Medicine Mondays:Essential Fatty Acids and Children,

Hi Everyone,

Welcome back to Medicine Mondays.

Each Monday I'll post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

Dear Dr. Cason,

For toddlers, is there a given amount of fatty acids they should have for good brain development? Are supplements available and ever necessary?With my daughters dairy, egg, and nut allergies, the fatty acids she can intake are limited. She eats a lot of avocados. What are other good sources?- Anonymous


Dear Anonymous,

When people talk about consuming fatty acids they are most likely referring to essential fatty acids (EFAs) They are called essential fatty acids because they cannot be made in the body from other substrates and must be supplied in food. These fatty acids are called Linoleic Acid (Omega -6) and Alpha-Linolenic Acid (Omega - 3).

In the body, essential fatty acids are primarily used to produce hormone-like substances that regulate a wide range of functions, including blood pressure, blood clotting, blood lipid levels, the immune response, and the inflammation response to injury infection.

You can get these EFA in supplements but since they are nutritional supplements and therefore not regulated by the FDA, there is no specific guidelines about what a safe amount is. I generally recommend that parents feeds their kids good healthy foods that will supply the EFA and don't worry about additional supplementation found in capsule form.

Most people forget that while eating Omega- 6 and Omega- 3 EFA are important what is more important is eating the right ratio of Omega -6 and Omega-3. Marion Nestle in Her Book, "What to Eat" points out that

Although these two essential fatty acids differ, the enzymes that work on them are exactly the same. This means that when you eat a lot of linoleic acid, Omega- 6, it can compete with the alpha-linolenic acid, Omega-3, for the enzymes that turn the alpha-linolenic acid into EPA and DHA, the two longer omega-3 fatty acids that seem especially good for health.

This means that it's important to eat the Omega -6 and Omega -3 EFA in the right ratio to prevent this competition. Nestle suggests eating balance of 6:1. Oils that have a good balance of Omega-6 to Omega- 3 are Flaxseed oil at 1:4, Canola at 2:4, Soy at 7:1 and a fairly good balance of these two EFAs can be found in Olive Oil at 9:1.

Most people get enough Omega- 6 without even trying. Examples are- Safflower oil,walnut oil, grass fed cow milk, olive oil, palm oil, sunflower oil, soybean, peanut oil and sesame oil to name a few. What they need to focus on is increasing their Omega- 3 intake.

Examples of food that have a good amount of Omega- 3 are oily fish, walnuts, flax seeds, pumpkin seeds, canola oil and soy. Omega eggs are also a good source of Omega-3 fatty acids and you can find them in your grocery store. The hens that lay these eggs are fed on healthier feeds, which results in eggs that contain omega-3 fatty acids. For a child that is allergic to nuts and eggs, I would focus on taking in a balance of salmon, flax seeds and canola and soy oil.

Soft Neurological Signs in Young Children and My Personal Experiment

Dear Dr. Cason,

I have a son who is 4 and also a twin. He twitches his fingers and does this circular motion with his hands when he talks, but mostly when he is excited.(his arms stay at his side).My doctor says its just a nervous thing and that he will learn how to control it, but it worries me. What do you think?- CS

Dear CS-

It sounds like what you are describing is neurological overflow or what others will call "soft" neurological signs". These soft neurological signs are often used to describe signs that are either difficult to obtain or interpret. It is commonly seen in immature nervous systems of very young children. Persistence of these signs beyond a certain age though may indicate a future problem with attention and/or learning disorders or other cerebral dysfunctions.

You can test your child for soft neurological signs a couple of different ways.

1. Ask your child to walk across a room on their tip toes. As they perform this look for tremors and "overflow" involuntary movements that occur with his hands and his face.

2. Ask your child to touch the tip of their finger to the tip of your index finger and then touch the tip of their nose again. Do this three times. As they perform this look for tremors and "overflow" involuntary movements that occur with their other hand and their face.

Remember again, that the presence of these signs may or may not indicate future problems. The best thing you can do is discuss your concern with your pediatrician and if you are still concerned, they can refer you to visit with a pediatric neurologist who can evaluate your child and offer specific recommendations.

I hope this helps. I couldn't find any specific ages in which these soft signs should be gone. Most articles suggested that beyond age 5 or 6 was concerning for other conditions. Now as luck would have it I have a 4 and a 6 year old. They are both full term and otherwise developmentally on target.Tomorrow I shall do my own little experiment and let you know what I found!

*Warning* This is not a true "experiment" and one should take it as an interesting task and not necessarily indicative of how other 4-6 year olds will perform.

*11/18/08 Update*

Standing at the bus stop today I had a chance to test my children. The older 6 year old certainly did well. The four year old splayed her fingers a little as she touched her nose and had difficulty with balancing as she did the tip toe walk.I wouldn't necessarily call this a soft sign but she did show less coordination. I would expect her to get better at this and have no worries about her development overall.

I'd be curious what other people found out! Let me know by leaving me a comment.

The Cold and Flu in Pediatrics

Dr. Cason,

Danger has had a cold for just over a month now. It was REALLY BAD for about a week and a half but now is just kinda there. She has a couple of coughing fits a day, usually while sleeping and always has a runny nose and last week a very mild rash formed on her chest and back of her neck. I took her to the public health nurse and she said it was fine. When do I need to be concerned about it? Do I need to be concerned about it?- Nikki

Hi Nikki!

