Tuesday, September 09, 2008

Potty Training Regression

Dear Dr. Cason - Do most kids regress with potty training after going for months?

My son tells us that he doesn’t have to go pee when he clearly does. Is this a power struggle?

- Anonymous


Dear Anonymous,

There are some reasons for potty training regression such as such as a bladder infection or life stressors. But when he says that he doesn't need to go, it's quite possible that your son really doesn't feel that he needs to go.

Remember that the bladder is a muscle and will accommodate to increasing urine by first spasming and then when it is ignored, the bladder will relax. Do this too often though and the bladder doesn't truly sense that it's full until the urethral sphincter spasms and then it almost too late. They then can be found holding themselves and running at breakneck speed to the restroom. All the while you are puzzled looking at them and exclaiming, "But you just said you didn't have to go!"

The way you help little kids to retrain their bladder is to have them do "timed voids" every two hours. Just take them whether they feel like they have to go or not. Gradually the bladder retrains itself.

If there appears to be any other persistent problems then take your child to their pediatrician they may need to rule out out other reasons for regression.


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Friday, March 07, 2008

ADHD Meds and Your Underweight Child

Dr. Cason,

Hello. I have a 10 year old little girl that is being treated for ADHD. She is currently on Vyvanse. The medication is working well for her. My problem is she is very underweight. She is 50 lbs. You can see every bone in her body! Protruding hips, ribs, and back bone. She is just scant of the 10% percentile on her growth chart so her pediatrician says not to worry unless she is 5% percentile. I could not even imagine what she would look like then!

We have tried to add other medications to increase appetite like Mirtazapine, but this is an extremely strong medication and knocks her out for a day. I don't want her to take that at 10. She eats high fat foods, (cheese, beans, ice cream, peanut butter, pasta etc.)I also give Pediasure once a day; she eats normally for her age but does not gain weight. I hear often from other people how skinny she looks too, so I don't think it's just me being too concerned.

She also seems to have a decreased immune system, she is sick often, and seems to catch everything going around. I am tired of being told not to worry when my child is always sick and is (not matter what the chart says) way under weight. Any suggestions?

Thanks so much... -K


Dear K,

Loss of appetite is a very common side effect of ADHD medications. ADHD meds can be very helpful for those kids where other options to treat ADHD meds haven’t been found to be helpful. Vyvanse (Lisdexamfetamine dimesylate) is a prodrug of dextroamphetamine which belongs to the group of medicines called central nervous system (CNS) stimulants. Stimulants are the most effective medications available for the treatment of ADHD as they increase alertness and concentration. Unfortunately the way that ADHD meds work also is the specific reason why your child is underweight. It suppresses appetite.

It sounds like you’re doing all the right things. Some people do add Remeron (Mirtazapine) because at low doses it acts as a antihistamine which increases sleepiness and stimulates appetite but there has been some concern over the use of anti-depressants and suicidal ideation in children. You definitely need to have someone experienced with ADHD
manage your child’s case.

Probably what will be most effective in helping your child gain weight is to give your daughter a
medication holiday if that’s feasible and okay with your doctor. You can give them a rest over the weekend and on vacations when increased attention won’t be as necessary for school or homework. I’ve also had some parents focus on feeding their children calorie rich foods as the medication wore off. This would be a time where the “No food before bedtime” rule could be bent.

I think your child is very thin as well. I charted her on a growth chart and my calculations showed a ten year old child who is 50 lbs is less than the 3rd percentile for her wt. Put another way, she is the average weight of a 7 year old. Given that she is on ADHD meds this may be the reason and if she otherwise looked healthy, it would be reasonable to not undergo other specific testing at this time. But if she’s sick a lot, she may be having other medical issues and would warrant a check up with her doctor. What labs need to be checked will be tailored to your child’s
specific situation and symptoms.

For now I would go back to your pediatrician and really talk with them. Bring up your concerns. Often when I have a family come in and express a deep concern, I will order labs even if I think everything is okay. I find it’s worth it to under go the tests for peace of mind. If the labs are normal you can assume it’s just the meds. You can then focus on giving her high calorie foods, medication holidays and returning for follow ups to monitor her growth. If your doctor isn’t comfortable managing the ADHD or poor weight gain, she can be referred to a behavioral specialist and a nutritionist for management.

Please see my other article on Tips on Mealtime and Your Underweight Child.

Best of luck to you,

Sheila Cason MD

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Sunday, February 10, 2008

Neglect in Children

Dear Dr. Cason,

Child Protective Services has just placed my Cousin-in-law's son with me after years of abuse and neglect. He is 4 years old and has epilepsy, but has not been to his neurologist in a year. He is very skinny, you can feel every bone in his body and his spine and shoulder blade are very pronounced. You can see all of his ribs, and his stomach sticks out. His head is very large for his body. I am trying to get him in to a specialist since his neurologist has retired, but his medical records have become trapped somewhere in the CPS system. Do you have any advice or recommendations until I can get him in? He eats so much; I don't know if he was underfed or if there is some underlying problem.

Thanks, Anonymous


Dear Anonymous,


I’m happy to see that Child Protective Services has placed this little boy with you. You obviously care about his well being and are looking into his various medical issues. If he is actively having seizures, then he needs a medical exam now- even if that means taking him into your local Emergency Room. If he is not actively seizing and appears thin but well then you can take him to your local pediatrician or family practitioner. Child Protective Services can point you in the right direction if you can't find one. Don't worry about not having his medical records right now just take him for the exam. As a general pediatrician I have often seen children within the foster care system. The majority didn’t have their medical records and I did the best I could to reconstruct their medical history and start the appropriate treatment.

Without a physical exam and a detailed medical history, it’s hard to say exactly whether the child’s thin appearance is due to an underlying medical issue or is simply related to neglect. His large head size could be related to his seizure disorder or could appear large in relation to his small stature. When the brain is actively growing in size – up until two years of age - the calories will specifically be used first for head growth then stature and lastly weight.

