Addressing Your COVID Concerns for Returning Back to School

The COVID-19 pandemic has forced all of us to make tough decisions about many aspects of our lives. With the new school year imminent, parents must decide how to proceed with their children’s education. Many of you have reached out to us to ask for advice regarding this decision, and we are honored that you have done so. The particular question most are asking is whether the better choice is in-person learning, or one of the virtual or homeschool options.

We believe that a safe, quality education is an important part of the health and development of all children. For most children this means attending school in person. For many families, in addition to quality instruction, school provides a safe haven from hunger, abuse, or a non-nurturing home environment. For others, effective learning from home is not feasible due to lack of resources or due to parents who work outside of the home. For others, learning from home is a viable option, but the mental and emotional benefits of in person learning and social interaction is vital.

The risk of severe illness from COVID-19 in most pediatric patients is very low. In addition, several studies show that transmission of COVID-19 from children to others is not nearly as common as transmission from adults to one another. Therefore we feel that for most of our patients, returning to their original school situation from last year is an appropriate decision. However, this is certainly not a "one size fits all" solution. If your child has significant underlying illness that puts them at higher risk, they may be better served with one of the online or virtual options for school this year. Children with significant heart or lung disease, cancer, or immunosuppression are among those who may be at higher risk. If your child is followed by a specialist for a concerning condition, we urge you to ask for their guidance in making your school decision, and we are also happy to be of assistance. In addition, your family situation should be taken into account. If your household includes individuals at high risk because of older age or underlying conditions, you may choose an online option. Or, if you are simply uncomfortable with the risk of in-person school or your child thrived with online learning and you are able to supervise schooling from home, this may be the option you choose.

The local public, private, and charter school leaders have done an admirable job of planning to make this educational year as safe as possible for students and teachers under the circumstances. They have the unenviable job of bringing our children together to learn, while somehow keeping them all apart! There will be successes and failures this year; no situation will be perfect at preventing all cases of disease. As parents, we can do our part by teaching our children about appropriate physical distancing and handwashing technique. We should be encouraging them to wear masks while in school and in any public place. Also, when our children show any signs of illness at all we should be heroes and keep them home. Your heroic decision to keep your child home with even minor symptoms may save the life of a classmate's medically fragile sibling or elderly grandparent!

If there is one certainty about this pandemic, it is that things will change. The virus hospitalizations and deaths may worsen and they may improve, our knowledge about transmission and treatment will change, therapies and vaccines may become available; all causing us to rethink our strategy. This situation is not like any we have faced before, and we need to realize, with patience, that everyone involved is trying their best to educate our children and keep them, their teachers, and their families safe. We will need to respond to this challenge with love and compassion not only for our own children, but also for their fellow classmates and their educators.

The Pediatric Division of Physicians' Primary Care of SW FL

Reach Out and Read

Physicians Primary Care of SWFL has partnered with Reach Out and Read, a national pediatric literacy program that promotes early literacy and school readiness. The program builds on the unique relationship between parents and medical providers to develop critical early reading skills in children beginning at 6 months of age. Reach Out and Read prepares young children to succeed in school by partnering with doctors who prescribe books and encourage families to read together.

• Used books are available in the waiting and examining room for children to read while waiting to see the doctor in all of our pediatric offices.
• At each well-child checkup, children 6 months of age to 5 years old are given a new book to take home. These books have been carefully chosen and are developmentally and culturally appropriate for the child.

Breaking The Finger-Sucking Habit

It has long been recognized that non-nutritive sucking is a normal, pervasive method of self-soothing in infancy.In one study, 31% of children at 1 year of age engaged in fingersucking and by 4 years of age, only 12% still suck their fingers.

If you have a 2 year old thumb-sucker, your toddler does not need any treatment at this time because most children will stop this behavior without any intervention by the time they reach the age of 3 to 4 years. Any attempt to break the habit is discouraged until the child is a year or two older.

Finger-sucking is a habit that needs to be broken eventually. Although there is no urgency about stopping thumb-sucking in a 2 year old, prolonged finger-sucking can have a number of harmful effects and is definitely a habit that warrants intervention in older children.Commonly reported sequelae include finger deformities and infections, various skin conditions (eg, skin irritation) and social stigmatization. In addition, malocclusion and malpositioning of the anterior teeth may result.The American Academy of Pediatric Dentistry advises a professional evaluation to address the habit if it continues beyond the child's third birthday.