You did the right thing by taking Danger in to be evaluated. You should expect her to be feeling better in a few days, most upper respiratory tract infections should resolve by one to two weeks. If she persists with her symptoms or suddenly develops focal signs such as a fever, ear pain or worsening cough, then return sooner.

I'm not sure what's going on with the rash. It could be a mild form of eczema- which can flare when kids are sick. If it is spreading or your child has a fever and looks very ill then seek medical attention immediately.

At this time of year we see a lot of cold and flu symptoms in children. Most kids just need a little monitoring and plenty of fluids. Two previous posts that I have written on the subject are:

1. Cold and Flu Season- When to Take Your Child to the Doctor

2.The Flu in Children

I hope she feels better!

Sheila Cason MD

Eye Color in Children

Hi,

Welcome back to Medicine Mondays. This week I'm going to talk a little about eye color.
The following question from a loyal reader

Dear Dr. Cason-

Danger has blue eyes, but since the hubs and I both have green eyes,
his parents have green and brown and my parents have green and brown
what are the chances that her eyes with stay sooo blue?
If they are going to change will they usually do so by a certain age?- Nikki

Dear Nikki-

Great question! I have always wondered the same and have anxiously waited to see what color eyes my children would have.

You may remember learning about dominant and recessive traits (Patterns of Mendelian Inheritance) in high school. You learned that there are two copies of each gene that we inherit from each parent. For a recessive trait to show through, we must inherit two copies of the gene that codes for that trait - one from both our mother and father. Well we used to think that 'blue' was the recessive variant of the eye color gene, and 'brown' was the dominant variant. In other words, we used to think that a person's eyes would be brown even if they only inherited one 'brown' gene from either parent and blue only if they inherited both 'blue' genes from each parent.

Well now you can forget about these nice linear rules when it comes to eye color. It's not that easy. We now know that eye color is a polygenic trait which then determines the amount and type of pigments in the eye's iris.

Color variations among different irises are typically attributed to the melanin content within the iris. Most babies are born with blue eyes because they contain low amounts of melanin. As they get older their melanocytes darken and their eyes change color. By six months of age most babies will have their eye color set, but you can see some gradual changes in the color all the way up to 3 years of age.

In general, you can probably still say that blue eye color is recessive but truthfully the color of one's eyes are controlled by a variety of genes. You'd be hard pressed to accurately predict what color eyes your child will have. You'll have to wait until she gets a bit older. Personally all three of my kids had bright blue eyes. My oldest kept hers and the two little ones now have green eyes! They are all sooo pretty!

Molluscum Contagiosum and Kids- What to Do?

Welcome back to Medicine Mondays.

Each Monday I'll post answers to questions I acquired. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

Today we're talking about Molluscum Contagiosum.

I received this question from a fellow reader:

My daughter was just diagnosed with Molluscum. Daycare is freaking out because they don’t know what it is (I’ve never heard of it either). They are asking me to get a note from the pediatrician on what it is so that they can explain it to the other parents... is it only spreadable when the warts are “an open wound” or is it spreadable all the time?

Molluscum Contagiosum Virus (MCV) is one of those annoying little skin infections that kids get. eMedicine has a great very indepth article that outlines the varies aspects of MCV infection. Here a brief exerpt.

MCV causes characteristic skin lesions consisting of single or, more often, multiple, rounded, dome-shaped, pink, waxy papules 2-5 mm (rarely up to 1 cm) in diameter. The papules are umbilicated and contain a caseous plug. MCV is an unclassified member of the Poxviridae family

MC is most common in children who become infected through direct skin-to-skin contact or indirect skin contact with fomites, such as bath towels, sponges, and gymnasium equipment. Lesions typically occur on the chest, arms, trunk, legs, and face. Hundreds of lesions may develop in intertriginous areas, such as the axillae and intercrural region. Lesions may rarely occur on the mucous membranes of the lip, tongue, and buccal mucosa. The palms are spared. Patients with eczema may develop large numbers of lesions.

MCV may be inoculated along a line of minor skin trauma, resulting in lesions arranged in a linear pattern- a process that is termed autoinoculation.

Treatment is generally avoided as most healthy children will resolve their lesions in 6-9 months. Some cases may last for years. If the lesions are spreading particularly fast or are becoming infected you may want to talk with your physician regarding special therapy. For most children freezing or burning off the lesions cause more harm and pain than do the original lesions. But this an options that many parents elect.

For a few individuals the Molluscum lesions may indicate that a person is immunodeficient or immunocompromised. Take your child to the doctor if your child has a particularly bad case of Molluscum and doesn't seem to be healing from them.

Other that that there's nothing much you can do. Except ignore it- which is what I do. That's my little boy in the picture! Oh and I send these kids back to daycare. It's unrealistic to keep them out.

Making the Right Medical Decisions for Your Child

Making the right medical decisions for your child isn't always simple or clear cut. Yet we as parents are faced with these decisions everyday. And as a pediatrician I'm also faced with answering these questions. Just today I spent extra time with a family. They were having a hard time making a decision for their child. Finally I just printed out some info and told them to go think about it. I trust that they will research the topic and come back with more questions and then we can really get down to understanding what needs to be done.

As parents we presumably want the very best for our child and in this day and age there's a lot of doctor mistrust. Gone are the days of paternalistic medicine -where what the doctor say goes. Now, everyone has an opinion from guy at the walk- in Urgent Care site to Cousin Betty who is a nurse and her daughter the dental assistant. Between all the varied opinions it can be hard to sort it all out and make a well informed decision.