Neglect, even treated, can have significant ramifications. The National Academies Press, in the online book titled: (1993) Commission on Behavioral and Social Sciences and Education, states that Even after diagnosis and treatment, the psychological consequences of emotional neglect persist. Some studies suggest that certain signs of severe neglect (such as when a child experiences dehydration, diarrhea, or malnutrition without eceiving appropriate care) may lead to developmental delays, attention deficits, poorer social skills, and less emotional stability.

So we will have to wait to see what his future holds for him. In the meantime he is lucky to be in a stable home and receiving the specific care he needs. To help increase your foster child's weight, please see my article labeled Tips on Mealtime and your Underweight Child for some specific recommendations. I wish you and your family well. No doubt that it will be a difficult time for everyone. Please let me know if I can answer any other questions.

Sheila Cason MD

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Monday, January 28, 2008

Tips on Mealtime and your Underweight Child

If you’re like me then you’re searching for ways to get good nutritious food in your kids’ belly but also finding ways to give them enough calories. Remember that as parents you are responsible for what is offered and where and when it is presented. You are also responsible for providing a safe and enjoyable environment during meal times.

Children on the other hand are responsible for deciding how much food they will eat and whether they will eat at all. Make sure you:

1. Offer variety of nutritious foods.
2. Offer foods that are safe.
3. Offer serving sizes that are appropriate.
4. Eat meals at the table.
5. Eat at regular times.
6. Serve as good role models when choosing foods to eat.
7. Don’t pressure or bribe the child to eat.
8. Avoid arguing or negative behaviors during meals.

Children should be eating at least three meals a day with two snacks. I’ve had parents think their child was “always eating” but when you broke it down they weren’t eating a lot of calories. They were snacking on rice cakes and grapes. I had one mom say that she thought carbohydrates were bad for her child and tried to limit them. Contrary to the adult diet kids actually need a lot of carbohydrates. Because kids are little and not eating a lot they need to have nutrient dense foods as well as energy dense foods.

A food is nutrient dense if the vitamin and mineral content is more than its energy or calorie content such as lean meats, beans, oranges, carrots, broccoli, whole-wheat bread, and whole-grain breakfast cereals. Energy dense foods contribute more calories than they do nutrients such as chips, sodas, cookies and ice cream. Remember to balance healthy nutrient dense foods with energy dense foods.

Feeding children particularly an underweight child can be stressful if you micromanage their meals. I know it’s tempting to chase them around the house with a forkful of food. But don’t. Try instead to:

1. Give them small meals that have both nutrient dense and energy dense foods and drinks.
2. Add fats to food such as butter on potatoes and toast, mayo and cheese on sandwiches.
3. Offer whole fat products, such as milk, cottage cheese, creamed soups, pudding and yogurt.
4. Add calories to foods such as fruit in heavy syrup and vegetable with cheese sauce.

Don’t forget to visit your pediatrician for a thorough exam.

Sheila Cason MD

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Monday, January 21, 2008

The Underweight Child

Dear Dr. Cason,

My underweight 2 1/2 year old (negative in the weight charts) was breastfeed until 22 months of age. She always refused a bottle. When I started to introduce milk to her at 12 months she wouldn't have anything to do with it.

I didn't really worry about it until after I stopped breastfeeding her. After trying all forms of milk (various formulas, even chocolate and strawberry milk) it turns out the only thing she would drink is Pediasure vanilla milk. That was fine but it started to get really expensive (I'd limit her to a bottle a day, but they cost more than $1 a bottle -- and that adds up). I found out that she loves "cafe con leche" -- milk with a tiny bit of decaf instant coffee, a little sugar, and a capful of vanilla extract. She looooooves it. It is cheap, healthy (I think), and tasty.

My husband is concerned that the coffee, since it is a diuretic, could dehydrate her (she does have a constipation problem which is relatively under control with Benefiber, Miralax, water, prunes, persimmons, whole wheat bread, etc.). I serve her about 2 cups of milk with a scant teaspoon of decaf coffee -- she drinks only one of these a day. I'd really appreciate it if you could tell me if this is healthy or dangerous? - J.

Dear J-

I feel for you. In a country that has excessive rates of childhood obesity, it can be disconcerting when the problem is actually the opposite- your child is underweight. The first thing you need to do with your underweight child is go to your pediatrician. There is a difference between a child who is just thin for their age and actually “failing to thrive”. Some people will think that every child that is less than the 5% in the growth charts is “failing to thrive” but this isn’t so. There can be healthy children that are just small and that is normal for them. A physician evaluates a child’s weight not based on just one point in time but rather over multiple points in time. At their well-child checks, we analyze their growth by looking at how their growth is plotted against the growth chart. It may be normal for a child to be at the bottom of the growth chart as long as they are still moving along at an acceptable rate. But there are some children who plateau and then drop, failing to even keep up with the expected growth patterns. These children are truly “failing to thrive”.

Making the diagnosis of “failing to thrive” vs. “small for size” is important. In a thin child who is still growing and doing well, you would just offer them nutritious foods and continue to monitor them. It’s important to avoid micromanaging a child and their meals. Over controlling a child can lead to control issues and food “strikes”. If, however, your child is actually dropping off the growth curve or failing to grow at the expected rate, then a diagnostic workup is indicated. Your pediatrician can look into whether there is a chronic medical condition that is contributing to their declining growth. If they are found to be otherwise healthy, then they may recommend keeping a food diary and meeting with a nutritionist to help boost their caloric intake.

In regards to your question about Pediasure and Milk here is the breakdown: Pediasure (8 oz) has 237 calories, 7 grams of protein 9 grams of fat and 31 grams of Carbohydrate. Whole Milk (8oz) has 146 calories, 7.8 grams of protein, 7.9 grams of fat and 11 grams of carbohydrate.When you compare the two, you are actually probably doing okay in terms of calories by giving her 2 glasses of her café con leche but she is definitely missing out on some iron.

