A Spoon-full of Sugar Helps the Medicine Go Down

Lots of parents have trouble getting their children to take medicine, so here are some tips to help:

Some techniques to help medicine go down easier:

Marry Poppins was right- a spoon-full of sugar helps the medicine go down! More accurately, a spoon-full of chocolate syrup will cover up the taste of most yucky medications. Apple sauce and yogurt are other common foods used to mask bad tastes. Many medications can be made to taste like your child’s favorite flavor by the pharmacist before you even pick it up, so ask about this when you submit your prescription. Some medications come in “orally dissolving tablets” which kids (age 3 and older) can put in their mouth and they will dissolve without having to chew or swallow.

Liquid meds are often easiest to give to babies with a syringe (a tube that looks like shot, but does NOT have a needle on it), which you can get at any pharmacy, baby store, or from your physician. Squirt small amounts of medication into your baby’s cheek and they’ll usually swallow it. Don’t squirt it directly onto their tongue or into the back of their throat, as this can lead to gagging. Follow-up with breast milk or formula (whatever they normally drink), before giving the next part of the dose. Alternatively, you can put the liquid medication in a bottle nipple along with a little breast milk/formula, and have them suck directly from the nipple, without the bottle attached. I do not recommend mixing the medication in a whole bottle, unless you know the baby will take the whole thing regardless of taste.

Most baby stores also sell special devices to help kids swallow medications,such as something that looks like a bottle, but keeps the medication separate, so you know exactly how much the child takes. I do not recommend giving children medications with droppers, because it’s difficult to measure the amount you’re giving, difficult to get all of the medication out of the dropper, and difficult to clean and dry the dropper fully between each use.

Learning how to swallow pills:

Once your child is ready to swallow pills (often by age 5!), it’s a great help to teach them how, since many medications are easier to take in pill form, the older they get, the bigger the dose, and some medications are not available in liquid/ chewable form. Starting young can also be beneficial in preventing anxiety associated with swallowing pills. Adolescents and adults often have trouble swallowing pills because they fear that the pill will get stuck in their throats. Relaxation techniques and deep breathing can help. Looking in a mirror, sticking your tongue out, and saying “aaah” out loud (this lifts the palate so you can see your throat), can help people see that their throat is much bigger then the pill, and ease some of the anxiety.

The first step in learning how to swallow a pill is to practice with something that is NOT medication. I recommend starting with small, smooth, round candies (such as mini m&m’s), and progressing to slightly larger candies (such as regular m&m’s). People with anxiety may want to start with tiny candies, such as sprinkles. Other people prefer to start with tiny bread balls (made from mashing a tiny piece of bread between your fingers), and go progressively bigger, since the bread dissolves easily in the throat. You will also need a big glass of water, juice, or carbonated beverage (such as plain soda water, which the pill can float on).

Younger kids can be told to just try swallowing the candy without chewing, because they are often successful without thinking about it. Older children, or those without a natural tendency to swallowing whole pieces, can start by visualizing the item floating down their throat on water, like a little boat. They should start by making sure the mouth is moist, by salivating or taking a sip of their drink. Nest place the candy as far back on the tongue as possible, using the teeth to scrape the candy to the back of the tongue (a mirror helps some people see how far back it is). Then take a big gulp of the liquid, which should float the candy and allow it to be swallowed, just as you would usually swallow any regular drink. Some children will swallow the candy (and later pills) more easily by drinking the liquid through a straw.

When it comes to taking real medicine, some people hide their pills in mini-marshmallows, which are slippery when wet, and therefore easier to swallow. I recommend trying this without medication first, since these are bigger then most pills. You can also try covering the pills in chocolate syrup, applesauce, yogurt, or jam (but see the warnings below before trying that).

I suggest experimenting with these techniques in a relaxed environment until you find something that works for you.

Warnings:

These techniques are for generally healthy children, with normal anatomy and mentation! They should not be used for children with any anatomical abnormalities, dysphagia (trouble swallowing regular foods or drinks), or any medical conditions that effect swallowing, the head/face, the GI system, or the neurological system.

All children should be supervised when practicing swallowing candies, and when taking ANY medication. NEVER tell your child that the medication is candy, as this can cause them to sneak some more when you’re not looking (many medications these days actually do taste like candy). Always keep medications (over the counter and prescription) and vitamins/ supplements out of reach AND in a LOCKED container. Kids are good at climbing and getting into high cabinets, purses, closets, and other hiding places.

Please speak to your pharmacist (who is usually in the back of the store, who has spent at least 5 years in post-graduate university studies, getting a doctorate degree in pharmacy), about what you can take your medication with, and whether you can cut, crush, chew, or open the medication. Many medications should NOT be taken with grapefruit juice. Some medications should NOT be taken with anything dairy. Some pills can be crushed and mixed with foods, where as others can not. Your pharmacist and/ or physician are the best people to speak to before taking your medication with anything but water.

Car Safety

Motor vehicle injuries are the leading cause of preventable death and disability in children in the USA. Using the right car seat the right away can prevent your child from getting hurt!

Vehicle Safety Information & CarSeat Review Sites:

The CDC 

The CarSeat Lady (PICU mommy doctor who specializes in car safety)

CarSeats For the Littles

The CarSeat Blog

Safe Kids Worldwide

Bureau of Highway Safety

NTHSA Car Safety

Tips for traveling with children in general

The Biggest Mistakes Parents Make:

1) Not installing the carseat properly

Most parents think they have installed the car seat correctly themselves, but 71% of car seats are not installed or used correctly!

The best thing to do is have your car seat installed and checked by a certified professional. You can find car seat inspection locations here and here.

