Car Seat Safety

California child safety seat law requires that children must ride in a properly installed safety seat or booster until they are at least 4’8” tall and at least 80 pounds.

Safety Seat Guide:

• Infants must ride in rear-facing (facing toward the back of the car) safety seats until they are at least 1 year old and weigh at least 20 pounds.
• Children over age one and between 20-40 pounds may ride in a forward-facing car seat.
• Young children between 40 and 80 pounds (usually 4- to 8-yearolds) should ride in booster seats.

Common Cold

Definition and Causes

The common cold is a viral infection of the upper respiratory tract including the nose, throat and sinuses. At least 200 different viruses cause the common cold. Children get colds frequently because they are exposed to new viruses (especially in daycare, play groups, church nurseries, and preschools). Colds are more common in the winter because people spend more time together indoors breathing re-circulated air. Exposure to second-hand smoke increases a child’s susceptibility to colds. Colds are not caused by immune deficiency, tonsil problems, poor diet, lack of vitamins, cold weather, air conditioners, or wet hair or feet.

Symptoms

Cold symptoms include cough, runny nose, sore throat, and fever. At the beginning of a cold, the nose produces clear mucus. After a few days, the mucus changes to yellow or green. This is normal and does not mean your child is infected with bacteria that needs antibiotic treatment. Most cold symptoms are much better by 14 days.

Home Care

Any child over the age of 5 without other symptoms (such as fever) may be treated at home for up to 10 days. While your child feels ill, restrict activity to bed rest and quiet play. Offer extra fluids. If mouth breathing, use a cool mist humidifier at bedtime. Keep your child upright as much as possible to relieve difficulty breathing or you can elevate the head of the bed slightly.

For a stuffy nose, put three drops of salt water in each nostril and leave in for one minute to loosen the dry mucus. The salt water can be a product such as NaSal, Ocean, or Salinex, or you can make it by dissolving ¼ teaspoon of salt in eight ounces of water. For an infant, suck out the mucus ‘gently’ with a nasal aspirator. For a child, have him/her blow his/her nose. Repeat this procedure several times in a row to clear the nasal passages. Cleaning a young infant’s nose is especially important before feedings and sleep.

Antibiotics do not kill viruses nor make the cold symptoms go away sooner. Unnecessary antibiotics can be harmful.

When to Call the Doctor

Please call for an appointment if you suspect any of the following complications of the common cold.

• Bacterial conjunctivitis (symptoms: green or yellow drainage from eyes).
• Middle ear infection (symptoms: excessive crying or irritability, earache, rubbing ears, shaking head).
• Sinus infection (symptoms: runny nose and a daytime cough, without improvement after 14 days of illness, eyelid swelling, bad breath, facial pain).
• Croup (symptoms: a cough that sounds like a dog or seal barking, hoarse voice, harsh noise when inhaling, difficult breathing).
• Wheezing (symptoms: whistling noise when exhaling, skin sinking down between ribs when inhaling, difficult or rapid breathing).
• Bacterial pneumonia (symptoms: fever, sudden deterioration, very ill appearance, difficult or rapid breathing, grunting, chest pain).
• If your child seems excessively ill or is getting significantly worse.

If your child is under 3 months old, be sure to call if the rectal temperature is above 100.4 degree Fahrenheit or if it is over 104 degree Fahrenheit at any age.

Constipation

Definition and Causes

Constipation, the painful or difficult passage of large or hard stools, is a common complaint of childhood.  Normal frequency of stooling varies widely. For newborns, especially breast-fed infants, 5 to 10 stools per day may be normal.  For older infants and children, intervals of as much as 4 to 7 days between bowel movements in the absence of pain, unusual posturing, or straining are normal.

The vast majority of cases of constipation are due to functional problems such as faulty diet, improper use of medication, inadequate fluid intake, toileting problems, or behavioral stool holding.

Symptoms

The most reliable sign of constipation is pain or discomfort with the passage of hard or large bowel movements that usually manifest as crying, grunting, or straining. Infants normally will grunt, strain, and turn red or purple in the face for a few moments before the passage of stool. This is abnormal only if it is prolonged for more than a few minutes, if accompanied by forceful crying, or if it occurs repeatedly without a stool being produced.

Home Care

The following recommendations may be followed in managing constipation.

Newborn to One Year

Increase fluid intake with water and/or juice. A juice high in sorbitol, which softens the stool, is best. Prune juice and pear juice or nectar are examples. For infants under 4 months, the juice should be diluted half-and-half with water and 2 to 4 ounces should be given each day.  Commercial formulas cause a firmer, denser stool than the loose breast milk stool.  Frequent formula changes may aggravate constipation. Further, controlled studies have conclusively shown that the iron in iron-containing formulas does not cause constipation.

