Two Parents

Most of us can remember the last time we saw an act of unconditional love but when was the last time you saw a life of unconditional love?

In my office I am privileged to witness acts of love and bravery. Every day I see parents with boundless awareness of the needs of their child. These families have helped me understand how to replace sadness and doubt with joy and loving acceptance.

This past week I was very busy.  Hospital and night call, inpatient rounding and daily office visits took their toll.  I was tired and thinking about the upcoming weekend autism walk at our local state park when two loving parents brought grace back into my life.

As I walked into my exam room and sat down on a stool I saw a mother holding her young son.  He broke away from her grasp, fell to his knees and tried to bang his head against the floor. His father reached over, pulled him to his chest and cradled him in the safety of his lap. His son fought and screamed as his father endured repeated head butts to his chest. The mother placed her hands on the knee and shoulder of her son.  She caressed him softly speaking to him with a voice devoid of fear and filled with love. The boy’s voice quieted as he relaxed into his father’s arms.

After I examined their son the father asked if he could take his son outside for a walk while I talked to his wife. As he walked out the door holding his son’s hand I could only think of the teamwork and cooperation in this family’s life. I turned to the mother and asked how she was doing, and she told me how difficult this was. I saw a tear in her eye and resolve in her face. We talked about solutions and jointly made a plan. I touched her shoulder as we left the room and told her to call me if I could help. She turned and smiled. The tear was gone.

The next day at the autism walk I watched a thousand families walk by in a parade of courage.  I knew each family that passed would continue to face daily obstacles beckoning fear. Yet, looking into their eyes, I saw how the unconquerable power of love fueled each of them for today and all tomorrows. In that moment I understood how extraordinary events have the power to awaken within each of us the capacity for extraordinary courage and endless love, and how the actions of two parents would remain within me forever.

When to Introduce Solid Foods

The introduction of solid food to your infant is one of the most common questions parents ask. The key is to introduce new foods slowly beginning at 6 months of age and avoid mixed foods that have various food allergens. There are certain foods you should be most cautious about. These include egg, peanut, tree nuts, fish and seafood. Introducing solid food prior to 4 months is associated with an increased risk of allergic disease. During the first six months of life exclusive breast feeding is recommended.

At 6 months infant cereal can be added first. Start with rice cereal and then proceed to the other whole grain cereals including oatmeal and barley. At 7 months begin vegetables and start with the green vegetable before the sweeter carrots and sweet potatoes. Generally add only one new food type per week and one food group per month. After vegetables have been introduced begin fruit and then meat. As solid intake increases formula or breast milk intake decreases. Make sure your child’s urine remains clear and urine output is at least 4 times per day. By age 1 year your child should be taking 3 food groups three times per day. The key is moderation and variety. Keep a log of the foods you introduce and look for adverse reactions including mood changes, skin rashes or GI upset.

If your child is at high risk for allergy the following schedule should be followed: supplemental foods 6 months, 12 months dairy products, 24 month’s egg and at least 36 months for peanut, tree nuts, fish and seafood. Certain processed foods including beef and kiwifruit that are less allergenic when cooked should be served cooked and homogenized.

The key is to follow a reasonable schedule that meets your child’s needs and preferences. There is no one right way of introducing food. Listen and watch your child. Respond to her cues and as always remember she is watching and smelling what you eat and how much you enjoy the foods you eat.

Simple Constipation Fixes

Dietary causes of constipation vary with the age of a child. For infants changing from breast milk to formula a decrease in stool frequency is common. This is also seen when there is a change from breast milk or formula alone to added cereal or a change from strained foods to table foods.

For children under age 4 years milk intake is often the cause. The first step is to decrease or stop all milk products for 1-2 months and use milk substitutes while continuing to provide vitamin and calcium supplementation. Always try to increase water intake as well as high water content foods such as fruits and vegetables.

