smoked or experimented with marijuana, but you will have opportunities to share details as time goes on.  Even though you turned out fine, it could be different for your teen, and there are reasons why your teen should wait to experiment or use marijuana.

If you suspect your teen is already smoking pot, or if you find a pipe or marijuana, talk to them about it immediately. Many teens will say “it isn’t mine.”  Question that.  Even in the unlikely event that the pot is not theirs, a willingness to hide it for a friend means that they are either also using or close enough to someone who does that they can be convinced. If you or a teacher suspects your child is smoking marijuana at school, address it right away. This is a significant warning sign for a concerning level of marijuana use.

All  parents will have a different message around marijuana, alcohol and other drugs.  Some parents will convey the message that they want their teen to wait until they are older and then decide if they are going to drink or experiment with marijuana.  Others say absolutely no use. Others may be more permissive.  When you decide what message you want to convey, be consistent, firm and caring.  No matter what message you decide to convey, you must let your teen know that you want to talk about this if it becomes an issue for them or their friends, or if they have any questions.

This is an opportunity to have a real conversation with your teen about an important health topic.

You want your child to share what they know, what their thoughts and opinions are, and what their friends are doing. Please listen and then express your opinions, knowledge and concerns for their safety.  The ultimate goal is to keep our kids safe, and teach them how to have fun and relax without turning to a substance that may have a real impact on their health and learning.

Dr. Branco is a practicing pediatrician in the San Francisco Bay Area and is very active with the local chapter of the AAP. Ellen Branco is a School Counselor and Health Educator in the San Francisco Bay Area. She has been working at independent high schools and counseling since 2001.