You can get advice on how to install all types of car seats here.

2) Putting the baby/child in with straps too loose, too high or low, and the chest clip not at the chest

Many parents place their child in the seat, but leave the chest clip too low and/or the straps too loose. The Car Seat Lady has a nice video explaining how to get your new infant in the seat just right. Remember, the chest clip should always be at armpit level. See above graphics (borrowed from the internet) for more information.

3) Turning a toddler forward facing too soon

Children should be at least 2 years old and have reached the maximum weight or height for rear-facing in their chair, before being turned around. Regardless of age or size, it is 5 times safer to be rear-facing!!

This video demonstrates why kids under 2 years old are in greater danger when facing forward in a crash.

This blog post by Dr. Stuppy is my favorite explanation on why kids should be rear-facing and stay in car seats as long as possible.

This website goes over common car seat direction myths.

This infographic goes over how car seats work, including forward vs rear-facing.

4) Putting a child in a booster, instead of a car seat, too soon

Parents often want to move their kids to booster seats as soon as possible, for the convenience of having a lighter, more portable, cheaper seat, but it’s NOT convenient if your child is hurt in a minor accident because you moved them too soon (and it will cost you a lot more money than a new car seat, too).

Children will always be safer in a 5 point restraint (aka harness system), than using a regular seat belt. I often remind my patients that race car drivers use a harness system, and don’t rely on simple seat belts to keep them safe.

More information on how to decide when your child can move to a booster can be found on CSFTL and TheCarSeatLady.

5) Letting the child use a regular seatbelt too soon

This is also a matter a cost and convenience, as well as peer pressure, but don’t let what other people do put your child at risk. Most children need to ride in a booster seat until at least age 10, since they need to be at least 57″ (4 foot 9) to fit with a regular seatbelt. TheCarSeatLady has another good explanation on how and why booster seats work. Aside from height, they also need to be mature enough to sit straight and still i  the car, since if they are leaning over in a crash, the seatbelt will not be in the proper place, and may not protect them as well as it can.

6) Letting a child/tween sit in the front seat

Children that are not fully skeletally mature (e.g. have not gone through puberty yet), and are younger than 13 years, should not sit in the front seat. Dr. Burgert does the best job explaining why on her blog. Regardless of age, size, or type of seat, everyone is safer in the back seat.

7) Using an old carseat

Carseats from online sites, such as Craig’s List, may have microfractures in them from unreported accidents or being too old. For your first baby, use a new carseat, or one you can guarantee has never been in a car that had an accident and has not expired. For more information on car seat expirations check out BabyLic’s post.

No one wants to think about getting into a car accident, especially when you’re transporting your most precious cargo. But with tens of thousands of deaths from motor vehicle collisions every year, no parent can afford to take chances. The odds are reasonably high that you will be involved in some kind of car accident before your littlest one turns 18. If your children are with you, you want to have done everything in your power to reduce the risk that they will suffer serious injury, and you will demonstrate to them the importance of car safety for when they have families of their own.

Traveling With Children

Fortunately for us modern moms and dads, anywhere we want to go is just a plane, train, or automobile ride away. Despite the conveniences of modern transit, traveling with children can be a difficult endeavor if you’re not prepared. So here are a few tips to make your journey smoother:

1) Know your rights.

This sounds funny, but a lot has recently changed in U.S.A. airport security rules. For example children under 12 do not need to remove their shoes during screening. According to the TSA’s website, you may carry as much juice and milk for toddlers as you “need until you reach your destination”. The precise definition of how much you need varies by who is screening you at security.  During one trip with my then 1 year old, the security agent at LAX insisted that 3 small juice boxes was too much for a 5 hour flight, and threw all of our drinks away. I did not know enough to argue and instead I spent $$$ buying some non-dilute juice for my child at the airport 🙁 This also brings up the point to remember to be flexible, and give yourself extra time for the unexpected.

For the latest information, check out the TSA website. For information on car seat travel rights, see this post by TheCarSeatLady.

2) Know your company.

Certain airlines and hotel chains are better at hosting children than others. Conversely, some airlines have recently banned children from first class on their flights, so don’t expect an upgrade (or even friendly service) on those airlines. In general, European and Asian companies are considered friendlier to children on flights than North American airlines, often providing coloring books, special snacks, small toys, and other treats for families.

Some airlines offer pre-boarding for families with infants and toddlers, while others have none. This may be more annoying than you think. When traveling with our then 2 year old, we had to wait until first class, business class, and everyone with a silver/gold card from the airline boarded (more than half of the passengers) before we were allowed to get on with a toddler, car seat, and hand luggage. Trying to get past the tiny aisle with people everywhere and a large car seat was not fun, and I think it disturbed the other passengers as well. Allowing us to board early, install the carseat and settle in would have prevented a lot of hassle for everyone. However, when we got to our destination we stayed at a hotel that provided us with squeaky bath toys and other amenities in the room that made us feel like family.

Check out this article on the most family friendly airlines.

 

3) More tips just for flying with children:

– Try and book a flight with as few stops as possible, as take-off, landing, and boarding are the toughest times.

– Make sure you have assigned seats together in advance. Many companies have been separating families on flights, and then you rely on your fellow passengers to switch seats so you can sit together, or charge extra money to seat families together (but a July 2016 ruling by Congress outlawed this for kids under 13 years old). This LA Times article gives tips on how to stay together.