For infants over 4 months, the juices mentioned above may be given diluted or full strength and strained foods high in fiber such as peaches, plums, prunes, apricots, spinach, or peas can be given. Avoid constipating foods such as bananas, applesauce, carrots, or squash. Remember to avoid foods, which are choking hazards for older infants and toddlers such as raw vegetables, stringy vegetables, peanut butter, and popcorn. Do not use rectal stimulation, suppositories, enemas, or laxatives without first consulting with your pediatrician’s office.

Over One Year

Toddlers who are in the process of toilet training are especially prone to constipation due to toilet resistance and resultant stool holding. A casual, non-forceful approach to toilet training can prevent this. Further, a toddler may have had a large painful bowel movement, which may even result in a small anal tear called a fissure. This can cause avoidance of stooling due to pain.

To soften the stool at all ages regardless of the cause of the constipation, one must avoid or decrease consumption of constipating foods: bananas, white rice, white bread, cheese, milk, ice cream, yogurt, and cooked carrots. Foods which soften stools include prunes, figs, dates, raisins, peaches, apricots, plums, beans, celery, peas, cauliflower, broccoli, cabbage, whole wheat bread, bran muffins, natural bran containing cereals, shredded wheat, graham crackers, oatmeal, high fiber cookies, brown rice, popcorn, melons, and berries. Increasing fluid intake of water or juices such as prune or pear juice is important at all ages.

When to Call the Doctor

Contact our office if the stools are recurrently blood-streaked, constipation does not resolve promptly, severe abdominal pain and/or vomiting is experienced, or if your child is consistently passing stool matter in his/her underwear.

Diaper Rash

Definition and Causes

Diaper rash is any irritation of the skin affecting the diaper area. It can be caused by many things including strong urine, stool, wearing wet or soiled diapers for long periods, loose stools/diarrhea, or irritation from soaps, perfumes, lotions, creams and commercial diaper wipes. It may also be caused by certain foods and bacterial or yeast infections.

Symptoms

Diaper rash is characterized by redness and puffiness of the skin. It may be limited to the buttocks or found in the anal, genital or groin areas. You may notice mild chafing on your baby’s thigh where the leg openings of the diaper have rubbed or redness in other areas where the diaper irritates the skin.

Prevention

To prevent diaper rash:

• Change diapers frequently and immediately after a bowel movement.
• Avoid diaper wipes. Use a washcloth with warm water and soap only for cleansing bowel movements.
• Expose baby’s bottom to air frequently.
• Protective ointments like Desitin or A&D may be helpful.

Home Care

As soon as you notice any irritation in your baby’s diaper area, take steps to clear it up. The earlier you take action, the less stubborn and severe the rash will be.

• Keep the skin in the diaper area clean and dry.
• Check diapers every 15 to 20 minutes and change the diapers as soon as your baby wets or soils.
• Clean the area gently but thoroughly using warm water. Stay away from disposable wipes until the rash clears up. Use a mild soap sparingly and only after a bowel movement. Thoroughly rinse soap from the skin with warm water.
• When the skin is clean, gently pat dry without rubbing. Pay special attention to folds and creases.
• Apply a layer of a nonprescription diaper rash ointment like Desitin, Diaperene, or A&D Ointment.
• Avoid tight fitting disposable, plastic covered diapers. Use cloth diapers (without plastic pants) if possible or the “cloth-like” disposables one size larger than normal.
• Expose diaper area to air as much as possible every day, especially after changing diaper.
• If using cloth diapers, launder with a mild soap such as Dreft. When the cycle is completed set your machine for an additional deep rinse. Add one cup of distilled white vinegar to the rinse water. Complete the cycle and dry as usual. Do not use fabric softener or softener sheets in the dryer.

If you followed the above instructions for a few days and your baby’s diaper rash is no better, or is now bright red, having large patches with sharp margins and small red spots nearby, your baby may have a yeast infection. This can develop when your baby is on antibiotics or any time he/she has a diaper rash. Once your baby has had a yeast infection he/she may be more susceptible to it again.

A yeast infection is treated in basically the same manner as any diaper rash. In addition you will want to do the following:

• Add one capful of distilled white vinegar per gallon of water to the baby’s bath water.
• Apply one of the many over-the-counter yeast creams (Gyne-Lotrimin, Lotrimin AF, Monistat) to the diaper area 4 times a day after cleansing well with mild soap and warm water and patting dry.

When to Call the Doctor

Call your child’s doctor if:

• The baby develops a fever.
• The rash does not clear in 5 days.
• The rash appears to be getting worse instead of better.
• Blisters or pimples develop in the diaper rash.
• You have concerns.