Certain foods can also be constipating including carrots, banana, apples, and rice. Try to avoid cereals that are not whole grain. Use oatmeal, cheerios and granola and increase the amount of bran in your child’s diet. Bran is found in brown rice, oatmeal, whole wheat bread, shredded wheat and unmilled bran or bran muffins. You can add bran to many foods and your child will usually not notice. Children under 6 years can be given 2 teaspoons per day and older children 3-4 teaspoons. Raw vegetables and unpeeled fruits can be eaten throughout the day.

Remember that fruits, fiber and fluids are the best treatments for constipation.

Constipation in Children

Constipation is defined as having fewer than 3 stools per week and most stools are hard and either pebble like or large and painful. Often constipation is accompanied by stool incontinence in children or abdominal pain.

Most breastfed infants under 3 months of age have 3 stools per day and formula fed infants 2 stools per day. As children reach age 12 months stool frequency decreases slightly and continues to decrease until over age 3 years 1 stool per day is the typical frequency. Infants without stools for up to 7 days are not unusual.

In the newborn period, delayed stool passage greater than 48 hours suggests an organic problem such as Hirschsprung’s Disease. Overall, newborn constipation issues suggest an organic or structural cause and constipation under age 12 months is usually dietary related. The onset of constipation after 18-24 months suggests behavioral causes and usually is functional. Constipation is considered to be functional if no organic cause is present. Acute constipation suggests an organic cause and chronic constipation suggests functional causes.

Common symptoms associated with constipation include diffuse colicky intermittent abdominal pain and rectal pain with defecation. Children with constipation will often be fidgety and uncomfortable and perform a “stool dance” when they feel this colicky pain. The child may clench teeth, cross legs, wiggle and squeeze the buttocks together and turn red in the face while trying to hold the bowel movement in to avoid discomfort.

Anal fissures are also common as is a small amount of bright red blood on the surface of stool that is passed. Rectal prolapse is much less common but can occur with chronic constipation and extended periods of “pushing” to have a bowel movement.

A family history of constipation is important as is a history of celiac disease, cystic fibrosis, thyroid disease or Hirschsprung’s Disease. A history of recent family or social-emotional stressors is also common as well as a history of developmental delay or special needs.

If there is a history of infrequent hard, large and painful stools as well as stool withholding behaviors (”stool dance”) and a normal physical examination then the cause is usually functional. If stools are small in caliber, associated with bloody diarrhea or bilious vomiting, weight loss, fever or persistent abdominal pain then organic causes need to be pursued. In cases of malabsorption constipation is common. This is seen in cystic fibrosis and celiac disease. As always a thorough history and physical examination will determine whether a functional or organic cause needs to be pursued.

Your child’s examination will include a growth evaluation with height and weight measurements as well as a general physical examination including an abdominal examination for distension, liver or spleen enlargement, abdominal masses including stool mass and an inspection of the anus. A rectal examination is common unless refused by a child. The rectal examination provides information about the anal sphincter tone and the amount of retained stool in the rectum. Stool can also be tested for blood. A neurologic examination including an inspection of the low back for any signs of spinal abnormalities such as sinus tracts or hair tufts or general asymmetry is performed and reflexes in the lower extremities will be checked to assess possible spinal cord abnormalities including a tethered spinal cord.

Laboratory and radiographic evaluations will be performed if medically indicated based on history and the examination. An abdominal x-ray may be obtained if a rectal examination is not done. This allows the amount of stool in the rectum and colon to be assessed.

Concussion Facts

Concussions are the mildest and most common form of traumatic brain injury (TBI). They account for 144,000 emergency department visits for children annually. School aged children suffer from post concussive symptoms longer than adults an college age students. Other causes of concussions include falls and car accidents. An estimated 20% of high school football players suffer a concussion and research shows the developing brains of adolescents are more vulnerable than adults and take longer for post-concussion symptoms to resolve. The most important fact to remember is that even mild brain injuries can be more serious then they seem.