– I take our car seat when flying with my son, to make sure he is strapped in securely during our flight (even turbulence can be dangerous to a lap child). This also ensures that he has a safe seat for automobile travel when we arrive at our destination. It is also easier for him to fall asleep during the flight in his car seat, and more difficult for him to annoy other passengers by kicking them or climbing on the chairs. We use a GoGo Kidz Travelmate to turn the car seat into a stroller at the airport. Booster seats are not necessary (or allowed) on flights, since there are no chest straps.

excited by the stuff he sees through the window
My son sitting in his carseat happily staring out the plane window

– To avoid pain from the changes in pressure in the ear during flights, teenagers and adults can chew gum or drink water to encourage swallowing, and thereby open up the eustachian tubes in their ears to relieve the pressure. For babies the best way to do this is breast or formula feeding. Breast or formula feeding has the added bonus of being a natural pain reliever. For toddlers, diluted juice in a straw cup works well. Older children can suck on lollipops to get them swallowing (and happy and distracted by candy). Nasal sprays can also help relieve congestion and prevent pain during the flight, but speak to your pediatrician about this (salt water sprays can help babies with stuffy noses, while kids with ear infections or sinus problems may need a prescription nasal spray). If all this ear tube talk is confusing, check out the ear anatomy pics on my pinterest page.

– I recommend waiting as long as possible before flying with infants. The younger an infant is, the less developed their immune system, and the more likely they are to get sick. The air on airplanes is re-circulated so it is very easy to pick up germs from other travelers, even ones who are seated far away from you. Infants younger than 2 months old who catch an illness with fever may have to undergo extensive testing, including blood, urine, and spinal fluid exams if they get sick. I know this is not possible for many families, but waiting until your infant is 9 months or older can save you a lot of hassle.

I advise checking the CDC travel web page, and making an appointment with your pediatrician at least 2 months before any foreign travel, so you can get any needed vaccinations or medications for your trip. You can also check out travel clinics in Los Angeles.

4) Have your bags packed with items that will keep your child calm, quiet and comfortable. 

I prefer small, light items. If you are used to distracting your child with your phone or other electronic items, keep in mind that you will not be able to use them on take-off or landing, and they might run out of batteries on long car trips, so make sure to pack low-tech items as well. I recommend packing a carry-on or car bag with:

  • baby wipes (good for cleaning up messes for kids of all ages, cleaning up yourself, and cleaning up icky surfaces)
  • snacks
  • your own sippy cups or bottles
  • more diapers than you think you need
  • several different sizes of ziplock bags (for messes, soiled clothes, soiled diapers, and they are just generally handy to have)
  • a medical bag (children’s acetaminophen, children’s ibuprofen, children’s benadryl, disinfectant, bandaids)
  • sunscreen (the sun through a car’s windows can burn a child, and then sun through a plane’s window has more radiation than down on the ground, so slather yourself and your child with sunscreen to avoid sunburns and -much later- skin cancer)
  • lollipops for older kids
  • extra clothes (even for older children, as it’s easy to get spilled-on during a flight or car trip, and you never know if, when or where you’ll get stuck)
  • books
  • re-usable stickers
  • dry-erase crayons/markers and board
  • a soft blanket
  • your child’s lovey (favorite blankey, stuffed animal, or other comfort item).

I’ve linked to a few of these items, as well as book suggestions, on pinterest.

Eat Pack Go has many more great travel tips, and the link is for a funny story illustrating why you shouldn’t feel bad about that huge carry on with extra supplies.

Traveling with children can be more stressful than traveling alone, but with patience, planning, and a large bag it can be a fabulous adventure.

Stomach bugs: what to do if your child is throwing up or having diarrhea

Vomiting and diarrhea viruses are not fun for anyone. Doctors refer to the most common cause of these symptoms as “viral gastroenteritis”. Some kids just vomit, some kids just have diarrhea, and the most unlucky have both. 

Most of these illnesses do not need to be treated with medications (antibiotics can make it worse, since they also kill the good bacteria in your tummy), and anti-diarrheal medicines (like Imodium) can be harmful to children. The most important thing is to keep your child HYDRATED (more on that below). If you suspect your child has vomiting or diarrhea from food poisoning or any other type of foreign ingestion, please call poison control 1-800-222-1222, who are free and staffed with physicians 24-7!

How can you tell if your child is starting to get dehydrated?

– their mouth/lips are very dry

– they are peeing less than usual

– they are thirsty

Now what?

You need to keep your child hydrated!

– A baby can continue to breast feed or take infant formula, if they are just a little dehydrated. If they vomit after every feeding, or are refusing the breast/bottle, then try to hydrate them with an Oral Rehydration Solution, like Pedialyte. Warning: the plain ones taste like salt water, so I suggest getting a few flavored ones and trying them out, to see which ones they will take. If they refuse the bottle completely, you can try feeding them via a syringe or spoon, giving small amounts every 15 minutes.

– A child who is getting electrolytes from food (such as chicken soup, or crackers, even if it’s just a little bit) can hydrate with water. If they are not taking in any food, or if they are throwing up the food, please hydrate them with an ELECTROLYTE solution (aka Oral Rehydration Solution, aka ORS). You can buy them at most USA markets (under brand name Pedialyte, or generic versions), you can make your own by mixing 1 liter (5 cups) clean water with 6 level teaspoons (=2 tablespoons) sugar and 1/2 teaspoon salt. You can add a little bit of orange juice or a banana for potassium. Common substitutions are rice water, congee, green coconut water, or mixing gatorade with water (although I do not recommend doing this, since it is hard to get the right balance of electrolytes this way). If your child does not want to drink, try giving them sips every 15-30 minutes, or giving them the ORS/Pedialyte in frozen popsicle form.