Excessive dairy intake (greater than 24 ounces in one day) can lead to iron deficiency. Kids will fill up on the calorie rich but iron deficient milk products and avoid any other “real" food. Pediasure can get expensive but some insurance companies will pay for it if it is part of the medical treatment for the child. The diuretic action of coffee is due to the caffeine. So a scant amount of decaf coffee, while not exactly nutritious, probably isn’t all that bad as well. You may want to try blending different things in with the milk such as a banana. My sister did this with great success for her kids!

To help the- otherwise healthy but underweight- child, try to look at why your child isn’t gaining much weight. Here are some common reasons:

1. Too much juice: Excessive juice can start to replace other food groups when children are too full to eat real food.

2. Low fat diets: Children under two years of age need high fat diets for growth and brain development.

3. Skipping breakfast: It’s just as important that children get calories and nutrients in the morning as well as at other mealtimes.

4. Restricted diets: Kids who are served vegan diets need to have their meals planned carefully to make sure that they are getting the nutrients that they need.

I hope this helps! My next post will offer tips on mealtime and your underweight child.

Sheila Cason MD

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Sunday, January 13, 2008

Corneal Abrasions in Children

A pitiful site isn’t it?

I thought so too! She broke my heart all day long. It started at 3:30 am when she came running to my room screaming, “I scratched my eye! I scratched my eye!”

I pulled her to me and saw that she was rubbing her eye like crazy with the corner of her blankie. I thought that might be the problem but she distinctly corrected me saying that her fingernail scratched her eye and that the blankie was helping. Who was I to argue?

This sounded classically like a corneal abrasion, a scratch or injury to the cornea, the clear surface that covers the front of the eye. It can be very common in kids and presents often with symptoms of eye pain, tearing, and light sensitivity. Because I never delay treatment when it comes to the eye – and neither should you- I took her to go see her Daddy. Lucky for us he’s an Ophthalmologist. We talked all about her fears before we got there: “No, he won’t cut on you. No, there are no shots. No he won’t poke your eye out.” She seemed a little reassured but still clung to me.

It was a relatively easy examination because of the mixture of anesthesia and fluorescein stain drops he put in her eye. I was surprised to see that – no kidding- within seconds she was back to normal. “How long does this last?”, I asked hopefully. “Only about 15 minutes”, he replied. It was just long enough for him to get his exam. The stain allowed him to see the scratch when viewed with a special light. And, as he said, it looked like she’d caught her fingernail on the cornea and peeled a piece of it off like wallpaper. After he prescribed some antibiotic ointment to prevent infection, placed a patch over her eye for comfort, she was my shadow for the rest of the day.

She did great despite my fear that she would cry all day long. My oldest hovered over her. It was such a cute site to see her leading her by the hand. For once there was no fighting! My youngest, however did his best to antagonize her; He kept leaning over and ripping the patch off. Poor thing! But within 12 hours she was feeling better. And by the next day you’d never know that anything was wrong!

Sheila Cason MD

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Friday, January 04, 2008

Baby's Sensitive Skin

Baby soaps and lotions always sound so nice, almost irresistible. Even I can hardly wait to use a special product when it claims to give me a delicious smelly baby as well as a calm happy baby who drifts off to dreamland peacefully. But for some babies it can be havoc for their skin. “Soothing” “Calming” “Refreshing”. Even I’m tempted to lather up my children and send them to bed squeaky clean and smelling delicious. In fact, when I mention to some parents to stop the sweet lotion and soaps they look a little dejected. If you’re using these baby soaps and lotions without any problem then keep on using it.

Unfortunately a baby’s skin is so sensitive and prone to rashes you may have to sacrifice the baby perfumes in favor of health skin. A baby can have an allergic reaction to what appears to be the most simple of cleansers, even those labeled just for baby or sensitive skin. Cetaphil liquid soap or a baby’s soap can work well for some babies but there are those few that will break out with even these good choices. If your child is this sensitive here’s what I like to use.

  • Plain water or a mild bar soap such as Dove for sensitive skin. I also like California Baby shampoo and cleansers.

  • Follow the bath with a good mild lotion. My favorite is Vaseline Deep Moisture Creamy Formula. Make sure you put it on when the skin is still moist.

  • Hydrocortisone 1 % cream used twice daily for 3-4 days can be used on reddened areas. Be sure to check with your pediatrician because the rash may a fungal infection and will need different medication.

These three things used in combination can calm most irritated skin. There are babies whose rashes are a sign of eczema and they will need to have their skin cared for by their physician. Make sure you check with your pediatrician for guidance. For now you’ll have to be content to see the pink fresh skin only scented with their natural sweet smell. What could be better than that?

Sheila Cason, MD

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Saturday, December 29, 2007

A Late Night at the ER

Jacob breathing 60 times a minute prompted a late night ER visit yesterday. After a round of Albuterol (he kept crinkling his nose in bewilderment), a dose of Prelone (he let it dribble out) and a chest X-ray (Whew! Just viral), we were on our way back home.

Now I'm counting breaths, watching for fevers and wrestling with the metered dose inhaler. As you can see, he likes to disassemble it and put in his mouth!

Here's what happened when I took it away:

I spent the next 15 minutes trying to get him calmed down so he wouldn't flare his lungs... or throw up!


Sheila Cason, MD

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Monday, November 19, 2007

Pain in Children - How to Cope with Painful Procedures

My oldest has an ulcer in her mouth. It’s her first and she’s been crying over the pain. I’m at a lost. I don’t like pain but I’ll normally just buck up and take it. However I certainly don’t expect a child to do this. Every child experiences pain differently and will need to be managed according to their differences. In researching pain in children, I ran across a great article discussing painful procedures in children. As a pediatrician and mom this is a phenomenal find! I jumped up, printed it and have been carrying it around waiting to read it in my spare moments of time. Well I read it. Here’s what I found.

In 2005 the Annals of Emergency Medicine published an article titled Pediatric Procedural Pain. In the paper they reviewed what we now know about pain and gave specific suggestions to help kids cope with painful procedures. It stated that “Pain is always subjective. Each individual learns the application of the word through experiences related to injury in early life.” This argues for reducing painful procedures as much as possible.

They listed numerous non pharmacological interventions that can be used to reduce pain and distress with procedures. Below are some highlights.

