Every checkup includes a physical examination where the doctor ensures the child is growing well and does not have any problems that could interfere with his health. Checkups are also accompanied by vaccinations to prevent the large number of serious diseases that children are at risk for.

Each question or test a doctor does has a purpose. For example, screen vision and hearing is screened yearly for two reasons:

• Children may not notice if they are not seeing or hearing well.
• Research has shown that vision and hearing can change over a span of six to twelve months.

The reason most pediatricians do not do blood tests every year is because the situation is different when it comes to blood work. Doctors routinely check for anemia (low blood count) at nine months and two years of age because the rapid growth of early childhood is a risk factor for developing iron-deficiency. However, if a child is healthy and has a healthy diet, the likelihood of developing anemia in elementary school is very low. This does not mean a doctor will not do blood work throughout this time period, however. But research does not support doing yearly blood counts on most children. Adolescent girls need blood counts more frequently because menstruation puts them at increased risk for iron-deficiency.

Other blood tests you may have heard of include:

• Cholesterol levels
• Liver and kidney tests
• Lead tests
• Vitamin D levels

While each of these tests is important, there is no reason to do them on a yearly basis. Each doctor will decide when to do them based on the child’s age and certain risk factors, which include family history, if the child has an underlying medical problem, and where the child lives.

If breast milk is unavailable, babies should be fed an iron-fortified formula. Babies are transitioned to whole milk at one year of age. In most cases, babies do not need the special formulas that are marketed for the second year of life.

The AAP recommends that children drink whole milk until two years unless there is a reason to switch the baby to low-fat milk sooner. Doctors may make this recommendation for clinical reasons or because there is a family history of obesity, heart disease or a cholesterol problem.

The reason the AAP recommends whole milk until two years has to do with a baby’s growth and development. Infants triple their birth weight by one year of age and quadruple their birth weight by two years. During this period, a baby’s brain and nervous system are making amazing gains in size and complexity. Because the brain and nervous system are largely composed of fat tissue, it is reasoned that the baby should have a higher fat diet during this period of time.

Whole milk contains approximately 4% milk fat. Because children often have difficulty with transitions, it may help to gradually switch your child from whole milk to lower fat milk. Therefore, some doctors recommend that children get reduced fat (2%) milk for a few weeks before switching them to low-fat (1%) or no-fat (skim) milk.

Swaddling is a time-honored method to help babies calm down. It helps fussy babies relax during wakeful periods and makes it easier for most newborns to sleep.

Infants respond to swaddling for two reasons:

1. Newborns have a number in innate reflexes, including the Moro (or startle) Reflex. If a newborn is jostled or surprised by a noise or physical movement, he will typically extend his arms outward and then rapidly flex them in front of his body. A Moro response can be triggered by an infant’s own movements or by actions coming from his surroundings. Either way, the reflex may cause the infant to wake up or start to cry. Swaddling inhibits the Moro Reflex.
2. Before birth, infants are in the confined space of the uterus. While it is important to be able to move their arms and legs after birth, research has shown that newborns calm down if they are held with their arms against their bodies. This can be accomplished by a reassuring hug or by swaddling them in a blanket.

Like all aspects of parenting, it is important to strike a balance with your baby. It is important for your baby to experience different types of physical interactions. This includes hugs, kisses, skin-to-skin contact, gentle rocking, and massage, etc. So while swaddling can be a real “life saver” when a baby is fussy it is best used when the child is sleeping or for brief periods (around 20 to 30 minutes) while awake.

Two aspects of swaddling are important for you to consider:

1. The best way to swaddle babies is by keeping their arms at their sides. The reason for this is because most babies will “break out” of the swaddle if their arms are positioned in front of their chest. There are a number of commercial blankets to make this easier to do.
2. The goal of swaddling a baby is to restrain his arms. The swaddle should not restrict the baby’s legs because it is important for him to be able to flex his knees and hips at all times. The reason this is important is because infants can develop a hip problem (developmental dysplasia of the hip) if their hips are restrained in an extended (straight) position.

Most doctors recommend that parents stop swaddling babies by about four months. At this age, the newborn reflexes that can interfere with a baby’s sleep have disappeared and many babies are starting to roll (and trying to break out of a swaddle). This is also the time when a baby will more actively interact with his surroundings. He will grab objects and explore them with his mouth. He may use a pacifier or suck his thumb for self-soothing purposes.

Although it’s relatively easy for children to leave a urine specimen during an office visit, it is much harder to produce a bowel movement on command. Also, kids may be embarrassed at the thought of having to collect a stool specimen at the doctor’s office.

This situation can be avoided if you bring a stool specimen anytime your child is being seen with significant intestinal symptoms. If in doubt, ask the nurse who scheduled the appointment whether a stool specimen might be needed. If you end up not using the sample, it’s easy to dispose of when you return home.

A few rules (and tips) are in order when it comes to collecting stool samples.