– For every age, and everybody in the house, WASH YOUR HANDS A LOT to prevent spread/transmission of the stuff that gets you sick. Teach everyone to wash their hands in warm water, scrubbing for at least 20 seconds (2 rounds of the Happy Birthday song). Try and use real soap and water, instead of no-rinse hand sanitizers, since they do a better job at killing the tummy microbes.

But what if they keep vomiting?

– Let their tummy rest.

– Call your pediatrician, or go to the hospital, if they have signs of dehydration tat are not resolved by giving fluids by mouth (see more below).

– Ask your pediatrician if your child is old enough and healthy enough for a medication against nausea/vomiting.

– Start with no food, but still give an electrolyte fluid (like pedialyte or ORS above), for the first 12 hours.

– When they are ready/want to eat, give bland foods (e.g. the popular rice, toast, soup broth, apple sauce) and avoid foods that are fried, acidic, oily, or contain milk.

But what if they have icky diarrhea?

– Change the diaper or bring them to the toilet frequently. Use a LOT of diaper cream to keep the area from getting chapped/sore. Put on a zinc cream (like the purple desitin) as if you are icing a cake – this acts as a barrier layer, to prevent acidic poop from sitting on the skin.

– Feed them binding foods, like rice.

– Sometimes the microbes that cause diarrhea, also cause a temporary lactose (the sugar in cow’s milk) intolerance, so avoid lactose-containing stuff, like cow’s milk and cheese. You usually have to do this for 2-4 weeks after the onset of the illness, until their GI system is back to normal.

– Try a children’s probiotic with lactobacillus once per day, such as children’s culturelle.

When my patients get sick this way, I often refer them to the great patient resources at UpToDate, such as this one on nausea and vomiting in children:

http://www.uptodate.com/contents/nausea-and-vomiting-in-infants-and-children-beyond-the-basics?detectedLanguage=en&source=search_result&search=patient+information&selectedTitle=7~150&provider=noProvider

or this one on diarrhea in children:

http://www.uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics?source=see_link

How can you tell if your child is dehydrated enough to warrant intervention (like an urgent care or ER), or at least a call to your pediatrician?

– they are not urinating (peeing)  often enough (every 4-6 hours for a baby, every 6-8 hours for a toddler/child, every 8-12 hours for an older child/teenager)

– they are crying, but can not make tears

– they are an infant whose fontanel (soft spot on top of the head) is more sunken than usual

– eyes look very sunken

What are some other signs that I should call my pediatrician about, or head over to the local urgent care/ER?

– persistent high fever (above 102.5 F)

– any fever in an baby younger than 3 months old

– severe abdominal (tummy) pain

– abdominal pain that moves to the lower right side

– lethargy or decreased responsiveness

– bloody (red or black) or bright green (like pea soup) vomit or diarrhea

– diarrhea not improving after 1 week

 

The good news is that most of these illnesses pass quickly without any medications, so hang in there, and keep washing your hands with soap and warm water!

Coughs, Colds and Croup

Even though it’s a beautiful Spring here in Southern California, we are still seeing some coughs, colds and croup, so here are my tips to help keep your family comfortable as they clear their viruses:

Helping a child with nose congestion:

–          Use a nasal saline mist (the kind that comes in a metal can, not drops) to spray moisture into each nostril and help clear her out. I like the mists more than the drops because you can hold the canister right below her nose and spray it in, without touching the canister to the actual nose, and without sticking anything directly up the nose. These are also sterile, so you don’t have to worry about the water source. The mist is gentle and cleans out the nose better than the drops.

–          Use a humidifier. Only put distilled or sterile water into it (not tap water). Clean it at least every 3 days. Do NOT use the menthol or eucalyptus discs/drops that come with some humidifiers.

–          If your child suffers from allergies and is over age 4, you can use an over the counter antihistamine to help dry her up (e.g. children’s Benadryl). Under age 4: ask your pediatrician about these. Do NOT use the over the counter medications known as “decongestants” or “medicated cough syrups”, as these have been shown to have more risks than benefits in children under age 6 years old.

–          If your child is very congested you can steam up your bathroom and sit in the bathroom with your child. Make sure the air is okay and the child does not have any access to the hot water. Never leave a child alone in the steam!

–    If you want to, you can use a vapor rub on the feet or chest of a child. It has not been proven to help or hurt. However, do not let the rub get near her nose or mouth! Vapor rub placed under the nose has been reported to cause wheezing in some children, and it is dangerous to ingest. Call poison control if your child eats any of this, or gets it in their eye 1-800-222-1222 (an important number to keep in your cell phone for emergencies).

–          Children under age 2 years usually can not blow their noses, so help decongest them (e.g. get the boogies out) by using a snot sucker device such as the Nose Frida (http://www.fridababy.com/) -you put in the nostril and use to literally suck the snot out. Sounds gross, but there is a filter (which needs to be changed every day) which prevents you from getting any snot in your mouth. You can do this before feeds and before sleep, or just as needed to clear out the mucus in your baby’s nose. I like this better than traditional nasal aspirators because it’s much easier to clean, is difficult to put it too far into the baby’s nose, and it gets a lot more of the snot out. The key to good suction is to hold the other nostril closed, when you suck out boogers from the first nostril (should take less than 1 second).

Helping a child with a “wet” or “phlegmy” cough:

Do all of the above for nasal congestion plus the following:

–          Have your child sleep propped up at 30 degrees so the mucus drains easily.

–          Give children over age 1 year a big spoonful of honey twice a day. The honey has been shown to help relieve cough symptoms in kids & help them sleep, in published randomized control trials (scientific studies). The honey they used was NOT “raw”, which can have dangerous bacteria in it. nor was it Menuka. Just plain pasteurized honey from the store works.