Concussions can be hard to diagnose since many adolescent athletes do not want to report the symptoms associated with such an injury. They are fearful of being removed from an activity they enjoy participating in and feel they are “letting their team and coach down” if they acknowledge the injury. The injury is a metabolic or functional alteration in how the brain works and diagnostic tools such as a CAT scan or MRI do not show the disturbance.

Cognitive testing and a thorough history and physical examination are essential for the diagnosis. Protocols to evaluate and treat concussions are usually followed with excellent long term success. Computerized and individual cognitive testing is often performed if medically indicated. Supportive counseling is also integrated into a treatment regimen if the child’s behavior or emotional response requires specific intervention.

The most common physical findings include headache, nausea, vomiting, balance problems, dizziness, visual problems, fatigue, noise and light sensitivity and possible numbness or tingling. Cognitive changes include psychomotor delays and regulatory function disturbances. Children complain of feeling slowed down in their thinking or having trouble concentrating. General difficulty with persistence, planning and attention are often seen as well as delays in inhibitory control and attention shifting. Emotional complaints include sadness, irritability nervousness and increased emotionality. Sleep disturbances are common with drowsiness often reported and sleeping more or less than usual. Sleep latency difficulty described as difficulty falling asleep is also common. All children react differently to head bumps. Those who have a concussion and have not had full resolution of signs and symptoms are at greatest risk for re-injury and more serious symptoms.

The first step in any evaluation is an on-site evaluation at the location where the child received the injury. This may involve a coach, trainer or medical support staff who have been trained in and completed concussion certification courses. The next step would be an emergency facility and then referral for follow-up care to their pediatrician. No child should leave an emergency department and return to practice that day and they should only be cleared to return to play or practice after they have received written approval from a physician.

A return to play protocol is followed. The child should have complete physical and cognitive rest and should not experience any concussion symptoms for a minimum of 24 hours. In general, the younger the child the more conservative the treatment. The following step protocol should be followed. The child or adolescent only moves on to the next step if they have been free of any symptoms for a minimum of one day to one week. Step duration must be determined on a case by case basis. When in doubt always error on the side of longer duration. Computerized cognitive testing can also be followed using the same criteria. If any symptoms return or computerized cognitive testing shows a decrease in function then the activity should be stopped immediately and additional rest obtained for a minimum of 24 hours. Thereafter, the child or adolescent should resume activity at the step prior to the one during which the symptoms were experienced. If no symptoms are experienced for 24 hours then step progression can restart.

The first step is light aerobic exercise for 5-10 minute periods with mild heart rate elevation and mild perceived exertion. This involves low intensity walking, spinning or jogging. There should be no weight lifting, jumping or running.

The second step is moderate exercise. Body and head movement should continue to be limited. Exercise time is moderate and less than the child’s prior level of exercise and includes moderate aerobic activity.

The third step is non-contact exercise that is more intense but without contact. Duration can approach prior levels and can include running, weight lifting and sport specific exercises. A cognitive component to the exercise can be added.

The fourth step is reintegration into full-contact practice with resumption of practice.

The final step is a return to competition.

This step progression must be done in collaboration with the physician, child or adolescent, parents, team support staff and all other caretakers who are involved in the care program.

Most children and athletes who suffer a concussion recover quickly and return to full activity and sport participation. If symptoms persist over time then a diagnosis of post concussive syndrome will be given and more extensive services and interventions may be required.

Breastfeeding Basics

In the last 20 years there has been a major change in breastfeeding practice. Most women in the United States initiate breastfeeding. This was not the case 20 years ago when infants were primarily formula fed. Parents understand breastfeeding is best for their infant for both health and nutrition. Breast milk protects infants from gastroenteritis, otitis media, respiratory illness, asthma, allergic problems and eczema or atopic dermatitis. Breastfed infants have a lower incidence of SIDS, obesity, diabetes, celiac disease, inflammatory bowel disease and even some types of leukemia.