1. Distraction: For an Infant use a pacifier, bubbles, and toys. For a toddler use bubbles, songs, and toys. For school age use video games, search for objects in pictures, stories, jokes, and counting. For adolescents use music, video games, and conversation

2. Deep Breathing: Have the child take deep breaths rhythmically.

3. Blowing: Take a deep breath and “blow away the pain”.

4. Suggestion: Put on a “magic glove” or “magic cream” that doesn’t allow pain.

5. Superhero imagery: Have the child pretend they are a superhero and on a mission.

6. Guided imagery: Help the child imagine a special place that they are visiting.

7. Rewards: Tell the child there are rewards, such as stickers, available.

8. Spot pressure or counter irritation: Rub the surrounding skin or provide spot pressure to the surrounding skin.

9. Sweet solution, pacifier, breastfeeding: Useful for infants of minor procedures.

Remembering that pain is subjective can help with the frustration over a child who seems to be over reacting to the pain. Maybe they are more sensitive than others to painful stimuli. Sometimes there’s not a lot you can do to avoid the painful procedure. However there are ways that you can help them cope and manage the pain better. I hope I gave you some good ideas.

Sheila Cason, MD

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Tuesday, November 13, 2007

Inappropriate Touching - Is it Child Sexual Abuse?

Question for Mommy MD:

Dear Dr. Cason,

I’m not sure where to start. I have a 4 year old little girl who pulled her cousins pants down a couple of days ago. I marked it as just curiosity and took the chance to open the floor for questions.

Then today I caught her with the same cousin who is two. He had his pants down and was lying on the floor; she had her mouth on him. I’m so full of mixed feelings and have asked her all kinds of questions. She said no one has done this to her or told her to do it. I can’t imagine when it could have happened but I do plan on having her checked.

But my question is:

Is it possible that this is still curiosity or is this a symptom of being molested and how can I get her to tell me?

I am a survivor of rape that took place for 13 years. I have always been protective, and I just don’t understand how it would have gotten pass me if someone had done this to her. Any thoughts would be greatly appreciated.

Anonymous


Dear Anonymous,

I’m sorry for your pain at this difficult time. It must be hard to suspect something and yet not know what the future holds for your child and your life. We all want to feel that our children
are 100% safe and when something threatens that, it’s devastating.

I can tell you that I am suspicious. Children are very curious at this age and it can be difficult to tell when a child is merely playing or actually imitating something she’s seen or been required to perform. But it sounds concerning enough that you must go see your pediatrician and they will refer you to the nearest facility that is trained to investigate such cases. They will help you to make sense of her actions. There is no way to “make” her tell you. In fact I would avoid overly questioning her. As pediatricians, we are trained as well to not overly question a young child. You want her response to be authentic and not merely a regurgitation of comments that are made to her. Your local Child Protective Services (CPS) is specialized in the interview process. Yes there is a specific way you must ask the question as to avoid leading the child or influencing her response. For this reason I leave the interview for the experts.

For yourself, as a survivor of sexual abuse there are many issues that you will need to work through. I hope that this has happened for you already. If not please seek counseling. There are wonderful individuals that can help you heal. Also know that you can be your child’s biggest advocate. You’ll have to balance your emotions in this transitional time until you find the answers. But trust the experts and talk with your pediatrician.

I’m glad that you took this opportunity to discuss and answer deeper questions with your child. No matter how this turns out, you’ll need to continually do this with her. I’ve had a lot of people, particularly women with a history of molestation, feel uncomfortable bringing up “private” issues. As parents we need to get over this. A penis is a penis, and a vagina is a vagina. There’s nothing inherently wrong with the words or the parts of the body. But they are private and kids need to be taught what’s appropriate. This way they can recognize when something doesn’t
seem right and tell an adult that they trust.

Please see my previous articles on “Playing House” and “Child Sexual Abuse”. I have listed signs that may be present when someone is sexually abused. I wish you and your little girl well. Please don’t hesitate to ask any further questions.

For more information on child sexual abuse or other forms of abuse, write to:

The National Committee for Prevention of Child Abuse
PO Box 2866
Chicago, IL 60690.

Sheila Cason, MD

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Monday, November 12, 2007

Abdominal Pain in Kids - Constipation

Standing at the exam table I bent down to feel her belly. She’d been having tummy pain so my routine question just rolled off my tongue. When was the last time you had a bowel movement? She looked at her daddy with a crinkled brow. He whispered: number two? Charmed I also then bent and whispered, “When did you last go number two?” Pleased -her doctor knew her code- she answered and we went on with exam. Turns out they have:

“A number one”- Check. (We all know this right?)
“A number two” - Check (See above)
“A number three”- Uh
“A number four”- Hmm
“A number five”- My own brow crinkled.

A little girl voice piped up and explained her family-speak:
“Number three” wipe – Ah of course. Front to back girls!
“Number four” wash hands- Imperative.
“Number five” dry your hands- Very nice. Follow with lotion too

Cute family. This made my day. I see this over and over in my clinic. Constipation is the number one reason for abdominal pain in kids. Check with your doctor first and see my articles on constipation in kids.

Sheila Cason, MD

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Wednesday, November 07, 2007

The Flu in Children

Panicking parents crowd my office each day. Complications from the flu was the cause of a father and son death recently here in Guam and it’s brought a heightened awareness of the flu. This isn’t entirely uncommon but scary none the less. I try to watch my children closely, and give them plenty of fluids and rest. But it can be hard.

Just this past weekend, my 5 year old was sick and resisting all efforts to nap. The other two were sick as well but responded well to separating and mild threats of punishment if they should even think of getting up. But my big girl just rolled around on my bed for two hours and approached me endlessly asking when it was time to get up. I finally caved in and let her settle down on the couch. Memories of sick days gone by came back as I tucked her blankie around her, brought her snacks and let her *gasp* watch Sponge Bob Square Pants on TV. At least she’s sort of resting; TV doesn’t use that many brain cells.