–     Warm liquids, such as chamomile (caffeine-free) tea and lemon, or chicken soup, can help people feel better.

–          Zinc may help shorten colds and soothe sore throats, but this has not been proven conclusively. You can get this in some non-medicated cough syrups, such as Zarbees (for over age 1 since it also contains honey), or in zinc lollipops (over age 2, observing child while they eat them). If your child is over age 6 years you can give him the zinc cough drops that are available at all pharmacies, but please supervise to prevent choking.

Helping a child with a dry, barking, or croupy cough:

Do all of the above for nasal congestion & wet coughs plus the following:

–          Use a cool-mist humidifier. Use distilled/sterile water in it. Clean it at least every 3 days by rinsing out the water tank with distilled vinegar and then washing that out. Do not put oils in the water.

–          If the child is having a coughing fit, or breathing like Darth Vader, take him/her for a walk outside in the cool air, or hold him/her in front of an open freezer for a few minutes, to reduce the swelling in the throat. If that is not helping, call your pediatrician for immediate medical advice, take the child to the office or ann ER. Please call 911 if (s)he is actually having trouble breathing.

Check out other mom pediatrician blogs on the topic, such as this one from Dr. Stuppy:

http://pediatricpartners.blogspot.com/2013/12/but-snot-is-green-or-how-can-we-treat.html

Other Important Stuff:

–          If your child is wheezing, noisy breathing, breathing hard, breathing quickly, breathing with flared nostrils, or other signs/symptoms not mentioned, please call your pediatrician or 911, or take them to the ER immediately. This information is not intended to act as a substitution for speaking to your physician or using common sense!

–          If your child is breathing so hard that they have trouble walking or talking, or if their lips or fingernails turn blue, please call 911 for immediate medical assistance.

Wheezing: Tips for Kids Using Inhalers

There are different kinds of metered dose inhalers (“MDI”):

1)      A “rescue inhaler” contains Albuterol or Levalbuterol, which opens up the lungs and reduces inflammation for quick relief. Brand names include Ventolin, ProAir, Proventil, or Xopenex. 6 puffs of these are equivalent to putting 1 vial of Albuterol or Xopenex in a nebulizer and sitting with the mask on your child for 15 minutes. These are usually used on an as-needed basis, up to every 4 hours. If your child needs to use this every 4 hours for more than 24 hours, needs it more often than every 4 hours, or needs this more than twice every week, please call your pediatrician.

2)      Some inhalers are used to prevent asthma, wheezing, and breathing trouble. These are only effective when used every day on a continuous basis. They are not used for fast-acting relief of an acute breathing difficulty, but may help when used during cold or allergy season, or if started right at the beginning of an asthma exacerbation or when a child is exposed to known triggers. Brand names of some of these medicines include Flovent, Qvar, Symbicort, Dullera or Advair. Flovent and Qvar are like using the Pulmicort/Budesonide in the nebulizer. Symbicort, Dulera and Advair also have other medicines in them for stronger asthma prevention. Please discuss if and when you should use these with your physician.

3)      There are also inhalers that contain powder or are not used with a spacer. Some brand names are: Maxair autohaler, Proair RespiClick, Asmanex Twisthaler, or Pulmicort Flexhaler. None of these need a spacer to work effectively, but these are only for older children who can control breathing in the medication and not breathing out into the device.

Please see the “Asthma Education For Kids” playlist from BoosterShotComics on YouTube, especially episode #1: “Iggy & The Inhalers” to better understand the roles of different medications used for wheezing or asthma. Episode 4 explains how to use a spacer with mouthpiece.

There are 4 main brands of spacers. They may be cheaper online than from a pharmacy, but always require a prescription.

1)      Aerochamber with flow-vu. This brand is a clear tube with colored ends and teddy bears on the side. It has a two-way valve (to get the medicine in and air out) and is anti-static (so the kid can inhale all of the medicine and it won’t stick to the sides). The flow-vu allows you to see when a child gets a breath with a good seal. There is a small orange one for infants, yellow medium one for age 1-5 years old, blue one with mask for older children that still need a mask, and blue one with mouth-piece for older kids that can seal their lips around it instead of having to use a mask (more comfortable, kids can usually start doing this around age 6).

2)      Vortex Non-Electrostatic Valved Holding Chamber. This device also has a two-way valve and is anti-static. It is metal, so it is more durable and machine-washable. It comes in 1 size with different sized masks that fit on the end. This has the advantage of only needing one device as the child grows older (you just switch the mask on the end, not the whole device).

3)      Optichamber. The original device is a plastic tube with 1-way valve that most pharmacies try to give our patients. Some versions are NOT anti-static, therefore much of the medicine sticks to the plastic, instead of being inhaled by the child. The single valve can make some children feel suffocated when breathing into the mask. I do NOT recommend this device. However, there is now an Optichamber Diamond version, which is anti-static, has a 2-way valve, and can be used comfortably. It comes with different size masks or a mouth piece, all clear, and very soft.

4)      InspiraChamber. This is a clear, anti-static, valved chamber, with purple ends. It offers very soft masks with a special place in the small mask to fit a pacifier, to calm the child while they inhale. It also has a flap that moves, so you can see if the child is taking a breath with a good seal and getting the medicine.

How to Use Your Inhaler:

Before using a new inhaler for the first time, shake it up, then put it into the spacer and press it 10-15 times to prime the device (e.g. makes sure the medicine is coming out in an even dose, and not just the propellent). The next time you use it, shake it first, but you do not need to prime it.