Make sure you gather all the information available and make the decision that you feel is the best for him, not just the one that makes you feel less squeamish.

This is what I recommend-

• Know every step of what is being done. This ranges from getting vaccines to antibiotics.

• Try not to get caught up in the anecdotal data that is floating around. "I once knew a friend whose brother's sister got sick that way!" isn't substantial enough evidence to avoid a procedure.

• Don't try to assume that your doctor will know everything. If you really need the opinion of a specialist then make sure you get to talk with one.

• If it doesn't seem right say so.

• Do your research.
  

• Ask your friends.

• Keep an open mind.

• Ask the right questions such as:
  

1. What would be the consequence of not getting the procedure/treatment?
2. Is this the standard of care?
   
3. Would the results change our management?
   
4. Are there other alternatives?
5. What are the risks?
   
6. Can I have a second opinion?
   

When Your Child Gets Iron Deficiency

Hi Everyone,

Welcome back to Medicine Mondays.

Each Monday I'll post the questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

Today I'm going to talk about my youngest son who was just diagnosed with iron-deficiency Anemia. I wasn't too surprised given that he'd been looking really pale but I have to say I was surprised that it was as low as it as. I thought we were doing all the right things such as eating high iron foods such as red meat, beans and raisins but it wasn't enough.

If you need to know the what and why's of iron deficiency then MedlinePlus has a good synopsis:

Iron deficiency anemia is the most common form of anemia. Iron is an essential part of hemoglobin, the oxygen-carrying protein in blood. Iron comes from the diet and by recycling iron from old red blood cells.

Babies are born with about 500 milligrams (mg) of iron in their bodies. By the time they reach adulthood they need to have about 5,000 mg.

Children need to absorb an average of 1 mg per day of iron to keep up with the needs of their growing bodies. Since children only absorb about 10% of the iron they eat, most children need to ingest 8-10 mg of iron per day. Breast-fed babies need less, because iron is absorbed 3 times better when it is in breast milk.

An iron-poor diet is a common cause of iron deficiency. Drinking too much cow's milk is a common cause of iron deficiency in young children because cow’s milk contains little iron and can get in the way of iron absorption. Cow's milk also can cause problems in the intestine that lead to blood loss and increased risk of anemia.

A common time for iron deficiency is between 9 - 24 months old. All babies should have a screening test for iron deficiency at this age. Babies born prematurely may need to be tested earlier. The adolescent growth spurt is another high-risk period.

Prevention is the best way to avoid any iron deficiency. Here's a list that includes some of the good, better and best sources of iron in foods.

• Good sources include tuna, oatmeal, apricots, raisins, spinach, kale, greens, and prunes.
• Better sources include eggs, meat, fish, chicken, turkey, soybeans, dried beans, peanut butter, peas, lentils, and molasses.
• The best sources are breast milk (the iron is very easily used by the child), formula with iron, infant cereals, other iron-fortified cereals, liver, and prune juice.

We now have him on an iron supplementation (I put it in his juice to help mellow the flavor) and I'm increasing his iron in his diet. We gave him Cream of Wheat this weekend and added raisins to boot. It's going to take a couple of months to get his iron levels up and then even longer to replace his iron stores. But if I'm consistent he should recover nicely and have no long term consequences such as decreased alertness, attention span and learning.

If your child has iron deficiency anemia, leave me a comment. I'd love to hear how you got their iron levels up!

Medicine Mondays: Food Allergies in an Adult

Hi Everyone,

Welcome back to Medicine Mondays.

Each Monday I'll post the questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

Here is a topic that we have been discussing for the past week on an older post Food Allergies in the School.


Food Allergies in an Adult


Dr. Cason -

Just a question - what could cause sudden almond allergy in an adult?- G

G-

I can't say I know for sure. Is it a sudden systemic reaction like hives or swelling, anaphylaxis to almonds or just contact dermatitis? - Dr. Cason

Dr. Cason -

The almond allergy only started a few years ago - now I can't even tolerate trace amounts of almond. The reaction is nausea, sweating, extreme abdominal pain (once so bad I was on the bathroom floor for an hour or so - I couldn't move). I was fine with almond until this started, also I can't tolerate coffee any more either - just makes me feel extremely nauseous!- G

G-

Sounds like you have a true allergy to almonds. Unless it was with something else that you are reacting to.

You can test the blood to see if you have an increase in IgE level to almonds. But the gold standard to see if you have an allergy to food is what happens when you eat it. You know that it makes you sick so you have your answer. I would probably still go and have them evaluate it though because it is unusual that you would acquire this as an adult.- Dr. Cason

Dr. Cason-

It was definitely almonds - I had my first reaction after eating some whole ones - just to be sure I tried it again, but only ate one. It definitely pays to ask - we went to a huge dinner last night, before dessert was served I asked if either contained almonds (I've never done that before) one was sticky date pudding, the other was a chocolate cake/mousse type thing - the waitress checked with the chef - both had almonds - I would never had guessed looking at them. p.s. Is there anything you can have, say like anti-histamine to help with a reaction?