Parents worry if their infant is receiving enough milk and if colostrum is enough for their infant. Usually there is no need to worry. Infants have a limited stomach capacity in the first few days of life. On day 1 the stomach can hold 1-2 tsp. (10cc) and this increases to 2 tbl (30cc) by day 3. By 1-2 weeks of life the stomach can hold 2-3 ozs. This is why milk does not need to be available in large quantities from the beginning. Your infant is born with enough nutrients to allow this transition to feeding by mouth to go slowly and successfully. By watching urine and stool output hydration can be monitored. We like to see 2 wet diapers every 12 hours and 1-2 stools on days one and two and 3-12 stools per day after day 3. Some infants skip up to 5 days between stools and this should be monitored by you and your pediatrician but is often normal.

Another way to follow your infant’s hydration is by tracking the weight. Infants often lose up to 7% of their birth weight. This should be expected. Greater weight loss will need to be evaluated. Most infants gain between 3/4 and 1 oz. per day for the first several months and 1/2 oz. after 6 months of age.

If bottle supplementation is needed then use of expressed or pumped breast milk is best. Formula is also reasonable. Most supplementation is in the 1/2 oz. (15ml) range and is given after your infant has breastfed. Advice and support from a breastfeeding consultant here in the office can help you with supplemental options. A few infants tend to have difficulty returning to breastfeeding after a bottle is given. Breastfeeding infants use mostly their posterior tongues to nurse while bottle fed infants suck with their anterior tongues and use less of their cheek muscles. We think this is a reason why some infants have difficulty transitioning back and forth and although this is uncommon it needs to be watched for.

Breastfeeding is recommended for a minimum of 12 months. And women in some industrialized countries nurse their children until 3-4 years of age. Breastfeeding for longer than 12 months does have cumulative benefits for both the child and the mother.

Please refer to other blog entries for more tips on successful breastfeeding.

Breastfeeding Benefits

An infant breastfed exclusively for more than 4 months has over 70% fewer lower respiratory tract infections in her first year of life. The severity of bronchiolitis is also reduced as is the incidence of otitis media, serious colds and throat infections. There is a protective effect of exclusive breastfeeding for 3-4 months in reducing the incidence of asthma, atopic dermatitis and eczema.

Gastrointestinal tract infections are also reduced by over 60% and the benefits last for 2 months after cessation of breastfeeding. The risk of inflammatory bowel disease is reduced as is the risk for obesity, childhood leukemia and lymphoma. Breastfeeding is also associated with a 36% decrease in the risk of sudden infant death syndrome (SIDS) and it has been calculated that more than 900 infant lives per year may be saved in the United States if 90% of mothers exclusively breastfed for 6 months.

Neurodevelopmental outcomes are also improved for infants exclusively breastfed for 3 months or longer. Breastfed infants have improved outcomes of intelligence scores and teacher’s ratings. These same benefits are seen for preterm infants as well as a lower rate of serious infections.

For the mother there is decreased postpartum blood loss and a lower frequency of postpartum depression. Breastfeeding for longer than 12 months is associated with a 28% decrease in breast cancer and ovarian cancer.

To help you with breastfeeding we do not support policies following delivery that interfere with early skin-to-skin contact or the supplement of water, glucose water or formula without a medical indication. We also do not restrict the amount of time an infant can be with her mother or feeding duration. We also do not endorse unlimited pacifier use. Pacifier use during the newborn period can be helpful for specific medical indications such as pain reduction and for calming purposes for drug exposed infants. Pacifier use should be delayed until breastfeeding is well established at 3 to 4 weeks after birth.

Facts About Obesity

Obesity is defined by using age and sex specific body mass index (BMI) information. The Center for Disease Control (CDC) defines overweight as a BMI at or above the 85th percentile and below the 95th percentile as compared to children of the same sex and age. Obesity is defined as having a BMI at or above the 95th percentile.