Recommended Interventions:

1. 1.Positive reinforcement.Verbally praising your child when he is engaging in appropriate behavior and not sucking the his finger is the mainstay of positive reinforcement.Providing the child with encouraging social support has been shown to be an important part of breaking the finger-sucking habit in children aged 5 to 15 years.

   Creating a reward system with your child's help is another way to provide positive reinforcement.For example, give your child a "star" on a calendar for each day he does not suck his finger.After an agreed on number of stars in a month has been reached, a desired reward is earned.Such reward should continue for several months to permanently end the habit.

2. 2.Negative reinforcement.Verbal chastisement and physical punishment are certainly not advocated. However, some pediatricians do recommend the use of various deterrents as a type of negative reinforcement. Deterrents include topical bitter substances and bandages that are applied to the finger the child sucks, as well as glove-like devices, which have been reported to be effective in decreasing finger-sucking ti cooperative children aged 7 to 10 years, especially during alone times and at bedtime.

3. 3.Distraction.Finger-sucking typically occurs when children ate bored or trying to fall asleep. When a child watches television, the finger has a tendency to make its way to the mouth.Thus, an obvious strategy for breaking the habit is to limit television time and other forms of idleness and instead promote activities that require the use of both hands.

   Children who received awareness training and who were able to respond to the urge to suck their thumb with an alternative behavior, such as fist or knee clenching, could successfully combat thumb-sucking habit. Awareness training involved helping children identify warning signs that indicated that they were about to start sucking their thumb. They learned to respond to these cues by clenching their fist or knees.

4. 4.Scheduled thumb-sucking.This paradoxical approach forces the child to engage in thumb-sucking for a scheduled period each day, making it an obligatory rather than a voluntary activity.This is an unusual approach, but for a few children it may make the habit less appealing.

5. 5.Dental appliance therapy.Some experts classifies orthodontic appliances as second-line therapy, which should follow the use of positive reinforcement and deterrents.Before choosing this intervention, it is helpful for the child to have a strong desire to stop the habit and to understand the role that the device will play in the process.Ideally, the child should have reached the age at which the first upper molars have fully erupted. Reports of adverse consequences of dental appliances include emotional distress, pain, dental changes, and palatal irritation, infection and embediment. A dental expert needs to be consulted to review the risk and benefits of a dental appliance before providing it to the child.

Reviewed by John W. Bartlett, MD, FAAP

Is Your Child Ready To Wear Contact Lenses?

If your child plays sports or is fearful of being call "four eyes," he might try to persuade you to let him get contact lenses. How do you know if contacts are right for your child?

There is no minimum age to wear contact lenses, according to pediatric eye specialists. Children in elementary school could be great candidates for contacts, while some high school students are not responsible enough for the daily care that contacts require. If your child needs constant reminders about daily tasks, he's probably not ready for contact lenses.

If your child is prescribed contact lenses, he will be responsible for:

1. 1.Washing his hands before touching his eyes or lenses.

2. 2.Taking the contacts out every night before bed.

3. 3.Disinfecting and storing the contacts overnight if the are not daily,disposable or extended wear lenses.

4. 4.Taking the lenses out without help at school if necessary.

Daily disposable soft contact lenses are a great option for younger ones because they don't need to disinfect and store the lenses every night.Extended wear lenses can be worn overnight, but pediatric ophthalmologists still recommend that these lenses be removed at night to reduce the risk of infection.

Your child should know how to remove the lenses immediately if his eyes hurt or become blurry or bloodshot. These can signs of an eye infection.If your child gets multiple eye infections or constantly forgets to take his lenses out at night, it might be a good idea to go back to wearing glasses until he is older.

Reviewed by: Georgia Rodriguez, MD

Healthy Family Living for 2011

Source: American Academy of Pediatrics

Gastroesophageal Reflux in Infants

Gastroesophageal reflux, or GER, is when food leaves the stomach and travels back up the esophagus (food tube). All babies have some GER because the sphincter muscle that keeps the food down in the stomach is less effective in babies. Of course, some infants do this more than others.

There is a spectrum of GER in babies ranging from asymptomatic infants who just have a little breast milk or formula come slightly up the esophagus, to infants who spit up with every feeding. Therefore, we need a way to decide which infants require further intervention, and which are just messy! By the way, when GER requires further intervention we sometimes refer to it as gastroesophageal reflux disease, or GERD.