My son playing with his inhaler and spacer to get used to it

To use a spacer with a mask:

  • Shake the inhaler before each use.
  • Put the inhaler mouthpiece into the spacer.
  • Hold the mask over your child’s nose and mouth and create a good seal. Holding your fingers like the letter C can help. If you’re using a device with flow view, you should see the flap move with each breath the child takes. Otherwise look at the child’s chest to count breaths.
  • Press the inhaler.
  • Have your child breath in and out six times (about 30 seconds).
  • Remove the mask and let your child breath normally for a minute.
  • Repeat if more than one puff was prescribed (most inhalers need 2 puffs per dose, but some use more or less).

While your younger child may not like the spacer and mask being held over his mouth and nose, it will go much quicker than using a nebulizer. Let the child play with it and practice putting it on stuffed animals or family members to make them comfortable. Some children will allow you to use it if they get to be the ones to hold it or press the inhaler (just make sure the seal is tight over their face so they get all of the medicine).

To use a spacer with mouthpiece (older children and adults):

  • Shake the inhaler before each use.
  • Put the inhaler into the spacer.
  • Have your child seal their lips around the mouthpiece and exhale.
  • Press the inhaler.
  • Have your child breath the medicine in and hold their breath for about 30 seconds. If they can’t hold their breath, they can take another breath or 2 in to get more medicine from that puff (any extra medicine should be sitting in the chamber).
  • Take the spacer out of their mouth and have the child breath normally for a minute.
  • Repeat if more than one puff was prescribed.

Keep in mind that while many experts believe that an MDI with a spacer is as good as, or better than, a nebulized treatment, some parents prefer a nebulizer, and that is okay.

If you are not sure if your child is actually wheezing, or what they have, this blog from Dr. Stuppy can help, with descriptions of different kinds of coughs and breathing, along with youtube video links.

If your child does NOT have asthma, reactive airway disease, wheezing, bronchospasm, or difficulty breathing, my post on Coughs, Colds and Croup may be more helpful.

Please note that this guide is NOT intended to diagnose or treat any illness or condition. Always speak to your own physician for advice. 

Tips for Sensitive Skin & Eczematous Kids

Part of the information is from UpToDate.com, but has been extensively revised by Dr. Shaham.
What is eczema? — Eczema is a skin condition that makes your skin itchy and flaky. Doctors do not know what causes it. Eczema often happens in people who have allergies. Another term for eczema is “atopic dermatitis.”

What are the symptoms of eczema? — The symptoms of eczema can include: intense itching (even before the rash starts), redness, rough patches of skin, small bumps, skin that flakes or skin that forms scales.

What can I do to reduce my symptoms? — Use unscented thick moisturizing creams (ointments preferred) to keep the skin from getting too dry. Also, try to avoid things that can make eczema worse, such as: being too hot or sweating too much, very dry air, stress, sudden temperature changes, harsh soaps or cleaning products, perfumes, wool or synthetic fabrics (like polyester), things that you may be allergic to (often foods for infants or pets for older kids).

Bathing Tips— Use warm water for bathing and washing hands. Use a mild, non-drying cleanser that is fragrance-free, dye-free, and allergy tested. Avoid body sponges and washcloths (friction can make the skin worse).  Gently pat skin dry with a towel, do not rub the skin. Kids with frequent eczema flares or infections can benefit from bleach baths, but ask your pediatrician first if this treatment should be used for your child.

Moisturizing Tips— Apply any special skin medications prescribed for you and then liberally apply a moisturizer. Use a moisturizer within 3 minutes of getting out of the bath, to lock in the moisture. Re-apply moisturizer throughout the day, whenever your skin feels dry or itchy. Regular petroleum jelly works very well for this. A recent study showed applying petroleum jelly 3 times a day to infants who had a family history of eczema helped prevent eczema in those babies.

More Tips— Use dye-free and fragrance-free detergents. Use an extra rinse cycle on laundry to get rid of any soap remnants. Keep fingernails short to avoid scratching. Consider weekly bleach baths if the eczema gets infected often. Check out www.eczemacenter.org  and the national eczema association for more information and videos.

How is eczema treated? — There are treatments that can relieve the symptoms of eczema. But the condition cannot be cured. Even so, about half of children with eczema grow out of it by the time they become adults. The treatments for eczema include:

  • Moisturizing creams or ointments – These products help keep your skin moist. An ointment (such as aquaphor or vaseline) can be soothing, lock-in the moisture and act as a barrier to environmental allergens. Other lotions (such as Cetaphil) help repair your skin’s barrier. These need to be applied at least 3 times per day!
  • Steroid creams and ointments – These medicines are different than the steroids athletes take to build muscle. They go on the skin, and they relieve itching, redness, and inflammation. (In severe cases, you may need to take steroids by mouth, but only under physician supervision).
  • Antihistamine pills – Antihistamines are the medicines people take for allergies and also relieve itching. Many people find that itching is worst at night, which can make it hard to sleep. If you have this problem, talk with your doctor or nurse about it. He or she might recommend an antihistamine that can also help with sleep, such as Children’s Benadryl (aka diphenhydramine HCl).

Private Parts: Talking to Your Child About Their Bodies, Behavior, and Babies

It is important to start speaking with your children about their bodies and behavior at an early age. If you create an open dialogue, without shame, your children will feel free to bring you their questions throughout their lives. This is often an uncomfortable topic for parents, so I have created a list of books and resources to help you get through it (scroll down). I also encourage you to discuss any questions you have on the topic with your child’s pediatrician (we are always here to help!).