For school aged children the average weight gain is 7 pounds per year and average height gain is 2.5 inches per year. When weight increases more rapidly than expected the first step is to look at healthy lifestyle choices including food intake and calorie expenditure. Frequent concerns include sweet flavored drinks, snacks and fast food with a lack of healthy fruits and vegetables. Other concerns can include the intake of whole milk instead of skin milk and general portion sizes.

As a parent you must focus on good health not weight management. A healthy lifestyle will lead to the right weight for your child. Along the way your child will also develop improved self-esteem and a healthy body image. For good health to be sustainable it must be linked to a positive self-image built around the importance of a healthy dietary intake and an active lifestyle rather than labeling a child as being obese or overweight.

By understanding the importance of lifestyle changes your child will develop the consistency and confidence needed to respond to future lifestyle decisions. By involving your child in all the decisions, including cooking and shopping, your child will become competent to manage their own dietary choices.

Physical activity can help this process. Exercise has clear benefits to the heart, lungs and musculoskeletal systems. The addition of 60 minutes of aerobic activity to your child’s daily schedule will also have longstanding social benefits. Aerobic social activities, such as family walks, provide talk and listening time for the entire family.

These family activities allow other family members to share in physical benefits.

Another benefit to physical activity is the association between physical activity and enhanced cognitive and academic performance. At least half of all studies have shown clear benefits including improved concentration, memory reaction time, attention, perceptual skills and verbal skills.

Sudden Cardiac Arrest in Children and Adolescents

The leading cause of non-traumatic sudden death in children and young adults is sudden cardiac arrest (SCA). There are numerous causes including structural, electrical, muscle and metabolic causes. Early recognition and diagnosis can be difficult. Many children and young adults who experience a SCA have had warning symptoms or a family history of premature cardiovascular disease. This makes it essential that all children be screened with a comprehensive family history and a thorough physical examination.

The focus during routine well-child visits is not on the detection of cardiovascular warning signs. Most well-child visits focus on health promotion, disease prevention, anticipatory guidance and some level of disease detection. An increased emphasis on cardiovascular disease prevention is essential and this is especially important for pre-participation physical examinations for sports.

Although between 50% and 80% of all athletes who experience a SCA did not experience previous symptoms, those that did have symptoms reported some of the following: dizziness, chest pain, fainting or syncope, palpitations and shortness of breath. For those children and young adults lucky enough to have symptoms these complaints cannot be missed. Similarly, a family history of sudden death from a cardiac cause must be looked for.

Although not everyone who experiences a SCA will have a warning sign those that do must not be missed. It has been reported that if the following risk factors are looked for up to 1/3 of all of those at risk could be detected. The risk factors include: history of syncope (fainting), history of unexplained seizure activity and a family history of sudden death caused by heart disease at an age younger than 50 years.

Many children experience syncope (fainting) that is triggered by prolonged standing, fear, excitement or the sight of blood. This is called vasovagal syncope and is associated with symptoms prior to fainting. Symptoms include lightheadedness, dizziness, sweating, nausea and tunnel vision. Children who experience cardiac syncope do not have these symptoms and usually experience a sudden collapse without warning. This is due to a potentially lethal heart rhythm abnormality. It is important any child with a history of syncope receive an electrocardiogram (ECG) and a thorough history.

Any syncope that occurs during exercise must be treated with caution. These children and young adults require a cardiac consultation and other testing including a cardiac ECHO, stress ECG and possibly advanced cardiac imaging.

Seizures can occur in association with a SCA and is due to the sudden loss of brain perfusion. The child will collapse and then develops some involuntary body movements after several seconds. If the loss of consciousness is due to seizure activity the muscle movements begin at the same time there is loss of consciousness.

It is important everyone is aware of the risk for sudden cardiac arrest (SCA) so that improved aware can allow ominous warning signs to be recognized early and prevent death or injury to many children.