Basically, there are three factors which would lead us to want to do something about an infant’s GER. One is if they are not growing well enough. This would be evident by looking at the growth chart. A second factor would be if the GER is causing respiratory symptoms. These might include chronic cough, wheezing, brief pauses in breathing, or occasionally, aspiration pneumonia (although this is rare). Another symptom leading to treatment of GER in an infant would be if it is causing pain. Of course this can be somewhat confusing because the babies don’t come right out and tell us they have heartburn. Sometime they will just cry or fuss after meals. Others will arch their backs after eating.

As you may have guessed, it can be difficult to tell if any of these symptoms are coming from GERD, or from something else. Unfortunately, there are not any quick and easy things that allow us to discern this. Often it comes down to simply trying an intervention to see if it helps. Other times we may need to resort to tests such as an upper GI barium contrast study to look at the anatomy of the GI tract, or a pH probe study to try to determine if GERD is the cause.

When we do intervene in a baby whom we feel has GERD, we usually start with the least invasive options unless the symptoms are severe. These may include things as simple as raising the head of the crib to a slight angle to let gravity help keep food down. We may also want to maximize ‘burping’ the infant so that the gas is not pushing the fluids back up the esophagus. Sometimes we will ask that you thicken infant formula with cereal in an attempt to prevent GERD. If these simple interventions fail, we may decide to try medications that block acid production in the stomach or empty the stomach faster. In a worst case scenario, there are surgeries available which can stop severe GERD.

In summary, most babies who spit up just cause extra laundry, and fortunately the problem tends to resolve itself with time; however, if you suspect that your infant seems to be having trouble due to GERD, let us know.

Reviewed by: Nathan Landefeld, MD, FAAP

Cradle Cap and Your Baby

Cradle cap, also known as seborrhea, occurs very often in newborns and infants.It generally begins in the first few weeks of life, and usually goes away by about 6 months old in most babies, even without treatment.You might notice thick, yellow scales that appear oily on your baby's scalp or around the eyebrows.Sometimes the crusting can cause irritation on the baby's cheeks, in her neck folds, or in her armpits.When this occurs, we call the condition seborrheic dermatitis.In either case, the rash is not contagious, and it rarely causes discomfort or itching for your baby. We're not sure why some babies get cradle cap and others don't, but pediatricians believe it is caused by hormones produced by the mother which are passed to the baby prior to delivery.These hormones cause the baby to produce excess oil, which then coats the skin and trap debris or dead skin cells.Sometimes, the skin can become infected with yeast, causing extra redness and possibly itching.

As mentioned, cradle cap will generally go away without treatment, but sometimes pediatricians recommend using oil (either baby oil or olive oil) rubbed into your baby's scalp and left on for about 30 minutes before washing with regular gentle baby shampoo.Doing this loosens the scales and makes them easy to brush off using a soft-bristled baby brush.Make sure to wash the oil completely off, though, or the scales can get WORSE! Occasionally, you might have to use a mild anti-dandruff shampoo, like Head and Shoulders, but check with your pediatrician first since these shampoos can irritate your baby's skin or burn his eyes.For seborrheic dermatitis, your doctor may recommend hydrocortisone cream, with or without a cream to treat yeast.

Keep in mind that seborrhea is not a dangerous or contagious condition, and it will not damage or scar your baby's skin.If the rash spreads outside of the usual areas, oozes, or seems very uncomfortable, please call our office to have your baby checked out by one of our pediatricians.

Reviewed by Eric Jones, MD, FAAP

Colic Remedies: Is TLC Better than Herbal Tea

Click here: Colic Remedies: Is TLC Better Than Herbal Tea?

Study Analysis Finds Scant Evidence That Fennel Extract, Herbal Tea, Sugar Solution Work, but ‘Common Sense and TLC’ May Soothe Colicky Baby. By Kathleen Doheny WebMD Health News.Reviewed by Louise Chang, MD.

March 28, 2011 -- When babies get colic, stressed out parents often will try almost any remedy, from herbal teas to sugary solutions or infant massage, to stop the constant crying.Now, a new analysis of these popular approaches finds little convincing evidence they work.Although some encouraging results were found for fennel, mixed herbal tea, and sugar solutions, Edzard Ernst, MD, PhD, who conducted the analysis, has this suggestion: "The advice is not to use any complementary treatment on them, because some of them are not risk free. All of them cost money."Instead? "Just apply common sense and TLC, which seem to be the best treatment for that condition anyway," says Ernst, a professor of complementary medicine at Peninsula Medical School, Universities of Exeter and Plymouth in the U.K.If that's not enough, he concedes, fennel tea is probably OK.