*Remember even if you have gone to the doctor and they diagnose your child with the “flu” you may need to go back for another examination particularly if:

1. They have had more than 3-4 days of fever.
2. Have focal complaints such as ear pain or chest pain.
3. Show signs of respiratory distress.
4. Look very ill or lethargic even if their fever appears to be lower.
5. Has asthma or another chronic condition such as heart disease.

See my previous post on when to take your child to the doctor. May you and your child be well during this time of year, Give your child the flu shot or if your baby is less than 6 months of age and can’t get their flu shot, go get your flu shot!

Sheila Cason, MD

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Monday, October 29, 2007

Cold and Flu Season: When to Take your Child to the Doctor

It’s late and I just got home. It was another very busy day in my clinic. Everyday I’m educating parents regarding their sick child. Sometimes it’s not always easy to tell when you should go to the doctor. A fever is considered any temperature greater than 100.4 degrees Fahrenheit. kidshealth.org has a good article on fevers.
Here’s what I tell my parents:

Seek medical attention if:
• There has been a fever present more than three or four days.
• A cough has been present for more than 2 weeks.
• A cold or upper respiratory infection has been present for more than a week to 10 days.
• There are focal symptoms such as ear pain, throat pain, chest pain or tightness.
• There is persistent vomiting or diarrhea.
• There is a fever greater than 100.4 Fahrenheit in an infant less than 3 months of age.
• There is a fever > 102 in an infant less than 2 years of age particularly if there are no other symptoms. This could mean they have a urinary tract infection.
• If you have any questions or concerns.

Go to the emergency room if:
• A child looks very ill or lethargic or is difficult to arouse.
• A fever is accompanied by a rash. Particularly if it looks purple or like blood under the skin.
• There is difficulty breathing and drooling.
• An infant/child’s lips are blue or they appear to stop breathing.
• You child has a seizure.
• Your child has a fever and stiff neck and/or severe headache.
• Your infant’s soft spot is bulging.
• Your child is inconsolable.

If you’re unsure whether to take your child to the doctor call your pediatrician. You should be able to talk directly to you doctor the same day. You may have to wait a few hours until they can get space in their clinic but your call should be returned by noon if you call in the morning or by end of the work day if you call after lunch. If your child is ill and needs to be seen that day, they should be able to accommodate you. Don’t expect to be seen the same day if it’s a chronic problem and can wait until the next day.

Sheila Cason, MD

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Sunday, October 28, 2007

Deceptive Medical Claims

Too often than not, I’m watching TV or listening to the radio and a doctor or other “expert” comes on claiming that XYZ can cure everything from gout to diabetes. These ludicrous claims, that have little scientific backing, are what make people think doctors are quacks. Recently I had a reader ask to clarify what the benefits of colon cleansings are. Colon cleansings! Did I miss that lecture in medical school? Having no more expertise that the average person I did some researching and found that this is one of the numerous deceptive medical claims that are out there on the market. So how do we decipher what is legitimate or a hoax? Well lucky for you, there is Quackwatch.org that can help provide you with some info.

Yep, there is a whole website devoted to debunking deceptive medical claims. Quackwatch, Inc., is a nonprofit corporation whose purpose is to combat health-related frauds, myths, fads, fallacies, and misconduct. Its primary focus is on quackery related information that is difficult or impossible to get elsewhere. Founded by Dr. Stephen Barrett, it now has a worldwide network of volunteers and expert advisors. Because of its rigorous adherence to scientific principles in evaluating medical claims they have received numerous awards over the years regarding their articles.

The future for quackery looks bright says James Harvey Young, Ph.D in his article “Why Quakery Persists”. Many people have suffered side effects from modern "miracle" drugs. This circumstance, added to the over prescribing of antibiotics, tranquilizers, and stimulants, has helped foster a stereotype of our nation being "drugged," thereby giving "natural" healers a promotional boost. In the early nineteenth century, quacks termed the doctor a butcher; today they call him a poisoner.

Be wary of grandiose health promises. It’s like they say, “If it sounds too good to be true, it probably is.” If you have questions then do your own research. Check out what other people and physicians have to say. Ask your pediatrician for their advice or go on to Quackwatch.org to see more info regarding the specific claim. Now as an educated health consumer, you can make your own decision. Oh and what about the colonics? They have lots to say about this as well! Check it out here.

Sheila Cason, MD

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Friday, October 12, 2007

Infant Cold Medications

The cold season has hit my pediatric office and our house as well! I’ve been fighting a virus for the last couple of days and now it looks like my 17 month old has it too. This morning, he’s been wandering around with his little pjs on and dragging his blankie. I would normally give him something for the cold but things have changed a little since he was born.

Last year when I wrote about infants and colds I recommended infant drops to help with the stuffiness. Well, I take that back! Yesterday The New York Times reported that infant cold medications have been pulled from the market. The Consumer Healthcare Products Association issued a press release yesterday 10/11/07 listing the infant medications that have been voluntarily removed by their manufacturers. They are as follows:

Manufactured by the McNeil Consumer Healthcare unit of Johnson & Johnson:

Concentrated Infants’ Tylenol Drops Plus Cold
Concentrated Infants’ Tylenol Drops Plus Cold & Cough
Pediacare Infant Drops Decongestant (PSE)
Pediacare Infant Drops Decongestant & Cough (PSE)
Pediacare Infant Dropper Decongestant (PE)
Pediacare Infant Dropper Long-Acting Cough
Pediacare Infant Dropper Decongestant & Cough (PE)

Manufactured by Novartis:

Triaminic Infant & Toddler Thin Strips Decongestant
Triaminic Infant & Toddler Thin Strips Decongestant Plus Cough
Manufactured by the Medtech Products unit of Prestige Brands Holdings:
Little Colds Decongestant Plus Cough
Little Colds Multi-Symptom Cold Formula

Manufactured by Wyeth:

Dimetapp Decongestant Infant Drops
Dimetapp Decongestant Plus Cough Infant Drops
Robitussin Infant Cough DM Drops

The Consumer Healthcare Products Association states: “Potential misuse of these infant medicines, not product safety, is driving the voluntary withdrawal. This withdrawal does not affect cough and cold medicines for children age 2 and older”.