Ear Infections

Definition and Causes

Acute otitis media is an infection (bacterial or viral) of the space behind the eardrum (middle ear).  In children, the eustachian tube (the tube that drains the ear) is shorter and more horizontal than in adults.  This results in poorer eustachian tube function.  In addition, children tend to get more respiratory infections.  With these infections, the eustachian tube can become inflamed.  Bacteria can travel easily from the throat to the middle ear and lead to infection.

Other risk factors for ear infections include:

• Daycare: Colds often lead to ear infections.  Children in group daycare settings have a higher chance of passing their colds to each other because they are exposed to more germs and viruses from the other children.  If your child has recurrent ear infections, he/she may benefit from a change to a smaller daycare setting or removal from daycare.
• Eustachian tube dysfunction/obstruction: This may result from allergies and enlarged or infected adenoids.
• Tobacco Smoke: Children who are exposed to second-hand smoke experience a higher risk of developing health problems, including ear infections.
• Bottle Feeding: Babies who are bottle fed, especially while lying down, have a tendency to experience more infections than breast-fed babies.  If you bottle feed your child, hold his/her head above the stomach level during feedings. Never let your baby have a bottle in bed.
• Age:Infants and young children are more likely to get ear infections.  The highest incidence is in children between the ages of 6 and 18 months.
• Genetic Issues: Children with problems such as cleft palate and Down Syndrome have underlying abnormalities that affect eustachian tube function.
• Inheritance: Children with parents and siblings with a history of ear infections have a higher incidence.

Symptoms

Ear infection symptoms include earache, irritability and crying (especially during feedings), trouble sleeping, fever, ear drainage (yellow or white fluid), and difficulty hearing.

Complications

An untreated ear infection can cause hearing loss, pain, and local infection that can spread to areas nearby.

Treatment

Bacterial ear infections may be treated with antibiotics.  If antibiotics are prescribed, It is very important to follow your doctor’s instructions and take the full course of antibiotics.  If antibiotics are stopped too soon, some of the bacteria that caused the original reaction may still be present and cause an infection to start over again.

Antibiotics are not used in viral ear infections or when simple fluid accumulates in the middle ear.  This fluid may take up to 3 months or longer to clear and is not considered an infection.  The treatment is to recheck the ears to see if the fluid has resolved. Unnecessary antibiotic use should be avoided, since this can promote the growth of bacteria that are resistant to the usual antibiotics.

Home Care

To relieve earache or fever, give acetaminophen (such as Tylenol) or ibuprofen (such as Advil or Motrin).  For ear pain, the following may also help: a warm washcloth held against the ear, chewing gum (if your child is old enough), keeping your child sitting up as much as possible, and prescription ear drops to numb the eardrum.

During an ear infection, avoid air travel and swimming until the infection is over.  A trip to the mountains is safe, but encourage your child to swallow fluids, suck on a pacifier, or chew gum (if your child is old enough) while changing altitude.

When to Call the Doctor

Call your child’s doctor if:

• You feel your child is getting worse, develops a stiff neck, or develops any area of redness.
• Pain or fever is not gone within 48 hours of starting antibiotic treatment.  Your doctor may need to prescribe a different antibiotic or refer to a specialist to obtain a culture of the ear infection.

Eczema – Atopic Dermatitis

Definition and Causes

Eczema is a red, extremely itchy rash.  It often starts on the cheeks between 2 and 6 months of age.  Later it is most commonly found on the creases of elbows, wrists and knees.  Occasionally the neck, ankles and feet are involved.  Eczema may have flare-ups when there is contact with irritating substances such as soaps, lotions and certain foods.  If scratched, the skin will become raw and weepy.  This is a chronic condition that often improves before adolescence.

Home Care

Instructions for bathing and moisturizing:

• Bathe less frequently and for shorter periods of time (every few days for no more than 10 minutes).
• Use cool or lukewarm (not hot) water.
• Use an oil-based bar soap, not a detergent soap when washing your child. Examples are Dove Unscented, Neutrogena, Eucerin and Cetaphil Cleansing Lotion.
• After bathing, pat dry.  Do not rub the skin.
• Help trap the moisture in the skin after a bath by applying lotion or cream to the entire skin surface while still damp.  Some lubricating creams are Lubriderm, Nivea, Eucerin, Aquaphor and Cetaphil.
• Benadryl for intractable itching (call your provider for dosing if under 2 years old).

When to Call the Doctor

Call your child’s doctor if:

• The rash becomes worse, oozes, weeps, or is crusty.
• Your child develops chickenpox or is exposed to chickenpox.
• Your child develops other allergy symptoms such as sneezing, wheezing, or severe congestion.