Colic: When and How It Strikes

The cause of colic is still not known. It occurs most commonly in the first four months of life.Besides constant crying, the baby may curl up the legs, clench the fists, and tense up the abdominal muscles. Crying can begin for no apparent reason. It can persist for three hours or more on a single day.Doctors consider it to be colic when the crying occurs more than three hours daily, three days a week for more than three weeks in a baby who is otherwise healthy.About one in five babies develop colic. A drug used in the past, dicyclomine hydrochloride, was found effective. But after reports of severe and potentially fatal side effects, it fell out of favor.

Colic Treatments: The Possibilities

In searching possible complementary medicine colic treatments, Ernst and his team found studies from medical databases through February 2010.They narrowed the analysis down to 15 clinical trials. Ernst says all had flaws.The studies looked at different treatments, including:

Despite the encouraging results for fennel, mixed herbal teas, and sugar solution, Ernst writes that design flaws in the study make it impossible to recommend the treatments.His best advice? ''See a doctor who can differentiate between serious problems and simple colic." Once that's done, he says, "you don't need to worry about him being seriously ill."Patience can help. "It goes away, treated or untreated," Ernst says.

Colic Treatments: More Options

Lawrence Rosen, MD, a pediatrician in Oradell, N.J., disagrees with Ernst's advice to do nothing about colic."There are always limitations to these studies," he says of those reviewed by Ernst."There have been some recent studies on probiotics that did find a significant difference," he says, with reduced crying times.For parents looking for relief for their child, Rosen says he suggests:

Before parents try any of these, he says it's important to first rule out other problems, such as a blockage in the intestines.Among other suggested measures from the American Academy of Pediatrics:

Click here: Colic Remedies: Is TLC Better Than Herbal Tea?

Chronic Daily Headaches

Chronic Daily Headaches (CDH) occurs in teenagers and pre-teens, and is described as very frequent or daily headaches that persist for weeks, months or years. Descriptions may be “hurts all over, throbbing, pressure like, and may be difficult to localize.

Headaches rarely have an organic cause, or disease. However, if headaches persist a physical examination is in order. Conditions at high-risk for CDH are medication overuse, obesity, sleep apnea disorders, anxiety and depression. Certainly if headaches continue to be persistent and there are additional symptoms such as personality change, vomiting, eye deviations or gait problems re-examination is indicated.

Brain scans, x-rays and other tests are rarely of value. Treatment consists of setting expectations and lifestyle changes. Regardless of what is done headaches will not go away within the next few days, and there is no quick cure. Medication overuse (particularly OTC meds) are seen in up to 50% of children with CDH. It may play a causative role, therefore, all abortive drugs should be stopped, and narcotics should never be used for the treatment of CDH.

The following rules are recommended:

Boys Don’t Get Cervical Cancer

Recently, the CDC recommended that all boys between the ages of 11 and 21 receive three doses of "the cervical cancer shot" called Gardasil. WHAT?!?! You read that right; the CDC and the American Academy of Pediatrics recommends vaccinating boys and girls with the HPV vaccine.

Actually, Gardasil protects against HPV (human papillomavirus), not just cervical cancer.HPV does, in fact, cause most cases of cervical cancer in woman, but it causes many other diseases as well.The virus is spread through sexual contact--any type of sexual contact--and is the most common sexually transmitted infection in the US. At least 50% of sexually active US adults get HPV at some point in their lives.Most people who contract HPV do not even know they have it, so most are spreading it unknowingly to their sexual partners, and symptoms of the virus may not show up for years after exposure. The good news is that most people with HPV will clear the infection on their own over time, and many will never show symptoms at all.Why, then, is the vaccine so important for both women and men?

The most common manifestation of HPV infection is genital warts, which affects both men and women equally.Genital warts themselves are not dangerous and will not develop into cancer, but most people prefer to have them removed for cosmetic reasons or because of discomfort during sex.Think about that for a second--REMOVED! That means cut, burned, or frozen off of a person's genitals. Not dangerous, but not fun either.Gardasil is protective against genital warts as well, and a shot is a whole lot less painful than treating genital warts once they develop. Reason #1 for getting your sons their HPV shots.