This isn’t too surprising. In January 2007 the Centers for Disease Control and Prevention released their Morbidity and Mortality Weekly Report. In it they “identified three cases of infant deaths in two states during 2005 that were determined by a medical examiner or coroner to have been caused by cough and cold medications” Since this time there has been increasing concern over the safety of over the counter cold medications for infants. It’s not unusual for parents to inadvertently overdose their infant by giving them multiple preparations all containing the same medication.

This move by the manufacturers is a good one for now. Until we know more about the safety of over the counter cold medication in infants, then we should opt for more benign treatments such as a warm bath, nasal saline, a humidifier, and tender TLC.

Sheila Cason, MD

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Thursday, September 20, 2007

Bathtub Safety

My baby is crazy for the bathtub! He giggles, laughs and generally has a rollicking good time. If there is any indication that it’s bath time, he turns and without looking back, hightails it in the direction of the tub. The other day I let him play for a while because it’s a good way for him to get comfortable in the water. But just because I want him to be comfortable doesn’t mean I let him take risks he can’t handle. I pulled up a stool and didn’t leave his side for a second. Sure enough 10 minutes into bath time, while he was slipping and sliding around, he fell back nearly submerging himself. I caught him just as he was about to go under.

As you know, from my January post: Drowning Prevention, I’m a big advocate for water safety. USA Safe Kids.org reports that drowning is the leading cause of accidental injury-related deaths among children ages 1 -4. 10% of all childhood drownings occur in bathtubs. Female children have a bathtub drowning rate of twice that of male children. My own daughter loves to put her face in the water and pretend she’s sleeping. Yeah I know. It freaks me out too!

I can’t emphasize this enough: Don’t leave your child in a bathtub unattended! Drownings happen fast and the consequences are devastating. Even I’ve been tempted to step away for a second to get something. It’s better to just pull them out and let them drip all over the place. That’s a mess you can clean up.

Sheila Cason, MD

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Tuesday, September 18, 2007

Thrush

Sometimes it’s the little pediatric problems that are the most distressing for parents. Take, for example thrush. I’ve had many a parent tearing their hair out because of this unwelcome organism. Seen with many babies this common condition is caused by Candida albicans. Candida is found typically in the mouth and on the skin and other places in all people. Normal bacteria that are present and a healthy immune system keep Candida in check. People who are immunocompromised or infants whose immune systems are not fully matured yet can commonly get thrush. Thrush looks like small white plaque like material on the inner mouth and lips. Some children can be very fussy while others appear to have minimal discomfort.

Treatment is usually saved for those babies who are uncomfortable or who have a more extensive case. Traditionally the topical application of Nystatin suspension has been used to treat thrush. You can drop the medicine in the baby’s mouth or apply it directly to the lesions with a cotton tip applicator. But be careful not to contaminate the bottle of medicine by touching the medicine dropper to your baby’s mouth and then replacing the dropper in the bottle. Sterilize the nipples of baby bottles and pacifiers. Nursing mothers will need to treat their nipples as well.

Gentian Violet is another alternative to therapy besides Nystatin. No prescription is necessary and can often be found in drugstores. Like the name suggests it’s purple and messy! Using daily for three to four days is typical. If your baby has not responded after 3-4 days or they have sores that develop, discontinue use and call your pediatrician. For thrush that has not responded to Nystatin, there is another class of drugs – the Azoles- that can be used. However this has been shown to cause liver problems in some people and should only be used when prescribed by your pediatrician.
There is a popular theory that says that otherwise healthy people can get systemic candidiasis. This “Candida Hypersensitivity” is then claimed to be one of the causes of “Idiopathic Environmental Intolerances” of which the symptoms are a long list of general complaints including fatigue, depression and joint pain. It is reported that a “Candida diet” along with certain vitamins and supplements can help eliminate the body of excessive yeast and restore balance. There is no scientific evidence that this is necessary. The American Academy of Allergy, Asthma, and Immunology (AAAAI) has evaluated “Candida Hypersensitivity” and reports that “there is no scientific proof that Candida albicans causes such a condition.” Admittedly the information available for and against systemic yeast infections is massive and confusing. What we do know is that the rare person that does succumb to a systemic yeast infection is also immunocompromised and extremely ill. They are being cared for in an intensive care unit and not walking around with vague complaints. Stephen Barrett, M.D. of Quackwatch.org has done a great job of compiling information regarding this theory.

Talk with your pediatrician before starting any therapy particularly if your child’s thrush is recurrent or severe. Severe thrush along with other clinical signs can be an indicator that there is an underlying immune deficiency. Remember that infant oral thrush is common. Just because you see a little thrush in the mouth does not mean that treatment is necessary.

Sheila Cason, MD

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Saturday, September 15, 2007

Salmonella

Ahh… What a great day! My kids baked a birthday cake for their daddy! There’s nothing better than seeing kids amped up about a chocolate cake. I usually don’t allow them to lick the bowl because raw eggs can harbor salmonella. But my chocolate mayo cake recipe is safe because it’s made with mayonnaise not raw eggs.

Salmonella refers to a group of bacteria that can cause a diarrheal illness. The serotypes Typhimurium and Enteritidis are the most common in the United States and has been known to cause illness for over 100 years. When people become sick with the bacteria it is known as Salmonellosis. Most people recover without antibiotics but some people can go on to have other complications. According to the CDC: Centers for Disease Control and Prevention:

“Most types of Salmonella live in the intestinal tracts of animals and birds and are transmitted to humans by contaminated foods of animal origin.”

In the 1970’s strict procedures for cleaning and inspecting eggs were implemented and made salmonellosis caused by external fecal contamination of egg shells extremely rare. However, there is a current epidemic of Salmonella infection that is due to intact and disinfected grade A eggs. The organism Salmonella enteritidis silently infects the ovaries of healthy appearing hens and contaminates the eggs before the shells are formed. Try to avoid eating raw eggs. This is especially important for high risk populations such as the elderly, infants and the immunocompromised. More information regarding Salmonella may be found from the CDC website.