Football Injuries

Football has the highest frequency of injury for high school sports. Head and neck injuries, heatstroke and musculoskeletal injuries are very common. The risk of repetitive minor brain injuries is also a major risk. Sport related head injuries make up over 20% of all traumatic brain injuries in children and adolescents. Although there are education and safety programs concerning sport injuries the risk of injury and death has not decreased. Between 10 and 15 children die each year from sports related injuries.

40,000 high school players suffer concussion each year. A concussion is a traumatic injury to the brain where a mechanical force causes direct disruption of brain function. It is associated with changes in metal status and does not need to be associated with loss of consciousness. If a child has a concussion a CT scan of his or her brain is normal. Only in cases where there has been bleeding within or around the brain or swelling of the brain would the CT scan be abnormal. This can be seen in cases of subdural or epidural hematomas. These events are frequently life threatening and require immediate intervention.

Long-term effects of repetitive brain injuries have been identified. These include an increase frequency of memory related diseases such as Alzheimer disease, depression and even brain atrophy. Studies of professional football players have strongly supported this link between repetitive minor brain trauma and long-term health problems. The risk of Alzheimer disease in professional football players aged 30-49 is almost 20 times higher than the general population.

Up to 15% of football payers each year receive neck and spine injuries. These injuries are the result of excessive flexion or extension of intervertebral joints. This leads to secondary injury to muscles, ligaments, discs and nerve roots. Pain can range from mild numbness or stinging to severe radiating pain. The pain may be at the site of the injury such as the back or shoulder or it may extend down an arm or a leg. Often the pain is not associated with muscle weakness and is related to muscle spasm. Gait changes and joint movement limitation are often seen and are usually due to pain or discomfort. Pain or weakness symptoms may begin immediately or may be delayed due to secondary problems due to swelling and inflammation.

Neck injuries can involve direct damage to the cervical spine or alignment of the spine. These injuries are often due to a force being directed to the top of the head and transmitted down to the neck during a tackle. Such a tackle is called “spearing” and can lead to permanent paralysis. If such an injury occurs during a game or in practice then extreme precautions are taken to immobilize the head and neck until appropriate radiographic and physical examinations have been performed.

Another type of neck injury is damage to the disks between individual vertebras. Chronic injury to the neck often leads to degenerative disc changes and long-term problems with pain, muscle function and gait.

Musculoskeletal injuries involving the extremities are common. About one-third of all limb injuries in childhood are sports related. The most common knee injuries include damage to one or more of the four ligaments that stabilize the knee. These are the medial collateral ligament (MCL) that stabilizes the inside of the knee; the lateral collateral ligament (LCL) that stabilizes the outer knee; the anterior cruciate ligament (ACL) the stabilizes the knee from rotating and slipping forward and the posterior cruciate ligament (PCL) that stabilizes the knee from rotating and slipping backwards. Often ligament injuries occur together. It is common for the ACL and MCL to be torn as well as the meniscus. When the meniscus is damaged this is called a tear. The knee meniscus is a C shaped cushion that the knee bones rest upon. A PCL injury is usually due to hyperextension of the knee or results from a flexed knee being forced backward causing direct damage to the PCL.

Traumatic injuries to hands, wrists, fingers, hamstrings, toes and shoulders are common as are overuse injuries to the iliotibial (IT) band. The IT band extends from your hip down across your knee on the outside of your leg. It stabilizes your knee and hip during running and can become irritated from rubbing on the bones on the outside of your knee. Pain is common on the outside of your knee and can run up the outside of your knee extending to your hip. Muscle strengthening exercises and stretching are often prescribed as are cold and rest.

When your child engages in any sport the best way to prevent injury is with proper preparation, proper guidance and the proper use of appropriate equipment. Injuries can and do happen even with the best preparation. Exercise and movement are needed for your child to grow into a healthy adult. At the same time you must make sure your child avoids and recognizes injuries and obtains proper treatment when injured.