We now know that HPV also causes nearly all cases of cervical cancer in women, as well as almost all cases of the much rarer cancers of the external genitals, vagina, and anus.By vaccinating girls and women against HPV, we can prevent most of those cases from even happening.The problem is, HPV is a sexually-transmitted infection, so vaccinating women is only solving half of the equation. Vaccinating potential sex partners is the other half of that problem.Since most people don't know they are carrying or spreading HPV, vaccinating boys and girls before they start having sex makes good sense.Gardasil is a dead-virus vaccine, meaning you are only getting bits and pieces of the virus with each shot, which stimulates your body to develop protective antibodies to the virus before you actually get exposed.People can NOT contract HPV from the vaccine, and getting the vaccine earlier protects folks for longer than if they received the vaccine as adults.So, reason #2 for getting your sons vaccinated is to protect his future sex partners from getting cervical cancer, especially if he is not yet or not currently sexually active.

That's not the end of the story, though.HPV also causes cancer in men!Though very rare, almost all cases of penile cancer are caused by HPV, as are nearly all cases of male anal cancer.These cancers are also based on sexual exposure via vaginal or anal sex.We also know that cancers of the back of the mouth and throat are predominantly caused by HPV stemming from oral sex, for both men and women, especially in folks who smoke or drink alcohol.The good news is that Gardasil, in protecting against contracting HPV, can prevent these cancers as well. Fortunately, these types of cancers are pretty rare, but if you can minimize that risk to nearly zero, why would you pass up that chance?Reason for vaccinating boys.

While no one enjoys getting shots, I think we all would agree that a series of 3 shots is much better than either contracting a sexually transmitted infection, having genital warts removed, or being treated for cancer.Most insurance plans are already covering HPV vaccines for boys, and have been covering it for girls for several years already.Our experience with the HPV vaccine in girls and women has proven it to be safe and very effective, with no more side effects than other vaccines.There is NO chance of contracting HPV from the vaccine, nor does it cause any other changes in a person's body or development. So, on first look, it may seem strange to offer a "cervical cancer vaccine" to boys and men, but it actually makes pretty good sense.Please contact your son's doctor soon to discuss Gardasil, and help protect not only his future sexual partners but him as well.

Reviewed by Eric Jones, MD, FAAP

ADHD Tips: How to help your child succeed

ADHD Tips from Teachers: How To Help Your Child Succeed

Be consistent

Establish a daily routine that kicks in as soon as your kid walks in the door.Snack, homework, dinnertime and bedtime should be as close to the same time each day as possible.This establishes a pattern and helps your kid stay focused on the task at hand.

Talk It Out with the Teacher

This is important.Communication should be clear and frequent between you, your child and the teacher.Talk to your child’s teacher weekly, if not daily – about what’s going on in school and at home.When you have a task or directive for your kid, provide short, clear directions.Then have your child repeat what he heard back to you to ensure everything was understood.

Stay on Schedule

Post schedules around the house that outline what happens every day in the hours before and after school.They’re as helpful to your child as your own schedule is to you and can keep you all on track.

Eliminate Distractions

Switching off the TV at homework time is a no-brainer, but here’s an important point:TV and video games should be off-limits for everyone when your child is hitting the books.Even if the sound is low or the video game is being played in another room, just knowing that someone’s getting screen time can be very distracting to kids with ADHD.

Limit Screen Time

Of course, we all need time to unwind in front of the TV sometimes, but it’s important to understand that for ADHD kids, TV and video games can really increase levels of distraction.Parents should be extremely active in limiting television time.Make it part of a positive regard system for when work is finished—not before.(This might mean less TV time for everyone in the family, but that might not be a bad thing, either!)

Use the Folder System

Assignments have less of a chance of creeping up on your kid if you create special folders or baskets for their work and fill them right after school every day.Label one “do this” and another “done” to keep daily and weekly assignments organized.

Organize the Backpack

Be there to help your kid empty and sort out his backpack when he gets home.Between hats and gloves, gym clothes, library books and homework folders, bags can get crowded and disorganized quickly.Weed out unnecessary objects daily.

Enforce Bedtime

It’s a brutal cycle:Your kid goes to bed later one night, then has a hard time concentrating the next day, then stays up later to get his/her work done because his/her focus is off.Don’t let the cycle start by making sure he/she gets enough sleep each and every night.