Fever

Definition and Causes

Fever is an elevation of the body’s temperature, which occurs in response to many different causes. Usually, fever alone is not an emergency and does not need emergency treat­ment.  It is most frequently caused by a viral or bacterial infection and is not a disease.  Fever is one of the body’s ways of combating the infection.

Symptoms

Normal temperature in infants and children ranges up to 100.4^o F rectally or 99.5^o F orally.  Axillary temperatures, which measure only surface temperature, range up to 98.6^o F.  Tympanic thermometers are available to measure the temperature of the eardrum.  It is considered to be inaccurate in infants and most toddlers.

Home Care

The usual reason for treating a fever is to make the child more comfortable.  Basic measures to lower the body temperature are: dressing in loose, thin clothing, frequent offerings of cool liquids by mouth, rest, and the administration of medications such as acetaminophen (Tylenol, Tempra) or ibuprofen (Motrin, Advil).  These medications serve only to lower the body temperature and to relieve aches and pains.  Doses of these medications accompany the packages.  Do not use aspirin or products containing aspirin in children.

“Infant Motrin/Advil Drops” are not recommended for infants under the age 6 months.  Do not interchange “Infant Motrin/Advil Drops” with “Children’s Motrin/Advil Suspension”, because the concentration of these products are different.  Likewise, do not interchange “Infant Tylenol Drops” with “Children’s Tylenol Suspension”, because the concentration of these products are different.

The dosages for “Infant Tylenol Drops” are as follows.  You may give a maximum of 5 doses in 24 hours.

Sponging or vigorous bathing is hardly ever necessary to treat fever.  However, if adequate amounts of acetaminophen or ibuprofen have been given and the child is still quite uncomfortable, sponging for 20 to 30 minutes may be helpful. NEVER rub down a child with alcohol.

When to Call the Doctor

All convulsions should be evaluated by your child’s physician.  In addition, call our office anytime there are symptoms bothersome or alarming to you such as severe headache or pain elsewhere, unusual listlessness or lethargy, a steadily worsening cough, persistent diarrhea or vomiting, breathing difficulty, rash, difficulty waking your child, or refusal of food or liquids.  We recommend that after 3 days or more of fever, even in the absence of other significant symptoms, you contact your pediatrician’s office.  If your child is under 3 months of age, be sure to call if the rectal temperature is above 100.4^o F, or if it is over 104^o F at any age.

Head Injury

Minor Head Injuries

Minor head injuries can cause a large area of swelling because the blood supply to the scalp is plentiful. For the same reason, small cuts can bleed heavily. Usually, there is pain at the site of impact, but no other symptoms.

Home Care

• Wound Care: If there is a scrape, wash it off with soap and water. Then apply a sterile gauze or clean cloth for 10 minutes to stop any bleeding. For swelling, apply ice for 20 minutes.
• Rest: Encourage your child to lie down and rest until all symptoms are gone (or for at least 2 hours). It is fine to allow sleep, but keep him/her near you so you can check him/her periodically.
• Diet: Give him/her only clear fluids (ones you can see through) until he/she has gone 2 hours without vomiting.
• Medication: Do not give any pain medicine.
• Awakening: Closely observe your child for the first 48 hours in order to detect a serious complication. Awaken him/her at your bedtime and approximately 4 hours later. Awaken him/her until he is walking and talking normally. If his/her breathing becomes abnormal or his/her sleep is unusual, awaken him/her.

When to Call the Doctor

Call your doctor immediately if the injury is not minor. For example, call the doctor if:

• You suspect that your child has had a concussion (confusion, memory loss, or temporary unconsciousness).
• The headache becomes progressively worse, or if it is severe.
• Vomiting occurs 3 or more times.
• Vision becomes blurred or double, or pupils become unequal in size.
• Your child becomes difficult to awaken or is confused.
• Your child shows a marked change in personality.
• Walking or talking becomes difficult.
• Numbness, tingling, or weakness occurs in arms or legs.
• Your child’s breathing pattern changes.
• Your child has a seizure.
• Your child’s condition worsens in any other way.

Infant Eating Guide

Newborn to Four Months

Breast Feeding: Initially, every 2 or 3 hours (from start to start) for 10 to 20 minutes per breast. After a mother’s breast milk is in and the baby is gaining weight, the night feedings can be stretched to every 4 or 5 hours if the baby wants to sleep. The number of feedings in a 24-hour period will gradually decrease over the first 4 months to approximately 5 to 6 feedings per day.