G-

Great that you asked! It's amazing the cross contamination that is present. One can never be too sure. Yes, you can take Benadryl (an Antihistamine) to help counter the effects that histamine has on the body. Medscape.com explains it nicely. (I added the emphasis)

All antihistamines are reversible, competitive antagonists at histaminic (H₁) receptors. They act by inhibiting binding of circulating histamine to its receptor site, but do not prevent histamine release. Administration of an antihistamine results in inhibition of respiratory, vascular, and gastrointestinal smooth muscle constriction, a decrease in histamine-activated secretions from salivary and lacrimal glands, and anti-inflammatory effects. Antihistamines also decrease capillary permeability, which reduces the wheal and flare response to an allergen, as well as diminishes itching.

If you truly have vomiting, facial swelling, tongue swelling, difficulty breathing and a drop in your blood pressure then what you are experiencing is anaphylactic shock. You need to carry 2 Epi Pens around with you. Benadryl is good if the symptoms are pretty mild- hives, itching- but for a life threatening reaction you want Epi! - Dr. Cason

Medicine Mondays- ADHD and Poor Weight Gain and Breast Feeding Frequency and Babies

Hi Everyone,

Welcome back to Medicine Mondays.

As suggested by the title, each Monday I'll post the questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

We had a couple of questions this week.

Here's the first:

ADHD and Poor Weight Gain

Question- Dr Cason,

I have a 5 year old boy that has ADHD and has been on Focalin XR 15mg. The meds aren't strong enough but they are scared to up his meds more because he is 35 lbs....

You can read the whole post here: ADHD and Poor Weight Gain

Nursing Frequency and Babies

This next question I just found buried in my comments. It comes from a friend of mine. She posted it on my other blog DrCason.org where I showcase my life as a Pediatrician and pretend to be a Photographer!

Question: Hello Mommies,

Just wondering at 8-9 months old how often everyone nursed? I am getting varying opinions from friends, between 4-8 times a day. We are eating solid foods 3 times a day and nursing 4 times a day. I have a chart for food qty at this age but I can’t find a good nursing chart. Just wondering?- JH

Answer:

Dear JH,

I haven't found a specific nursing chart per se and as a physician I don't refer to them. I usually look at how the babies are growing and thriving. You have to remember that some babies are snackers and love to nibble and nosh their way through the day.

Some babies though prefer to be off and crawling around much like a busy 8 or 9 month old. Who has time to eat when there is so much of the world yet to be explored!

Look at your child. Don't worry about the number of times she eats. (Though 4 sounds good to me) She may be a very efficient nurser and gets a lot when she does nurse. Just ask yourself, Is she growing? Is she happy?

If she is tugging and punching at your breast when you are nursing then you know your supply is decreasing. Just make sure you eat and drink and keep nursing and it'll increase. Also see your pediatrician and look at her growth. At about this age babies will plateau a little because they are too bust exploring. It's normal and I usually don't worry about it.

Hope this all helped! See you all next week-

Sheila Cason MD

Medicine Mondays- The Importance of School Physicals

Hi welcome back to Medicine Mondays-

As suggested by the title, each Monday I'll post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

This week I don't have a question but rather an article about the importance of School physicals! Has your child had theirs yet??

The Importance of School Physicals

Well it’s that time of year again, school is back under way and if you haven’t got your child’s annual physical yet, make sure you put it at the top of your list of things to do.

You may think that because you take your child in frequently for that never ending cold that he’s getting enough of the doctor’s time but that’s not so. A 10-15 minute sick visit isn’t enough time to talk about your child’s short stature or the fact that he’s just went up two pant sizes. Before you go for your appointment, make sure you record any medicine they are taking, make a list of issues you’d like to discuss and bring your immunization record. At the visit the doctor will review a few key points. I’ve outlined those below.

General Health and Well-Being

One of the first things the doctor will do is screen your child by checking their height, weight, blood pressure and temperature. We’ll also place a PPD to screen for tuberculosis, check a CBC to screen for anemia and do a urinalysis to screen for infection and protein. We’ll test their hearing and vision as well as discuss their appetite and sleep habits. In addition to this we’ll also address how your child is getting along with everyone. Are they contributing to the family? Are there chores that are being accomplished? Are they receiving an allowance and finally has there been any notice of depression or mental health issues.

Review of Illnesses

A thorough head to toe physical exam is completed next. We’ll discuss any acute illnesses your child may be having such as a cold or virus. If the current illness is complex or your child is running a fever, then we’ll treat the illness and often may ask to reschedule the well visit and/or delay immunizations. Once the acute illnesses are addressed we’ll move on to discuss any chronic medical issues. This is an important time to review conditions that your child may not be resolving. Most parents can’t even begin to talk about the importance of chores or potty training if their child is having recurrent urinary tract infections. This is also the ideal time to review sub-specialist recommendations and make any changes to the treatment plan as deemed necessary.

Height and Weight Analysis

After the acute and chronic illness, the pediatrician will then review the general height and weight of your child. We’ll look to see that they are growing appropriately- at least an average of 5 cm per year. We don’t analyze the height and weight at any one time but rather we look at the trends over a course of many visits. Looking at it this way we can easily see if there are sudden spikes in the curve or if they are reaching a plateau. We’ll also look at whether your child is proportional in relation to their height and weight. A child in the 50th percentile for their height should have a relatively similar percentage for their weight. Like most things in health, we look for balance. Most everyone will receive counseling regarding healthy eating. With obesity being a growing epidemic it is never too late to talk about limiting juice and fast food consumption. If your child already has a weight issue then we may analyze it further with labs tests to screen for diabetes, liver disease and thyroid issues.