Stay Close

No one likes a helicopter parent- or being called one- but ditch the labels and recognize that your subtle supervision during homework time can really help your child.Frequent positive verbal cues like, “That assignment’s really coming along!” or “I can’t believe you’ve done that much work already!” both encourage and help your kid stay focused.

Use Charts and Checklists

You don’t have to be your child’s only source of feedback.Simple visual reminders like charts and checklists can keep your kid focused on his schoolwork, even when he’s at home.They allow your child to do some self-monitoring, letting him/her see how much he’s/she’s accomplished and what still needs to be done.

Break it Down

If your child is feeling overwhelmed by something on the to-do list, help her break it down into smaller, more manageable steps.For example, don’t just list “do science project” but rather “brainstorm flow chart for science project; choose and shop for supplies for science model.”Smaller goals feel much more accessible, and checking things off the list is gratifying.

Limit Choices

For kids with ADHD, too many options can be overwhelming.If you tell them they can watch TV or play their DS or call a friend or get dessert, then focus wavers from any one task- even if it’s a fun one.Instead, help your child stay on target by limiting the this-or-that decisions.

Reference: Joanna Batt from Parenting.com

2011 New Car Seat Guidelines

Florida Needs Booster Seat Law
Pediatricians have always been interested in protecting our patients from life ending or altering bad events.Hence the emphasis and laws on immunizations to protect against dangerous infectious diseases with dramatic beneficial results.As infections declined as a cause of serious morbidity and mortality in American children it was logical to attack other etiologies – accidents, the leading cause of death in children older than 1 year.Since motor vehicle accidents lead the list of causes it was necessary to protect infants, children and adolescents while riding in cars; hence child passenger car seat laws.Dynamically tested infant car seats were developed and laws passed to protect infants in motor vehicles.This March the American Academy of Pediatrics issued new guidelines advising parents to keep their toddlers in rear-facing car seats until the age of 2, or until they reach the maximum height and weight for their seat.

Furthermore, the updated AAP policy advises that most children will need to ride in a belt positioning booster seat until they have reached 57 inches (4’ 9”) tall and are between 8 and 12 years old.The concerns are that an adult restraint system may injure the child i.e., the shoulder belt may damage the child’s windpipe (trachea) and lap belt may ride up across the abdomen and rupture the spleen, or liver.The lap belt needs to ride low across the hips to be effective.These policies and related articles can be found at www.HealthyChildren.orgincluding a list of products for 2011.

Florida is 1 of only 3 states without a booster seat law- 47 states have a booster seat law for older children.As a parent I’m certain you will achieve peace of mind while driving knowing your children are safe and secure.However, there are good economic reasons why Florida needs a booster seat law.Estimates are savings of $100 for $1 spent on booster seats:

Bruce H. Berget, MD, F.A.A.P.

Taking Care of Picky Eaters

Picky eating is a norm in up to 20 percent of toddlers and preschoolers. Your toddler may only eat chicken nuggets for days. Don’t be frustrated with this behavior. Most children eat a variety of food and nutrition over the course of a week. Most picky eaters will grow out of this passing stage. They will try to eat new foods in the early school years because of peer pressure. In the meantime, continue making healthy food choices available. Offer them finger foods and table foods that are easy to chew which they can feed themselves. Also, accept the fact that your child’s appetite and food preferences may change everyday. Sit down with your toddler while he feeds himself.

For more tips on picky eaters, go the Children’s Nutrition: 10 tips for picky eaters (http://www.mayoclinic.com/health/childrens-health/HQ01107)

Reviewed by Nuel Celebrado, MD, FAAP

Solid Foods Introduction

A common question we receive as pediatricians is how and when to start solid foods in infancy. The best time to start this process is between 4 and 6 months of age, when your baby can sit with some support and move his head to participate in the feeding process. This is also about the time that the “tongue-push” reflex is extinguishing, allowing babies to be more successful eating from a spoon. Research has shown that in most cases, introducing solids foods early will not help your baby sleep through the night. Also, studies show that starting solid foods prior to 4 months of age can increase your infant’s risk of food allergies and obesity.

Cereals are usually our “first foods”. Starting with rice cereal is a good idea, as it is less likely to cause allergies as other cereals. Oatmeal and barley cereals may be tried 2-3 weeks later. Strained or pureed vegetables and fruits are the next foods added to your baby’s diet. The order in which you add veges and fruits is not important. However, baby’s love “sweet” foods, so we usually recommend starting with vegetables first (i.e. they don’t always want their carrots and peas if they’ve already had peaches and pears!). Remember no more than 1 new food every few days and no more than 3 new foods per week.