All three of my kids really enjoyed making the cake. You can see how excited the baby is to lick the bowl! Tomorrow I’ll give you the recipe!

Sheila Cason, MD

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Friday, September 14, 2007

Feral cats

My three year almost killed a kitten recently because of her childhood exuberance! It’s hot here in Guam so we spend most weekends slathered with sunscreen and playing at the pool’s slide. Recently I found the kids giggling and squealing over a tiny feral cat that was hanging out by the steps to the slide.

He was so cute and if I wasn’t a pediatrician I might have loved over that kitten myself! But I am a pediatrician and I couldn’t help but think what disease that little guy was carrying. The local animal shelter works with the community to find homes for these cats. But despite this, they are still abundant. In fact, as I am writing this a feral cat just walked by my window. Children need to be watched around feral cats they can carry diseases. The CDC: Centers for Disease Control and Prevention report that “Infants and children less than 5 years old are more likely than most people to get diseases from animals. This is because young children often touch surfaces that may be contaminated with animal feces (stool), and young children like to put their hands in their mouths. Young children are less likely than others to wash their hands well.” The most common disease that can be transmitted are: Cat Scratch Fever , the Plague and Toxoplamosis.

My girls resisted the kitten as long as they could. They crouched and said hello every time they walked up the steps. For most of the day, I caught little children careening down the slide and sent them on their way. But late in the day, a little brown furball came flying down that slide too. I scooped him up as he came by me and wouldn’t you know it my 3 year old, giggly and blissful, came flying down right after it. Yep! She had picked up that kitten and sent it off for a ride! Can you believe that? Just goes to remind you that kids and animals need to be watched, not only for their own safety, but for the animals!

Sheila Cason, MD

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Monday, September 10, 2007

Constipation in Children: Part Three - 10 Tips for Prevention and Treatment

The following is a guideline to handle constipation in kids. Remember to talk with your pediatrician. Believe me they are familiar with constipation and want to see your child feel better.

1. Drink plenty of water: If you drink a lot of water your colon doesn’t need to take it from your food. If you have a hard time getting your child to drink then have them eat fruit. Fruits have a lot of water naturally.

2. Increase fiber: This means whole grains, fruits, and vegetables. Fiber holds in the water and can make it easier to go. But if you increase fiber without increasing water they will get more constipated!

3. Get plenty of exercise: Kids should have an hour a day. Make sure they exercise outside of school. One PE session a week is not enough!

4. Decrease refined food: Such as cracker and chips. If you don’t watch it, it’s easy for the kids’ diet to consistent mostly of refined foods. Don’t cut the carbs just make sure they are whole grains. Look at the label it should say greater than 3 or 4 grams of fiber per serving. Don’t eat “white” foods such as white bread or white rice.

5. Decrease your dairy: No more than 24 ounces of dairy in one day.

6. Limit bananas: This advice is mixed. I see so many people will say no, it causes no problem and others will say yes, it does. I’d welcome any comments that people have.

7. Get a bathroom schedule: Remember that the body wants to go to the bathroom after eating. It’s nature. Don’t fight it! Give kids plenty of time in the morning to go before school. Some kids will be constipated after starting school or camp because they withhold going.

8. Go when you need to go: Don’t ignore the urge. The colon will only expand and adjust to the stool, and then it’ll keep doing its job. The colon will extract more water from the stool, and the stool will become harder. This, for obvious reason, makes it even harder to go.

9. If your child is chronically constipated then evacuate the stool to begin with using enemas or suppositories. Don’t overuse enemas. It can mess up the colon’s natural ability to function. Stool softeners are not habit forming and can be taken for a long time without any problems.

10. Keep the stool moving by using oral agents: Such as mineral oil, Lactulose, milk of magnesia and polyethylene glycol which is also known as Miralax. Miralax and Lactulose work by keeping water in the intestine. You may need to adjust the dose because the stools can get runny. Lactulose can cause cramps. Mineral oil works by coating the stool and helping it glide out. It doesn’t taste great but by keeping it cold it can be made more palatable. Do not give mineral oil to a child under 4 years of age or a child who has swallowing problems. They may accidentally get it into their lungs and cause a serious type of pneumonia. Let your pediatrician guide you!

Good luck! Remember again that if you increase fiber without increasing water your child will get more constipated! Make a plan with your pediatrician and then stick with it. If it isn’t working call them! The may be able to tweak the plan a little and answer questions so that your child can be successful.

Sheila Cason, MD

Sources: The North American Society for Pediatric for Gastroenterology, Hepatology and Nutrition http://www.naspghan.org/

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Sunday, September 09, 2007

Constipation in Children: Part Two - Encopresis

Encopresis is a common pediatric problem. It is defined as having fecal soiling. Often the child will be unaware that they have liquid stool leak in the underwear and not notice the smell. Encopresis often is a result of chronic constipation. Constipation first occurs because of a recent viral illness or happens because they are withholding. Kids at school and camp often don’t want to go in public restrooms and will ignore the body’s urge to go. This makes the stool back up and become even harder, which makes having a stool painful and the child withholds even more stool and the cycle continues. If this cycle is left to perpetuate it will cause encopresis. If you remember the colon’s “job” is to extract water. If the stool builds up and stays in the colon, water will be extracted. The stool will get harder and the colon stretches to accommodate the new larger amount. A colon that is over stretched doesn’t work correctly, and then the child doesn’t feel the urge to go which leads to more stool holding. This cycle results in encopresis. It’s because the new stool that’s being formed has nowhere to go, and it leaks around the hard stool into their underwear.

To help the colon return to its normal size, you need to get rid of the stool. You can do this with enemas and suppositories under your pediatrician’s guidance. Too many enemas or laxatives may interfere with the body’s ability to use the bathroom. You may also use oral medication to help clean your child out and keep them regular. Again your pediatrician can help.