A Private Talk

If your child is older than twelve then we’ll ask to talk with them alone to address risky behavior. The teen talk is critical to ensure a teenager’s well being. The American Academy of Pediatrics in 2005 estimated that almost 50% of teenagers had engaged in sexual intercourse already and nearly 50% also had tried cigarettes smoking. Taking the time to discuss these private issues is important to ensuring their safety. All answers are confidential. Though if a child wants to hurt themselves or another person then we are required to report it. If I hear something else concerning, then I encourage the child to talk with the parents with or without me. These questions include but are not limited to:

• Do you have a boy friend or girlfriend?
• Have you engaged in any sexual activity
  
• Do you smoke or drink?
• Do you do any other recreational drugs?
• How is school?
• Do you feel safe at home?
• Are there questions you’d like to ask?

School Issues
Next we’ll move on to review your child’s school performance. We’ll discuss grades, motivation, concentration and homework. We’ll ask how the previous year went and how the relationship with the teacher and classmates were. We’ll discuss any issues that the teachers may have had concerns with. As a child gets older and the school work becomes more difficult a child may have difficulty keeping up. They may suddenly develop behavior problems that hadn’t been present otherwise. Further testing may be needed to search for Attention Deficit Disorder or other learning disabilities.

Safety Review

One of the most important discussions we’ll have is a review of safety. This includes protecting children from head injuries, falls, and drowning. In particular we’ll review car safety and the proper ages to be restrained in the car. The American Academy of Pediatrics reports that motor vehicle injuries are the most common type of fatal injuries among children and the leading cause of death among children younger than 18 years of age.

Sports Readiness

If your child is involved in any sports then we’ll often address aspects specific to that sport. We address any past history that may be relevant including asthma, heart disease and orthopedic issues. Most importantly we’ll ask of any family history of sudden death in a person less than 50 years of age. This could indicate an inherited disease that puts your child at an increased risk.

Immunization Update

As the visit concludes we’ll review any vaccines that need to be given. By the time a child finishes high school they should have received all their shots and will only need Tdap every 5-10 years. Use the following guide to determine whether your child is up to date. This is just a guideline as some offices use a different vaccination schedule. Also make sure you review your insurance coverage; Meningococcal and HPV are not covered by all plans. Rotavirus is not on this list, though it is recommended by the AAP and given by some clinics.

• At Birth- Hepatitis B#11 Month- Hepatitis B#2
• 2 months- DTaP # 1, IPV #1, Hib#1, Prevnar#1
• 4 months- DTaP # 2, IPV #2, Hib#2, Prevnar#2
• 6 Months- DTaP #3, Hib #3, Prevnar#3
• 9 Months- IPV
• 12 months- MMR#1 and Varicella#1, Hep A #1
• 15 Months-DTaP #3, Prevnar #4 and Hib#4
• 18 Months-Hep A#2
• 4 Years: MMR #2, Varicella #2, IPV#4, DtaP #5
• 11 Years: Tdap, Meningococcal, HPVl#1 and 6 months later HPV #2

As you can see there are a lot of issues that could be discussed. Often it’s not possible to cover everything in one visit but with regular scheduled care during the year which includes sick visits and phone calls, we can come close to addressing it all. As the school year is about to begin you’ll find it gets harder to get an appointment.

Call today to get that ball rolling with your child’s pediatrician.

Don’t miss this valuable annual opportunity to review your child’s health

Statistic source: http://www.aap.org/advocacy/washing/Statistics.pdf

Imaginary Friends and Children

Is there someone new at your house lately? It can be disturbing to find that your child's new friend isn't one you can see. But don't worry this is a normal part of a child development particularly around the age of 3 and 4. In fact there is some research out there that speculates that those children with imaginary friends are more creative and imaginative.

This can be a delightful peak into your child's imagination. And it's more common than you think.
When I asked my readers at DrCason.org if they had any experience with imaginary friends this is what they said.

As for imaginary friends, yes, they have been around a lot lately. My son, now 3.5 years old, tells me, “My friends are here” and “We are having a sleepover.” They have slept over almost every day for the past few weeks! I even call their imaginary moms to see if they can come over to play or have them come pick up the kids if they are not behaving. (At the request of my son, of course!). I think it is great and I tell them they need to behave and play nice. I treat his imaginary friends like I would if his real friends are over. I don’t want him to think there is something wrong with having imaginary friends.

I had an imaginary friend as a child. Humpty Dumpty and his family (he had a sister, mother, and father) lived in my bathroom, although Humpty would come out and play with me in the rest of the house, too. My mom made me a handmade Humpty Dumpty doll and I remember going into the bathroom and telling him I couldn’t play with him after that.

My daughter had an imaginary friend named Dubbie Dubbie and Dubbie. To this day we aren’t sure if Dubbie was one person or three. We also don’t know what Dubbie looked like. He or They hung around for about a month, then was never spoken of again. She was 2 at the time. Now she’s four and gives me a dirty look when I bring him/them up.

Strangely enough, my child started playing with an imaginary friend just today! We were at my parent’s house for dinner and she was in the bathroom playing with “X-”. I said, “But I’m X-.” and she said, “No, this is X-. (pointing at no one) She lives in the bathroom, she’s my best friend!”

As for imaginary friends, My eldest created two imaginary friends for herself. Claire Bonnet and Lucy. They would only come to play when she was sick and or in hospital. Lucy came with her for each and every operation and test and Claire bonnet was always there afterward to pick up the pieces. She was the only one to have the imaginary friends though. It was really interesting to watch. Especially as she was one of twins, so she always had company.