Babies need more iron starting around 6-8 months of age, especially exclusively breastfed infants. For this reason, it is important to ensure infants of this age are getting enough iron-containing foods, with meats, vegetables and cereals having the highest levels. If parents do not have food allergies it is OK after about 6 months of age to start pureed or softened fish and eggs, says the American Academy of Allergy and Immunology. Foods like avocado, mango and strawberries are also Ok after this time. A good rule of thumb is to start with the basics (sweet potatoes, carrots, peaches, etc.) but be sure to present your infant with a variety of foods. Honey should be avoided in the first year of life as well as tough to chew foods that could be a choking hazard (peanuts, raisins, grapes, hot dogs, raw carrots, candy, popcorn, etc.).

Solid food feeding volume should be about 2-4 tablespoons (1-2ounces) of each kind of food per meal. If your child is still hungry, feed her more. Finger foods are small, bite size pieces of soft food. They can be started between 9-10 months of age, or whenever your baby develops a pincer grasp. Good finger foods are dry cereals (Cheerios, Rice Krispies, etc.), slices of cheese, pieces of scrambled eggs, slices of canned fruits (peaches, pears or pineapple), slices of soft fresh fruits (especially bananas), crackers, cookies and breads. Once your baby is up to 3 meals per day, he may need a small snack to tide him over between meals. The midmorning or midafternoon snack should be a nutritious, nonmilk food like fruits or cereals (see above list of finger foods!). Structuring baby’s meals around parent’s mealtimes makes sense and sets the stage for family mealtimes later on. Your infant will want to try their parent’s food and feeding table foods can begin between 9 months to a year of age. Just be sure to follow the rules about tough-to-chew foods and choking hazards listed above.

How your child looks at food, mealtime and eating is very much role modeled by their parents. Keep meals nutritious and make this time fun and relaxed. Bon appétit!

Reviewed by Angela D'Alessandro, DO

Pacifier: The Basics

Use of pacifier is a self-soothing behavior that is normal in your early child’s development.For this reason, a pacifier is meant to satisfy your baby’s noneating sucking needs, not to replace or delay meals.So offer a pacifier only after or between feedings, when you are sure he’s not hungry.

Pros and Cons.
Children who use a pacifier are less likely to suck their thumb or fingers.Also, pacifier use has been associated with decreased risk of sudden infant death syndrome (SIDS). Its use, however, has been associated with an increased risk of otitis media and early cessation of breastfeeding. If you’re breastfeeding, wait until your baby is one month old before using a pacifier.

Choosing and cleaning
Pacifiers are available in a variety of shapes and sizes. Look for a one-piece model that has a soft nipple. It should be dishwasher-safe so that you can run it through the dishwasher or boil it before your baby uses it. You should clean the pacifier this way frequently until he’s six months old as his immune system is still maturing. After that, you can just wash it with soap and rinse with clear water. There is no correlation between price, brand, or styles and effectiveness. Once you decide which one your baby prefers, buy some extras. Pacifiers have a way of disappearing or falling on the floor or street when you need them most.

Pacifier Safety
Purchase pacifiers that cannot possibly come apart. The shield between the nipple and the ring should be at least 1.5 inches across. The shield should also be made of firm plastic with ventilation holes. Also, never use the top and nipple from a baby bottle as a pacifier. If the baby sucks hard, the nipple may pop out of the ring and choke him. You must never tie a pacifier to your child’s crib or around the neck or hand. This is very dangerous and could cause serious injury. Replace pacifier if the rubber is discolored or torn. Follow the recommended size of pacifier for your baby’s age as they can choke on a pacifier that’s not the right size for his age.

Pacifier and teeth
Pacifier use has been associated with increased prevalence of malocclusion in the primary and mixed dentition and increased risk of trauma to the upper front teeth. The prevalence of malocclusion increases with increased duration of the sucking habit. To minimize the dental effects of pacifier use, we recommend intervention to address sucking habits by three years of age.

Weaning
Most often children will stop using pacifiers on their own. Harsh words, teasing, or punishment may upset your child and is not an effective way to get rid of pacifier use. Praise and reward your child when he does not use the pacifier. Star charts, daily rewards, and gentle reminders, especially during the day, are also very helpful. Because of peer pressure, most children stop using their pacifiers before they get very far in school.