Formula Feeding: Initially feed the baby every 2 to 3 hours.  Babies usually take between 1 to 2 ounces at first, with a total of 15 to 24 ounces per day during the first month.  After the first month, babies will reach a plateau of 24 to 32 ounces per day.  Never give your infant low iron formula, because this can lead to iron-deficiency anemia.

Four to Six Months

Continue breast or formula feeding as above.  Formula feeding time will decrease to every 3 to 4 hours. You may now start rice cereal diluted with breast milk, formula or water.  The usual amount is 2 to 4 tablespoons 1 to 2 times a day (any time of the day is fine).  At first, make the cereal on the watery side, and then thicken as tolerated. The baby should be spoon-fed. You may also try oatmeal cereal, but it may cause constipation.   If this is the case, you may give 4 ounces of water per day.  Do not place cereal in the bottle, unless directed by your pediatrician.

Five to Six Months

You may begin yellow and orange colored vegetables (carrots, squash, and sweet potatoes).  Introduce one new food every 3 to 4 days in order to detect any food allergies.  Watch for rash, itching, congestion, wheezing, stomach pain, diarrhea or vomiting.  If this happens, stop the new food.  You may try it again in smaller quantities in one month.  The new food should be given alone when first introduced.

Six to Seven Months

Continue breast or formula feeding (24-32 ounces per day).  If desired, give diluted non-citrus juice (up to 8 ounces per day), introducing juice with a sippy cup.  Your baby may now have 2 to 3 solid meals per day at this age.  Pick two of the three food types (vegetables, fruits, and cereal) for each meal.  According to pediatric dentists, it is better not to give juice at all as juice commonly causes tooth decay in infants.

Seven to Nine Months

Continue the breast milk/formula and juice as above.  You can now introduce “Stage 2” foods including poultry and red meats as a good source of iron and protein.  You can also introduce plain yogurt.

Nine to Twelve Months

Continue breast milk/formula and juice as above.  Small finger foods, easily mashed between the gums, should be introduced.  It is recommended that parents and caregivers take a cardiopulmonary resuscitation (CPR) class (if not taken previously) before the introduction of table foods.  Examples of recommended food include:

• Grains: Cheerios, selected other cereals and baby crackers
• Vegetables: Green beans, split peas, skinless lima beans, steamed carrots, mashed potatoes, yellow    squash, sweet potatoes
• Fruits: Skinless pears, bananas, skinless steamed apples, peaches, and apricots
• Protein: Boneless white fish, ground meat, tofu, cottage cheese, small pieces of chicken

After Twelve Months

Introduce whole-pasteurized milk (16 to 24 ounces per day).  Your child can now have eggs (introduce the yolk first), citrus foods and honey.  Diluted juice should be limited to 12 ounces per day.

Special Considerations

• Bottle: Never prop the baby’s bottle or allow your baby to sleep with the bottle.  To prevent tooth decay, introduce the sippy cup at age 6 months and do not use the bottle after age 12 to 15 months.
• Nutrition: Fast food, chips, Fritos, and packaged snack foods are high in fat and salt.  Cookies, candy, cakes and sodas are high in sugar.  All of the aforementioned foods should be limited and used only for infrequent special occasions.
• Allergies: Avoid cow’s milk, eggs, citrus foods and honey before 12 months.  Also avoid nuts, peanut butter, and shellfish, especially if there is a family history of allergies to these foods (discuss this with your child’s doctor).
• Choking concerns: Avoid foods with skins, stringy foods, nuts, raisins, sunflower seeds, popcorn, carrot chunks, pieces of uncut grapes and hotdogs.  Do not give any food the size of a quarter or bigger until after the age of 3 years.

Never leave your child alone while eating!

Recommended reading

For more information on feeding techniques we recommend: Feed Me, I’m Yours by Vicki Lansky and Child of Mine by Ellyn Satter.

Medication Safety Tips

About your child’s medications

Tell:

• All your child’s doctors about every medication he/she takes.  Keep a list of all the medications and bring them when you bring your child to the doctor’s office.
• Your child’s doctor about his/her drug allergies and the adverse reactions he/she has had.

When your child’s doctor writes a prescription

Ask:

• What is the purpose of the medicine?
• What are the side effects and what to do if they occur?
• The pharmacist when you pick up your child’s medicine, “Is this the medicine my child’s doctor prescribed?”
• The pharmacist if you have any questions about the directions on the medicine labels such as how often it should be taken.
• The pharmacist for the best device to measure liquid medicine because household spoons are not very accurate.  If a cup or dropper is included in the package of a liquid medication, do not use it for any other medication.

Give:

• Only prescriptions prescribed for your child.  Be careful not to give a prescription to another child.
• All the prescribed medication and at the time printed on the medication label.
• Over-the-counter medications while carefully following the directions on the labels.