I have a 14 year old who had an imaginary friend for quite a long time, a few years, as I recall. She called her imaginary friend Sam. I never knew whether Sam was a boy or a girl.

My 10 year old son had an imaginary friend when he was young also. I think his name was Henry or something but I don’t remember and wasn’t around very long.

Pretty cute huh? In fact it makes me wish my child has one so I could see in their world a little!

• Listen carefully to what your child says to his imaginary friend. You might be able to identify some of the stressors that your child is coping with.
  
• Don't let the "friend" get away with breaking the rules. Just tell your child that rules are the same for "Princess Amy" as with anyone else.
• Try not to be overly inquisitive about their friend. If they mention it then great- ask a few questions. But let your child's friend be their friend not yours.
• Talk with your pediatrician if you notice that the "friend" is interfering with your child from interacting or developing his own "real" friends.
  

Medicine Mondays: Circumcision; Discipline and Young Children; Vitamins and Children; Bug Spray and West Nile Virus

Hi Everyone!

Welcome back to Medicine Mondays where each Monday I post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and the medical advice that your family doctor can provide.

Circumcision

Question:
My 2 year old son had a circumcision at birth, it seems as though it were incomplete, his foreskin is mostly still intact, although “loose” I still have to retract and clean underneath, he absolutely hates it. With that being said, my middle son’s circ. was complete and perfect. I’ve had this on my mind since his birth, he had several resistant ear infections, so placing ear tubes at 9 months took priority. So, all along both of my pediatricians have said the same things, wait, it will get better, it would only be cosmetic, the risk outweighs the benefits– infection, sedation… So, what to do? My husband wants the extra foreskin removed, in my heart, I do, too , he will look “like” his brother, but medically speaking, it’s not necessary. Why now? Well, I don’t want to wait any longer, he’s already 2, potty training… and the 2 older ones are in school. My close friends say, do it, even my medical friends, they’ve had close friends who have regretted not doing it. Let me know what you think!

Answer:
You're right, a circumcision or revision of a circumcision is not medically necessary. If you ask a hundred people you may get a hundred different opinions but really the best answer is what your family wants to do. There are plenty of people who still circumcise their child and a growing number of people who do not. What is boils down to is what you're comfortable. Make a decision that feels right for you and then discuss it with a pediatric urologist. They will be able to guide to as to what time is best for your son if you do decide to revise the procedure.

Discipline and Young Children

Question:
How should I discipline my 15 month old as far as hitting other kids at school is concerned? Was told she had some alone time today because he hid another toddler and pulled her off a toy outside, (of course it is the teachers kid!) She has an older brother that is a bit pushy and I think she is projecting on other kids.

Answer:
A 15 month old is too little to exhibit a lot of self control but this doesn't mean that it's okay! At this age if they get upset they can hit or bite to get their way. It becomes particularly effective if they then get what they want following the incident. I have found that saying firmly, "We don't hit our friends!" and then having the child say their sorry or offer a hug is the best response. Don't expect your child to be perfect and remember that it does get better! Time outs can be effective but make sure that it's no longer than one minute for each year of their age.

Vitamins and Children

Question:
A friend’s child just had her 2 year check up at Kaiser and had blood work done showing her child’s iron levels were low. She was told to begin giving her daughter a children's vitamin with iron. However, my son didn’t have this blood work done when he had his 2 year appointment at your old office. What is your opinion on vitamin supplements for toddlers? My son is a pretty good eater, though he’s not a big fan of meat. I can usually get a veggie or two in him, but his favorites are fruit, yogurt, and oatmeal.

Answer:
Each pediatric office does their screening a little different. At my previous office we screened at 9 months of age. If the hemoglobin was low then we placed children on an iron rich diet or iron drops and then rechecked in a few months. The next routine screening was at 4 years of age- sooner if they were shown to have a problem. I haven't routinely recommended vitamins for a child unless it was clear that their diet was lacking. If a parent is concerned then just a plain chewable multivitamin is fine- liquid if they are under 3 years of age. Your dentist can also determine if your city has fluoridated water and whether you need a fluoride supplement.

Bug Spray and West Nile Virus

Question:
A case of West Nile Virus was found in a dead bird in our neighborhood. What are symptoms of West Nile Virus? Should bug spray be used on kids anytime they go outside?

Answer:
The Center for Disease Control and Prevention has a West Nile Virus Home Page that can guide you in whether your city is at risk for contracting the disease.

The CDC reports that The Symptoms of West Nile Virus are:

• Serious Symptoms in a Few People. About one in 150 people infected with WNV will develop severe illness. The severe symptoms can include high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness and paralysis. These symptoms may last several weeks, and neurological effects may be permanent.
  
• Milder Symptoms in Some People. Up to 20 percent of the people who become infected have symptoms such as fever, headache, and body aches, nausea, vomiting, and sometimes swollen lymph glands or a skin rash on the chest, stomach and back. Symptoms can last for as short as a few days, though even healthy people have become sick for several weeks.
  
• No Symptoms in Most People. Approximately 80 percent of people (about 4 out of 5) who are infected with WNV will not show any symptoms at all.

The best defense is to apply mosquito repellent to protect your child against being bit.