Jaundice: Why is my baby yellow?

If you have a newborn in the household, you may have heard your doctors and nurses talk about the terms "jaundice" and "bilirubin" levels. What do these terms mean? Or you might have noticed that your newborn's skin has a slight yellowish tone. Why would this be? Well, jaundice is simply a medical term for the yellowish color in the skin that is caused by the molecule called bilirubin. Where does bilirubin come from? We all make bilirubin as our red blood cells (oxygen carrying cells) break down. Bilirubin is a break-down product of the heme molecule - the actual molecule in the red blood cell that binds and releases oxygen. Red blood cells last about three months in our body before they are replaced by new ones created in the bone marrow, so they're always turning over, generating more bilirubin. Under normal circumstances, the bilirubin is processed in the liver, and then dumped into the GI tract where it is excreted as part of the stool. In an older child or adult, total blood bilirubin levels would normally be less than 1.2 (milligrams per deciliter).

This number may be slightly distressing to you since you may be hearing your doctors and nurses discussing numbers that seem much higher in your newborn, numbers like 5, 10, 15 or even higher levels of bilirubin. But before you get too upset, realize that bilirubin levels are normally quite a bit higher in newborns than in older patients. This is because before a baby is born, the mother's liver is doing most of the work of removing the bilirubin. It seems to take a little while for the newborn's liver to "turn on" and start doing the job on its own. Also a newborn has a lot more red blood cells (per volume) than older patients and therefore has more bilirubin to process in the first place.

There are other reasons why bilirubin levels can rise in a newborn, including dehydration, abnormal red blood cells (they may break down more quickly), antibodies from the mother's immune system (that mark red blood cells for destruction), excessive bruising (bruises are simply more blood that must be broken down), abnormalities of the liver and the liver enzymes that process bilirubin, infections, prematurity, factors in breastmilk and related to breastfeeding, and many other reasons.

If bilirubin is usually a normal product of processes in the body, why do we care about it? Because we know that if the levels get too high, the bilirubin can permanently deposit in the newborn's brain causing damage called "kernicterus." This can result in mental retardation, deafness, balance problems, and cerebral palsy. Obviously we never want this to happen, and that is why we are so vigilant about monitoring bilirubin levels and watching for jaundice in your newborn.The levels of bilirubin that can cause kernicterus depend on a number of variables (such as prematurity and protein levels in the blood), but are generally in the 20's or higher. We can monitor your infant's bilirubin levels with a device that measures levels through the skin or, more accurately, with a blood test involving a few drops of blood from the heel. Generally speaking, we tolerate higher levels of bilirubin as your baby ages. For example, a bilirubin level of 10 would be concerning if it occurred on the first day of life, but not at all if on day four. It is also important to keep in mind that premature infants are more susceptible to the harmful effects of bilirubin, and require intervention at lower levels than a term newborn.

What can we do if the bilirubin levels get higher than we'd like? If the levels start to cause some concern, we may want to temporarily supplement breastfeeding with some formula. This helps with dehydration and also causes more stooling, which eliminates the bilirubin in the GI tract before it can be reabsorbed into the bloodstream. Also, we may want to institute "phototherapy." Phototherapy is when we expose the newborn's skin to visible light, either through special light banks in the hospital, or with some indirect sunlight through a window or on a porch. The light helps to change the bilirubin molecule into a more easily excreted form. If we use phototherapy on your newborn, it is important that as much skin is exposed to the light source as possible, so they should be undressed except for a diaper. Also, the air temperature must be warm enough for a mostly naked baby! Very, very rarely, in some of the worst cases with very high bilirubin levels, an exchange transfusion of blood may be necessary. Unfortunately, when a newborn's bilirubin levels are elevated we may need you to come into the office frequently or even daily for a while to make sure they remain in a safe range. We realize that this is not a great time to be travelling, but we need to do what is safest for your newborn.

What can you do to prevent problems from jaundice and kernicterus? First, make sure you come for the hospital follow-up as instructed in no more than two to three days after hospital discharge. This is when bilirubin levels are often at their highest and we can catch them before they become problematic. Also, if you notice your newborn's skin looking a bit yellow at any time, whether it's the first day of life, one week old, or one month old, he or she should be seen that day with no exceptions.

By Nathan Landefeld, M.D., FAAP