Remember:

• to use only antibiotics prescribed by your child’s physician and NEVER use leftover antibiotics.
• to take medication for the prescribed period of time. If there is any unused antibiotic after treatment, discard it.
• to renew the prescription before it is finished, if a refill is necessary.
• to keep each medication in its original container.
• to store medications in a locked cabinet where children cannot see or reach them.

Poisoning

If you suspect your child has swallowed or inhaled a poison or other potentially dangerous substance, call Poison Control at 1-800-222-1222.

Sinus Infections

Definition and Causes

A sinus infection is an infection of one of several sinus cavities that normally drain into the nose.  Blockages of the opening between the sinus and the nose can lead to a sinus infection (as caused by colds and/or nasal allergies).  Risk factors include day care attendance and exposure to second-hand cigarette smoke.

Symptoms

Acute sinus infection symptoms include cough and/or runny nose that does not improve after 10 to 14 days.  It can be accompanied by high fever with green or yellow nasal discharge for 3 days, dark circles under the eyes, bad breath, pain around the face and headache (often appearing as behavioral changes in young children), irritability and lethargy in older children.

Complications

If a sinus infection is not treated, a child could develop serious complications including infection of the tissues around the eye.  This may damage vision, cause infection of the brain, and can lead to neurological injury.

Treatment

Antibiotics are the usual treatment for an acute sinus infection.  Follow your doctor’s instructions closely.  If you stop the antibiotics too soon, some of the bacteria that caused the original infection may still be present and can cause an infection to start over again.

Home Care

Rinse the nose with saline drops (there are many over-the-counter saline drops available).  Your doctor may advise a topical nasal decongestant (such as Afrin or Neosynephrine – for 3 days only) and/or prescribe a nasal steroid spray to help decrease swelling inside the nose.

To relieve sinus pain or discomfort with fever, give acetaminophen (such as Tylenol) or ibuprofen (such as Advil or Motrin).

When to Call the Doctor

Call your child’s doctor if:

• You feel your child is getting worse, develops a stiff neck, or develops redness or swelling of the face.
• If pain or fever are not gone within 48 hours of starting antibiotic treatment.  Your doctor may need to prescribe a different antibiotic or refer to a specialist to obtain a culture of the infection.

Sleep Problems

Tips to Preventing Sleep Problems

Newborn

• Place your baby in the crib when he/she is drowsy but awake.
• Hold your baby for all fussy crying during the first 3 months.
• Carry your baby for at least 3 hours each day when he/she isn’t crying.
• Do not let your baby sleep for more than 3 consecutive hours during the day.
• Keep daytime feeding intervals to at least 2 hours for newborns.
• Make feedings in the middle of the night brief and boring.
• Do not awaken your infant to change diapers during the night.
• Do not let your baby sleep in your bed.

Two Months

• Try to delay feedings in the middle of the night.
• Give the last feeding at your bedtime.

Four Months

• Try to discontinue feedings in the middle of the night before it becomes a habit.
• Do not allow your baby to hold his/her bottle or take it to bed with him/her.
• Make any contacts in the middle of the night brief (less than 1 minute) and boring, except if you feel he/she is sick, hungry, or afraid.

Six Months

• Provide a friendly soft toy for your child to hold in his/her crib.
• Leave the door open to your child’s room.
• During the day, respond to separation fears by holding and reassuring your child.
• For middle-of-the-night fears, make contacts prompt and reassuring.
• Move the crib to a separate room.

One Year

• Establish a pleasant and predictable bedtime ritual.
• Once put to bed, your child should stay there.
• If your child has nightmares or bedtime fears, reassure him/her.
• Do not worry about the amount of sleep your child is getting and keep naps to less than 2 hours long.  He/she is getting enough sleep if he/she is not tired during the day.

[Adapted from Pediatric Telephone Advise, 2004, by Barton D. Schmitt, M.D.]

Sleep Problems: “Trained Night Feeder”

A “trained night feeder” is a child who:

• Is 5 months or older and awakens for feeding at night, on most nights.
• Is bottle- or breast-fed until asleep.
• Awakens to be fed at night since birth.
• Is less tired than his/her parents.