EPA recommends the following precautions when using insect repellents:

• Apply repellents only to exposed skin and/or clothing (as directed on the product label.) Do not use repellents under clothing.
• Never use repellents over cuts, wounds or irritated skin.
• Do not apply to eyes or mouth, and apply sparingly around ears. When using sprays, do not spray directly on face—spray on hands first and then apply to face.
• Do not allow children to handle the product. When using on children, apply to your own hands first and then put it on the child. You may not want to apply to children’s hands.
• Use just enough repellent to cover exposed skin and/or clothing. Heavy application and saturation are generally unnecessary for effectiveness. If biting insects do not respond to a thin film of repellent, then apply a bit more.
• After returning indoors, wash treated skin with soap and water or bathe. This is particularly important when repellents are used repeatedly in a day or on consecutive days. Also, wash treated clothing before wearing it again. (This precaution may vary with different repellents—check the product label.)
• If you or your child get a rash or other bad reaction from an insect repellent, stop using the repellent, wash the repellent off with mild soap and water, and call a local poison control center for further guidance. If you go to a doctor because of the repellent, take the repellent with you to show the doctor.

For more information go to The Center for Disease Control and Prevention West Nile Virus Home Page.

OK everyone, thanks for the questions! I'll be back next week!

Medicine Mondays: Children and Twitching; Pregnant and Breastfeeding; Hair Loss after Pregnancy

Hi welcome back to Medicine Mondays-

As suggested by the title, each Monday I'll post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

The following comes from a reader on my personal blog- DrCason.org

Children and Twitching

Question:

My baby does this thing a couple times a day where her left foot twitches, and when I say twitches I mean TWITCHES, it usually only happens if there is a little bit of pressure on it, like if she is pushing on my hands with her feet. What’s that all about?

Answer:

What you are describing is called clonus. Clonus is a series of involuntary repetitive movements that occur when the muscle is stretched. It is usually found at the ankle. This is a normal finding in newborns. If it is present when you are older it can be a sign of neurological injury. It is best to go to your pediatrician so they can exam your baby and determine whether this is still within a normal range for your child.

Anemia and Getting Pregnant

Question:

When having my baby I lost a lot of blood and ended up have 2 blood transfusions. MY hemoglobin are back to normal now(I’m an iron champion!) but she still told me that I should wait until my baby is at least 6 months before we start trying to baby number two. THAT SUCKS! I do NOT want to be like 7, 8, or 9 months pregnant in my middle of summer. Do I really have to wait?

Answer:

I can't answer this as an OB so it's best to go to your doctor to find out her reasons. But as a pediatrician I can say that the baby's iron level is heavily dependent on the mother's iron stores. So the health of your baby is really dependent on you! Just because your levels have now come up to normal does not mean that your stores are at a normal level. Go back and talk with your OB. It may be that she will be flexible with her recommendations and you can work together to create a plan for your next pregnancy!

Pregnancy and Breastfeeding

Question:

If I increase my food intake by a gazillion times is it safe to breast feed while being pregnant?

Answer:

I have heard of a lot of women doing this. Most people are concerned with 1. The possibility that the growing fetus will be deprived of essential nutrients and 2. That the hormone- oxytocin- that is released during breastfeeding could induce labor. Only your OB can tell you what they are comfortable with and what precautions you need to take.

Hair loss after Pregnancy

Question:

When will my hair stop falling out by the handfuls? My hair is everywhere I’m like a big shaggy dog!!

Answer:

Oh my goodness this happened a lot to me as well! In pregnancy one of the reason that your hair gets so thick is that it goes into a resting phase. That is you actually cont to grow hair but the shedding stops. The American Pregnancy Association says this about hair loss and pregnancy:

The most common period of hair loss occurs approximately three months after delivery. The rise in hormones during pregnancy keeps you from losing your hair. After delivery, the hormones return to normal levels, which allows the hair to fall out and return to the normal cycle. The normal hair loss that was delayed during pregnancy may fall out all at once.

Up to 60% of your hair that is in the growth state may enter into the telogen resting state. The hair loss usually peaks 3-4 months after delivery as your hair follicles rejuvenate themselves. As noted before, this hair loss is temporary and hair loss returns to normal within six to twelve months.

There you go everyone. More Medicine Mondays next week. Drop me a comment or an email if you have a question for me!

Medicine Mondays- Early Intervention, Teething, Allergy Testing, Hidradenitis- Suppurativa and Infertility

Hi Everyone!

Welcome to my second installment of Medicine Mondays!

I started Medicine Mondays just last week on my other website DrCason.org and have had such a good response that I've decided to move it to my professional site. This way even more people can benefit from these great questions!!

As suggested by the title, each Monday I'll post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and the medical advice that your family doctor can provide.

Okay! Lets get started:

Early Intervention and Speech Delay in Children

Question:
When should Early Childhood Intervention be called in on a situation? My daughter now 15 months old really doesn’t say anything. I discussed with our pedi at her 9 month appointment in preparation for her 12 month appt. where she is supposed to be saying 6 words including mama and dada. Well, at 15 months says mama and dada occasionally and doesn’t really say anything else - audible that is. I think she tried to say her brother’s name and maybe ball or milk, but not much else. She I ask for Early Intervention to come in and work with her? I know the little ones all talk at their own pace and I am thinking it will just come, but what if there is something going on that I am ignoring.
We are starting sign language which she does: more and please. Jakey spoke late right?

Answer:
Yes. Jakey spoke later than my other two girls and I wasn't so much getting worried as I was just getting overwhelmed with all the screaming!! His language blossomed with signing!