Some tips:

  • Watch out for everyday opportunities to teach your child about privacy and hygiene.
  • Encourage your child to ask you questions, to learn that they can feel comfortable coming to you with their thoughts.
  • Try to be calm and open about the topic (pay attention to your body language and tone of voice).
  • Give simple and short answers.
  • Make sure your answers are age appropriate.
  • Young children take everything you say literally, so avoid metaphors.
  • Use anatomically correct terms for their body parts (i.e. penis and vulva, not “weewee”)
  • Avoid shame and ridicule.
  • Become closer to your child by showing them that you accept & support their feelings.
  • Set rational and consistent limits.

Here is a great blogpost by Dr. Claire McCarthy on getting started with the conversation: “6 Tips For Talking To Your Kids About Sex.”

I also recommend looking at the website “Empowering Our Children,” which is designed to teach parents how to protect their children from sexual abuse.

The “ScaryMommy” website has a good post on what these conversations with toddlers may look like.

My Book Recommendations:

For parents to read overall:

This is the best book for parents to read on the subject. It tackles every sexual stage of development from infancy (yup, some babies masturbate) through adolescence, as well as age-less topics, such as homosexuality. I recommend starting to read this book when your child is young, although it’s never too late to learn.

Books to read with your children (or for them to read by themselves), by age group:

Toddlers & Pre-Schoolers:

My favorite overall book for toddlers. Teaches basic anatomy, privacy, and even how babies are born.

A very simple book on pregnancy and birth to read to young children. No lies (e.g the stork), but no anatomy or private parts mentioned either.

This book is great for families that conceived via IVF, adoption, surrogacy, or traditional means. It talks about sperm, egg, uterus, and birth, but each as its own thing, and at the end it asks, “Who was waiting for you to be born?” Technically accurate, but simple, with cartoonish illustrations.

This is the classic “how babies are made” children’s book, but take a look through this book before buying it, as it is may be too explicit for some families (see the anecdote at the end of this blog post).

This book discusses inappropriate touching/abuse. It does not discuss development or how babies are made.

School Age Children:

Covers all of the basics, including proper anatomy, mostly with diagrams, and a little cartoon guidebird.

Tweens:

Very similar to the school-age version by Harris (above), but with more words, less illustrations, and more details.

My tween patients report that they love this book. It goes over what to expect in puberty and how to take care of girls’ changing bodies. This book includes discussions on hygiene and how to use menstrual products. There is a version for boys. There is also a version with the number 2 at the end for teenagers.

Dr. Stuppy and the Mighty Girl website also have good posts on discussing puberty.

A Funny Story About Me:

When I was 3 years old, my mother (who is a pediatrician as well) read me the book “Where Did I Come From?” I went to my religious nursery school and proceeded to tell everyone, “I was the fastest sperm!” Some of the other parents were not happy when their own children went home and repeated the same thing to them. My mom got a stern ‘talking to’ by the school. We still laugh about it, to this day. The moral of the story? Teach your children about their bodies and development before anyone else does, or you may not be happy with what they learn 😉

For newer blog posts on the subject, as they come out, you can also follow my pinterest boards on Teenagers, Parenting, and Kids’ Health.

Preparing for a Perfect Pediatrician Experience

Taking your precious baby to the doctor can be a harrowing experience, but with a little preparation, it can go as smoothly as a baby’s bottom. Here are some tips for getting your children, and yourself, ready for your next visit.

Lior has his own real stethoscope
My baby gets used to the stethoscope

1)      Prepare your children in advance by reading books about going to the doctor, so they know what to expect. This is especially important for toddlers, who are old enough to remember prior visits involving shots, but is also good for older children.  Try to do this far in advance of any appointment, such as having a regular bedtime story about visiting the doctor, so your child considers it a regular thing. If your child loves a certain character, e.g. Elmo or Dora, read them a book involving that character’s visit to the doctor. Otherwise, I recommend books like the Usborne First Experiences series. I pinned links to these books (and others) on my pinterest boards (http://pinterest.com/motek42/).

2)      Get a doctor play set and have your child practice using the stethoscope, otoscope (ear light), and other tools on their family members and stuffed animals.

3)      If your child has a “luvvy” (special blanket or toy to make them feel comfortable), be sure to bring it with you to the visit, even if they only use it in bed at home. This will help comfort them.

4)      For young children, bring a doll, so the physician can check the doll first, lessening the fear the child may have about the medical tools. You can also have the doctor check mommy or daddy first, but in my experience children are comforted more by having their doll checked then their parents. It works even better when the doll has ears and a mouth that opens.

5)      Bring snacks and drinks. You never know if you will have to wait a while for the doctor to see you, or just sit and wait for a test result. Sugar has been found to be a natural pain reliever in babies, and I find that breast milk or formula for babies, juice or a lollipop for toddlers, calms them down faster than anything else after shots. One caveat- do not let them eat/drink during the visit, especially if they will have their throat checked (like for sore throat or tummy pains), as the food pieces can get in the way of the doctor having a good look, and can interfere with tests, such as the one for strep throat.

6)      Bring diapers, wipes and baggies for soiled items (these are good things to have in your bag at all times, prior to school age). You can not rely on your pediatrician having the size or brand of diapers your child uses on hand. Wipes come in handy for many things, not just cleaning little butts, and the pediatrician visit often brings out the snot, spit-up, and other fun stuff. Help the next patient have a more pleasant experience by placing any soiled items in a sealed bag, so the room does not smell bad. An extra baggy also comes in handy for soiled clothes and toys.