What to do for a “trained night feeder”:

•  Gradually lengthen the time between daytime feedings to 3 or 4 hours.
•  At naps and bedtime, place your baby in the crib drowsy but awake. This is so he/she can learn to put himself/herself to sleep without the breast or bottle.  Once he/she is in the habit of putting himself/herself to sleep, he/she can then do the same when he/she awakens at night.
• If your baby is crying at bedtime or naptime, visit your baby briefly (up to 1 minute), every 5 minutes for younger or more sensitive babies, gradually increasing time to every 15 minutes.
• If your baby is crying during the middle of the night, try soothing him/her by the bedside for 5 minutes. If he/she continues to cry, temporarily hold him/her until asleep.
• After the last feeding of the day feed him/her only once during the night and only if 4 hours have passed since the last feeding.  Make this feeding boring and brief (no more than 10 minutes).  Stop feeding before he/she falls asleep, and replace it with holding only.
• Stop giving your baby any bottle in bed.
• Help your child attach to a security object, such as a cuddly stuffed animal, other soft toy, or blanket.
• Eventually phase out the nighttime feeding.  Do this when the time between daytime feedings is more than 3 hours and your child can put himself/herself to sleep without feeding or rocking.  Gradually reduce the amount you feed him/her at night.  Reduce one ounce of formula every third night.  For breast-feeding, nurse on just one side and reduce the feeding by 2 minutes every third night.

Sleep Problems: “Trained Night Crier”

A “trained night crier” is a child who:

• Is 5 months or older and wakes up and cries most nights since birth.
• Is held, rocked, or walked until asleep.
• Does not need to be fed in the middle of the night.
• Is less tired than his/her parents.

What to do for a “trained night crier”:

• At naps and bedtime, place your baby in the crib drowsy but awake.  This is so he/she can learn to put himself/herself to sleep without the breast or bottle.  Once he/she is in the habit of putting himself/herself to sleep, he/she can then do the same when he/she awakens at night.
• If your baby is crying at bedtime or naptime, visit your baby briefly, every 5 minutes for younger or more sensitive babies, gradually increasing time to every 15 minutes.
• Make visits brief (up to 1 minute), boring, but supportive.  Speak reassuringly to him/her and do not show anger during these visits.  Touch him/her gently and help him/her find his/her security object.
• Do not remove your child from the crib.
• If your baby is crying during the middle of the night, try soothing him/her by the bedside for 5 minutes.  If he/she continues to cry, temporarily hold him/her until asleep.
• Help your child attach to a security object, such as a cuddly stuffed animal, other soft toy, or blanket.
• Eventually phase out the nighttime holding only after your child has learned to quiet himself/herself and put himself/herself to sleep for naps and at bedtime.  Go to him/her every 15 minutes while he/she is crying, but make your visits brief (up to 1 minute) and boring. 

Other ideas for both “trained night feeder” and “trained night crier”:

• Move the crib to another room. If he/she must stay in your bedroom, cover one side rail with a blanket so he/she cannot see you when he/she wakes up.
• Avoid long naps during the day. If he/she has napped for more than 2 hours, wake him/her up.  If he/she has the habit of three naps during the day, try to change this to two naps a day.
• Do not change wet diapers during the night.  Change them only if soiled or if treating a bad diaper rash.
• If your child is standing up in the crib at bedtime, try to get him to lie down.  If he/she refuses, you can leave him/her standing up.  Eventually, he/she will lie down without your help.
• Keep a diary of when your baby is awake and asleep.  Bring it to the office for your doctor to review.

When to Call the Doctor

Call your child’s doctor if:

• He/she is not gaining weight.
• His/her crying seems to be due to a physical cause.
• He/she acts fearful.
• there is someone in your family who cannot stand his/her crying.
• the above suggestions do not improve your child’s sleeping habits after 2 weeks.

[Adapted from Pediatric Telephone Advise, 2004, by Barton D. Schmitt, M.D.]

Sore Throat

Definition and Causes

A sore throat is a feeling of fullness or pain in the throat.  A child too young to speak may demonstrate this by refusal to eat or drink.  Most sore throats are caused by a virus and are part of a cold.

Symptoms

A sore throat may be accompanied by fever and body aches and may last up to 5 days. Tonsillitis, or the temporary swelling and redness of the tonsils, may be present in any throat infection.

Complications (Strep Throat)

A strep throat is usually more severe with fever, difficulty swallowing, painful swollen glands and pus on the tonsils.  Children may also have headaches, stomachaches, and vomiting or bad breath.  Some children may also have a fine sandpaper-like rash.  A throat culture or rapid strep test is the only way to distinguish a strep throat from a viral sore throat.  Typically strep throat does not have a lot of associated cough or runny nose.

Treatment

A sore throat does NOT require antibiotics.  They have no effect on viruses, may interfere with the correct diagnosis, and may cause future antibiotic resistance.  Some viral infections causing sore throat may result in a rash if treated with antibiotics.

Antibiotics are necessary only for the treatment of strep throat.  If your child has a positive strep culture, it is important to finish the entire course of antibiotics.  Your child may return to school or daycare 24 hours after starting the antibiotics, if feeling better and free of fever.