Each child moves at their own pace and even little goobly gook could actually mean something to them. Be patient and use sign language to augment her language. I wrote an article giving you some Tips to Using American Sign Language if you need some suggestions.

Now in regards to Early Intervention. I have one rule. If I am really concerned then I refer any time there is something suspicious.

I have found that you really can't go wrong. There really is never too early of a time to call in for an evaluation. If a child is suspected of having a problem, such as speech delay, it can help to refer them early and get some additional services going.

Speech delay by itself is not that worrisome at 15 months- some babies just develop on their own. Such as my son. But I will look really closely at whether the child is socializing well. Are they looking at you for social cues? Do they point to what they need? If you point at something, do they follow your finger and look as well. These are very important markers in detecting autism. Autism that is detected at an early age can be helped a lot with early intervention.

Having said all of that, it might be that your child is right on target. Make an appointment with your doctor so they can evaluate her again!

Teething and Analgesics

Question:
Is it true that you can give tylenol or motrin for up to 5 days for teething? Then is it 5 days off and back on again?

Answer:
I don't give Tylenol or Motrin for that long. You shouldn't need to either at least not for teething. I would talk with your pediatrician to see if there is something else going on. If they are uncomfortable try teething rings or Orajel. Hyland make some teething tablets and some people swear by it!


Children and Biting

Question:
How do I get my 15 month old to not think her brother (3.5 years old) is a piece of meat she can just bite all the time? We really think she is a tiger and he is her prey! We tell her no, but she just laughs at us and then goes back in for the kill.

Answer:
LOL! Mine have all done that too. Most kids are just testing boundaries. Let them know that this is not acceptable by firmly saying no and then redirecting them. But don't go overboard! I have found that if you get too dramatic about the event then they are intrigued by the response and will seek to repeat the offense. Then you're in trouble!


Allergy Testing in Children

Question:
My eldest (14yo) daughter just had allergy testing (not nearly as involved as your son’s) because she reacted to some almonds she ate…but the testing came up negative. Ummmm…can you explain to me why she would still be reacting to them if she tested negative? We’re not talking anaphylaxis…just some mild swelling. They did do a RAST at the clinic...I don't know the results of that one...we never saw those results. The tests the allergist did were scratch tests on her arms, and the only reaction she had was to the control.
The allergist made a comment about her having just an oral reaction to the almonds, but not being truly allergic. I wish he'd explained more!


Answer:
Ahh! this is a little tricky. What most people are talking about when they talk about food allergies is an immediate IgE mediated allergic response. This is when the mast cells that contains histamine come in contact with an allergen and break open inducing an allergic response. The reaction can be as simple as some hives or mild swelling or as dangerous as an anaphylactic reaction.

We can test a child's blood for their IgE level in response to a certain allergens (RAST testing) and this can help in predicting what their reaction to the food or allergen will be. I say "help"and "predict "carefully because we don't know EVERYTHING we need to know about allergies in kids. We do think that the gold standard for whether a child is allergic or not is actually what happens when they eat the offending agent never mind what the RAST level is. In the future I will be writing a deeper in-depth article about this using all my info that I have gleaned from my son's allergies.

Now what to do about your child's allergic reaction? With a RAST that's negative and a skin test that's negative and an allergist saying she's not allergic, then she's probably not allergic. At least not with an IgE mediated allergic response. BUT you need to be absolutely sure about this before you give her almonds in the future.

I have heard of Almonds inducing a contact dermatitis. This may be what you are talking about with your child. This can cause redness and painful fissuring of the lips.

Hidradenitis-suppurativa

Question:
Do you have any ideas on how to help Hidradentitis- suppurativa?
I am trying only over the counter medications or herbal remedies as I don't have a doctor. I've had this condition for the past 30 years, but only a few weeks ago found out the name for it. I've gone to doctors in the past for help but have never had any success.

Answer:
This is a tough condition to have. It is chronic skin inflammation that we think may be actually be a severe form of acne. I recommend that you seek the help of a dermatologist. They will be able to help you in the management of your condition. There is no reasons to be treating yourself- unless its so mild that you can control it!

Your doctor may suggest some topical or oral medications as outlined in the article I've highlighted above. (I know that you've seen this as you sent me the link!)

One thing that I will mention as a side note is that we are currently learning more about acne and its relation to diet and inflammation. A low glycemic diet rich in veggies, fruit, seafood, and grass-fed meat can help control acne because it controls inflammation. Since Hidradenitis-supportiva is acne related this may help it as well.

Infertility

Question:
Hi Dr. Cason! I just found your site (DrCason.org)today and I love it already! I have a question and maybe you can answer it. My husband and I have been trying to conceive for over a year and have been extensively tested for various things. The only thing that has been abnormal has been my progesterone and estrogen ( both are low). I purchased progesterone cream, do you think this will do the trick? My husband is in the army and it is a fight to get anything done at our military treatment facility. They do not want to help us. Every last thing has been a struggle!

Answer:
Welcome!! Now I'm not an OB/GYN but I will say that if your progesterone and estrogen are low it may be contributing to your infertility problems! You need estrogen to ovulate normally and progesterone to help make the endometrium viable.

I know so little about infertility issues that I found you another expert! Edward Joseph Ramirez, MD, FACOG.I just searched and searched and found you someone who is Army trained!! Yeah !! It just might make a difference in your case as he may still have some contacts in the military and may be able to point you in the right direction!

Good luck everyone!

Please let me know if I can answer any more questions or point you in the right direction!