7)      Dress your child appropriately, and bring a blanket. Clothes that are easiest to remove or lift-up are best. No need to dress fancy. You should also bring a small blanket to cover your baby, since they will likely have their clothes removed for vitals signs (measuring) by the nurse, and you don’t put them back on until after the physician has checked your child. If you have an older child, at least have them remove any jackets and tight or complicated clothing.

8)      Bring ANY MEDICATION you have given your child, even if your doctor prescribed it, it is herbal, or over-the-counter. This is the best way to avoid diagnosis and medication errors.

9)      Entertainment. Quiet books, reusable stickers, or even movies on your phone are a good way to keep children quiet while waiting for the physician or nurse. These can also be good tools for calming children down if they get upset during the visit. I do NOT recommend these as temper tamers for everyday use, but they are fine on special occasions.

10)   Don’t forget a list of questions to ask the doctor, so you make sure to get the most out of your visit. You may also want a paper and pen to write down any diagnoses or instructions, so you don’t forget how much ibuprofen you are supposed to give when your toddler wakes up screaming at 3am. If your doctor has not brought it up, you may want to ask them what do if your child worsens, and when to return.

11)   If you need a copy of vaccination records or school forms, contact the office in advance, and do not forget your paperwork! You should also bring your insurance card (if you have one and expect the insurance to cover your visit) each time.

12)   When possible, try to schedule your visits for the first time slot of any shift, so that you can avoid a possible wait if the office gets backed up. You should also try to schedule visits for the middle of the week, or early afternoon, as Mondays, Fridays, weekends, and evenings tend to be the busiest times in the office. Alternatively, you may want to try the last appointment of the day. This will have the greatest chance of having to wait, but then neither you nor the physician feels rushed.

13)   Give yourself an extra 15 to 30 minutes to get to the appointment, find parking (or deal with public transportation delays), and complete any forms.

14)   Finally, try to relax! When you have a positive attitude, your child will feel better too.

Getting Ready for Camp

Camp is a great way for kids to improve their social skills, exercise, and explore new things.

If you are considering sleep away camp, but aren’t sure if it’s the right thing to do, click here for a psychologist’s perspective on camps away from home.

Whether you decide on day camp or sleep away fun, here are some tips to get ready:

Day to Day


Sunscreen

Lather up your child with a full shot-glass worth of sunscreen every morning. Then send them to camp with a sunscreen stick, so they can reapply it as needed throughout the day (especially before and after water activities, and at lunch time). Get new tubes of sunscreen every year, and pay attention to expiration dates. Sunscreen should be thrown out 1 year after it is opened. Any sunscreen you use should be SPF 30 to 50. For more information on sunscreen choices, click here. A hat and clothing are also good ways to protect your child from harmful rays.

Insect Repellent

If your child will be in an area with mosquitos or ticks, don’t forget the insect repellant. These only need to be applied once a day. If there are deer ticks in the area, please do a tick-check daily to make sure none are taking a ride, especially in the hairline. Ticks usually have to be attached to the skin and feeding for 24-48 hours before they transmit diseases like Lyme Disease, so a daily tick check can really prevent your child from getting sick. If you do find a tick, pull it out completely with tweezers, or follow the tips at HealthyChildren. Do not apply vaseline and do not burn the tick, as this can cause the tick to vomit into the host and transmit disease. For more information on insect repellants in kids, click here (Tara Haelle talks about the latest science and studies on types of repellents) and here (Dr. Iannelli discusses what to buy).

Food

If your child is going to a day camp, don’t forget ice water and healthy snacks and lunch, for maximum energy and hydration. At sleep-away camp, food in the cabins can attract bugs, so it’s better to leave it at home.

Safety

Teach your child to swim before they go to a camp with a pool or lake. Empower them to be protective of their body, and not to allow unwanted touches. For more help with that, see here and here. Finally, remind them to wear helmets for certain sports (rock climbing, skateboarding, bicycling, and horseback riding are popular camp activities).


Help From Your Pediatrician


Forms

Most camps require health forms to be completed by your primary care physician before you can attend camp. If you have had an annual physical office visit less than a year from the form due date, most offices will complete your forms without a visit. Some camps require the forms to be completed with a doctor’s visit after April, in which case you should make an appointment as soon as possible. Either way, you will need to contact your PMD office well in advance of when you need the forms completed. Some camps are now also requiring immunization records. If you have an up to date yellow immunization card you can give the camp a copy. If you don’t have one, get a copy from your pediatrician (it’s a good idea to have these at all times anyways).

Medications

If your child will need to take any medications at camp, even over the counter ones, get the medication forms from camp and send them to your prescribing physician at least a couple of weeks before they need to be submitted. You should also speak to your doctor about prescribing extras for camp, especially inhalers and spacers. If your child has asthma, or wheezes, send a copy of their Asthma Action Plan to the camp.

Allergies & Special Diets

If your child has real allergies or medical diets (like with celiac disease), inform the camp ahead of time, and call to make sure they can accommodate your child safely. Allergy warning bracelets can help avoid accidental ingestion at camp, by reminding staff before they share food or special camp treats. If your child has a possibly anaphylactic (life threatening) allergy to insects, food, or anything, be sure to send an Epi-Pen or Epi-Pen Jr set (2 pens in case of anaphylaxis, not just 1) to the camp. You should also have an allergy plan, so the camp (and you) knows when to use the pen. You may need extra forms to be filled out, to be able to have these used at camp, and an extra prescription, so call your primary care or allergy doctors’ office at least a month before camp starts to have this done. Teaching your child the symptoms to look for, and how to use the epinephrine is also important.

You can read more about creating a healthy camp experience at the AAP’s parent site, but most importantly, have a fun summer!