Home Care

Acetaminophen (Tylenol, Tempra) or ibuprofen (Motrin, Advil) may be given if your child has a fever or a great deal of discomfort.  Encourage plenty of fluids.  Provide your child with a soft diet including cool liquids and popsicles for a few days if they prefer it.  In children over four, throat lozenges may be given for pain.

When to Call the Doctor

Call your child’s doctor if:

• The pain is severe.
• There is unusual drooling, spitting or your child is having great difficulty in swallowing.
• Your child cannot fully open their mouth.
• Your child is acting very sick.
• A sunburn-like rash appears.
• Breathing or swallowing becomes increasingly difficult.
• Fever lasts for more than 3-4 days.

Teething

Definition and Causes

Teething is a normal process of new teeth working their way through the gums.

Symptoms

Teething may be associated with drooling, finger sucking, or biting on hard objects.  The gums may be red and swollen.  Some babies may be irritable, pull on their ears, have difficulty sleeping, or refuse to eat.  Occasionally a low-grade fever may occur.  Teething may occur as early as 3 months or as late as 13 months.  Drooling around 3 to 5 months of age is normal and may not be related to teething.

Home Care

• Vigorously massage gums with your finger.
• A cold teething ring helps to reduce inflammation.  Do not tie the teething ring around your child’s neck.  Chewing a cool wet cloth is also helpful.
• Avoid hard foods your baby might choke on (such as carrots), but soft teething cookies are fine.
• Acetaminophen may help (please check the bottle label or call your doctor for dosage).
• NEVER use home remedies such as whiskey or aspirin on the gums.

When to Call the Doctor

Call our office if your child:

• Has vomiting, diarrhea, or fever, as this may be a sign of illness.
• Is constantly pulling on his/her ears.
• Does not feel better after the above treatments have been tried.
• Has a fever over 101^o F.

Vomiting & Diarrhea

Definitions and Causes

Vomiting is the forceful ejection of the stomach contents through the mouth. Diarrhea is the sudden increase in the frequency and looseness of stools. They usually are caused by viral infections. Bacteria, excessive intake of fruit juices, or a food allergy can also cause them. When vomiting and diarrhea occur together, vomiting is treated first until it is resolved, and then the diarrhea is treated.

Home Care for Vomiting

It is best to give small amounts of clear fluids frequently. Breast-fed babies should be nursed more frequently than usual (every hour or so). It is very important that your child drink plenty of fluids, which should be given frequently in small amounts. Clear fluids include electrolyte solutions such as Pedialyte, Kao-lectrolyte, Lytren, Infalyte and Gerber Pediatric Electrolyte Solution. You can give Gatorade diluted with an equal part of electrolyte solution. Pedialyte pops also can be given. Do not give plain water, fruit juices, formula or cow’s milk for 8 hours.

Under One Year

Give 1 teaspoon of clear fluids every 10 minutes for 1 hour. Then increase the amount given gradually every hour for 6 hours as tolerated.

One Year and Older

Give 1 tablespoon (1/2 ounce) every 10 minutes for 1 hour. Then increase the amount given gradually every hour for 6 hours as tolerated.

Home Care for Diarrhea

Babies who are breast-feeding should continue to nurse and be supplemented with the “BRAT” diet (see below) if old enough to have solids. If the child is having severe diarrhea (over eight large watery stools per day), begin clear liquids (see above) along with the “BRAT” diet for several hours.

After 6 hours without vomiting (or right away if your child has not been vomiting) begin the “BRAT” diet:
B – Bananas
R – Rice or rice cereal
A – Applesauce
T – Toast (also saltine crackers, pretzels, and/or custard style yogurt)

If no vomiting occurs with the “BRAT” diet for several hours, and even if the diarrhea persists, the foods that can be added include: baked or mashed potatoes, plain pasta, noodles, chicken, turkey, low sodium chicken soup, and cooked yellow or orange colored vegetables (carrots, squash, and sweet potatoes).

When to call the doctor

Call our office if your child:

• Does not urinate or have a wet diaper for more than 8 hours.
• Does not make tears when crying.
• Has a very dry mouth.
• Has green or bloody vomit.
• Has persistent vomiting for more than 12 hours (if your child is less than 12 months old).
• Has persistent vomiting for more than 24 hours (if your child is 12 months or older).
• Becomes difficult to awaken or is confused.
• Has blood in the stool.
• Becomes dizzy when standing.
• Has frequent watery diarrhea with vomiting more than 3 times per day.
• Has symptoms that continue to become worse.
• Cannot keep down even small amount of Pedialyte.