If the colon is kept clear and regular, it will go back to its normal size and the child should then be able to have spontaneous regular bowel movements. This takes a lot of dedication on the parent’s part and it may also take to help of a pediatric gastroenterologist to make this work. I see a lot of parents who give up too early or stop once the child’s bowel movements normalize a little. You have to continue the treatment and talk with your pediatrician. The North American Society for Pediatric for Gastroenterology, Hepatology and Nutrition’s website is an excellent resource. You may access them at http://www.naspghan.org/.

They can help you find a pediatric gastroenterology specialist in your area. Tomorrow I’ll give you tips regarding the prevention and treatment of constipation.

Sheila Cason, MD

Sources: The North American Society for Pediatric for Gastroenterology, Hepatology and Nutrition http://www.naspghan.org/

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Saturday, September 08, 2007

Constipation in Children - Part One

Like any mom, I’m a little obsessed with my children’s bowel movements. Am I crazy if I say I know when they go and the consistency?

Before children I would say, “Yes Ma’am you are.”

But now? Now I know I’m just like every other mom that comes in my office.

Constipation in kids is one of the most common complaints I see in my office! Constipation is defined as a decrease in the frequency of bowel movements or passing painful hard bowel movements. A lot of parents want their children to go everyday. I have to admit, I’m one of those people! But there is no ideal schedule per se. What you really want to know is what the stool looks like. I’ve had parents say their child goes everyday but its tiny hard balls and they cry. That’s constipation. Some will say they go after a week and it clogs the toilet. That’s constipation. Some will say they go every three days but it’s soft. That’s not constipation.

It’s normal for kids to get constipated when the have had an illness, been traveling, or have started school or camp. Once they get behind in their fluids then constipation often ensues. The treatment tends to be multi factorial. If the child has a lot of stool and is having fecal soiling called ”encopresis” then they may need an initial clearing out with an enema or suppository. But most kids only need a little tweaking with their diet. You can increase their water, fiber and avoid dairy and make sure they visit the bathroom after eating.

By working with your pediatrician you can devise a plan for your child. If they have chronic constipation or encopresis then you may need to be seen by a pediatric gastroenterologist. This is a specialist that takes care of children with chronic constipation, abdominal pain, diarrhea, vomiting, and other medical disorders of the gastrointestinal tract. My husband teases me that I spend too much time looking at my kids’ poop but I recently was happy to see he was really like me and other moms when I saw him leaning over the toilet analyzing our kids green stool. It turns out that grape juice turns the stool green! Who knew?

Sheila Cason, MD

Sources: The North American Society for Pediatric for Gastroenterology, Hepatology and Nutrition

http://www.naspghan.org/

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Saturday, September 01, 2007

Food Allergies in the School

It’s almost school time for my kindergartner, and I’m scheduled to bring snacks for the entire class. I don’t know what I’ll bring but I know that it won’t be anything with peanuts. There is a little girl in her class that’s allergic to peanuts- I know because I asked! I know all about peanut allergy from my 6 year old nephew. Since my sister found out that he was allergic, I have learned more from her than all of my medical school and residency training put together! This is mostly because the field of allergy and immunology is rapidly changing. We now know things that we didn’t know five to ten years ago.

A food allergy is an immune response to certain types of food. The most common food allergies in children are eggs, peanuts, milk, nuts, soy, fish, wheat, and shellfish.
The symptoms of food allergies can be varied. The most common reactions are: vomiting, diarrhea, hives, eczema, difficult breathing, and possibly a deadly reaction – anaphylactic shock. I once had a patient that handed her granddaughter a bit of an almond. The little girl immediately started sneezing!! The grandmother watched her puzzled until she realized she was allergic and showing early signs of an anaphylactic reaction. They called 911 and the child was given immediate medical attention. It happens that fast!

If you suspect your child has an allergy, talk with your pediatrician. And if your child isn’t allergic, remember that other children may be. With the increase in food allergies, chances are, you know a child who has a food allergy. Be aware of the foods you send with your child to school. Be especially careful of feeding other people’s children. I know I will. I’ll be extra careful and treat that mother’s little girl just like she was my own child.
The American Academy of Allergy, Asthma & Immunology has more information that can be accessed at their website: http://www.aaaai.org/.

Sheila Cason MD

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Tuesday, November 21, 2006

It’s looking a little bit like cold season…

Soooo now, much as I needed last night to be a restful night, it was anything but. The baby, now along with teething, has his first bad cold. Poor little thing! Every time he woke up and tried to suck his thumb, he could not breathe amongst the mucus!! So you know my theory on sick babies – Do not let them cry it out. Yep! You guessed it. I pulled him into bed with me, and a fitful sleep we all did have.

If your baby is sick with crankiness, nasal congestion and little or no fever, mommy medicine does well. Infants less than 2 months old need to be evaluated by a physician. This is especially so if they have a rectal temperature greater than 100.4º F! I tell all my parents about my mommy medicine. Before bedtime, give your baby a bath with warm water and pour some water gently over his head to help with some of the congestion. Then dry him off with a large fluffy towel and clear out his nose with a nasal bulb suction. Give him some Tylenol for the fever. Studies in medicine have not shown the infant’s cold medication to be particularly helpful, but I think it helps a little. If they are over 3 months you can use infant decongestant and some Vicks Babyrub on their chest. Babies love the touch! After this, dress him and place him to sleep on his back.

Your baby should be getting better after 3 or 4 days. A physician should evaluate colds that are prolonged. The most important thing your baby probably needs is sleep! So this is where I throw out my strict sleep guidelines and let them sleep whenever and wherever. I love the extra cuddles! I just hold my baby tight and breathe in his sweet smell. It’s the little things in life….

Dr. Sheila Cason



Update: October 12, 2007


It is now recommended that no infants under 2 years of age take infant cold medications. Manufacturers of infant cold medication have begun voluntary withdrawal of their products from the market. As stated in the press release from The Consumer Healthcare Products Association website “Potential misuse of these infant medicines, not product safety, is driving the voluntary withdrawal. This withdrawal does not affect cough and cold medicines for children age 2 and older.”


Please see my recent article regarding infant cold medications.

Sheila Cason, MD

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