• Do not scoop poop out of the toilet. It needs to go directly from the child’s bottom right into a container that comes with a tight-fitting lid.
• Older kids may be horrified at the thought of collecting stool, even in their own home. If this happens, ask your child to defecate into the container and leave the bathroom. You can then go in and prepare the sample for the office.
• Some kids may complain because there isn’t enough room to hold a container while they poop. In this instance, it may help if the child sits on the toilet backwards. One of my colleagues calls this going “cowboy style.”
• It may be hard for younger children to poop without urinating at the same time. In this situation, you can create a “hammock” out of plastic wrap that hangs below the toilet seat. If you poke a few holes in the plastic, urine can leak through the wrap, but the stool will be “caught.”
• Depending on the tests being ordered, the doctor may want poop that is kept cold, left at room temperature or both. If the sample needs to be cold, you should keep it in the refrigerator. However, regardless of where the sample is kept, putting it in a brown paper bag will keep the rest of the family from walking around holding their noses all day.

Bilirubin is a breakdown product of red blood cells. Red blood cells live for three months after which the body breaks them down. Tens of thousands of red blood cells are destroyed and remade every day. Part of the breakdown process involves the release of bilirubin into the circulation. Before birth, a baby’s mother helps clear bilirubin from his blood. (Bilrubin is removed from the body by the liver.) Once the baby is born, he has to take over this process himself. Like many things, a newborn’s ability to process bilirubin is immature. As a result, bilirubin builds up in the circulation and can be seen in the baby’s skin.

Bilirubin is not dangerous to newborns unless it gets very high. The hospital staff follows standard protocols to make sure bilirubin levels stay in the safe range. In the past, this was done by visually checking the baby’s skin color. Nowadays, the bilirubin is checked every eight hours by placing a bilirubin meter on the baby’s forehead. If the reading is higher than expected for the baby’s age, the nurse will order a blood test to confirm the reading.

Most of the time, nothing needs to be done to treat a baby’s bilirubin. If the level continues to rise, the doctor may do additional blood tests, supplement the baby with formula or treat the bilirubin with something called phototherapy. This involves exposing the baby’s skin to ultraviolet light that increases bilirubin breakdown.

Because parents are commonly discharged when their newborn is 48 and 72 hours old, jaundice may not be noticed during your time in the hospital. When you have your first post-hospital visit, the doctor will carefully assess the baby’s skin to make sure he hasn’t gotten jaundiced since his discharge from the nursery. If necessary, additional blood tests and recommendations will be made at that time.

It is important for you to know that jaundice in the immediate newborn period is different from jaundice at any other time in a child’s life. If you notice that your one to 2-month-old baby is jaundiced, you should promptly call your doctor for an appointment.

No one has researched the best way to wean babies, but the following method is the one I’ve been using for the past twenty years:

Most creams contain a substance called propylene glycol. Although propylene glycol is not dangerous, it can sting if a child has tiny cuts or cracks in his skin. The best way to deal with this is to use ointments instead of creams.

I prefer ointments not only because they don’t sting, but also because they do a better job moisturizing the skin. Parents are often hesitant to use ointments because they are greasy. You can manage the greasy quality of ointments by being careful to only apply a thin layer to the skin. The best way to do this is to rub some ointment onto your palms before applying it to your child’s skin.

Breastfed babies usually have loose, seedy or runny stools. They can be yellow, green or brownish in color. The reason parents worry about green stools in babies is because older children and adults only have green bowel movements when they are sick. There is a simple explanation for this.

The body uses bile acids to digest fats. Bile is pea green in color. In children and adults, waste moves through the large intestine slower than in newborns. This allows the “good” bacteria that live in the intestine to metabolize the bile, which converts it to a brownish color. Because fecal material moves through a newborn’s intestinal tract rapidly, there is less time for intestinal bacteria to convert the bile from green to brown. When children and adults have diarrhea, peristalsis is sped up causing green poops.

If a baby has a big sucking need, it can be difficult for parents to satisfy his non-nutritional sucking needs with the breast or bottle alone. However, lots of babies spit out their pacifiers leading parents to think the baby doesn’t want it. This is not usually the case. Babies do not suck like we do. When a baby nurses or takes a bottle, his jaw moves up and down and his tongue moves back and forth to get milk. We call this the sucking (extrusion) reflex. Babies do the same thing when they suck on a pacifier, only in this case they inadvertently push the pacifier out of their mouths when sucking on it. In time, babies learn how to hold the pacifier in place with their lips, but in the beginning parents need to do this for them. If a baby truly doesn’t want his pacifier, he will turn his head or arch his neck to reject it.

The same symptoms can occur if a girl sits in soapy water for a long period of time. Therefore, it’s a good idea not only to avoid bubble baths, but also to have your kids play during the first part of the bath before you wash them and shampoo their hair.

If your child develops painful urination after a bath, there two things you can do to relieve the symptoms. Both approaches flush the chemicals from the urethral opening and should be done twice a day. If the symptoms don’t resolve promptly, make an appointment to see your doctor.

• Fill the bathtub partway with warm water. Have your daughter lean back with her knees apart. Ask her to gently separate her outside vaginal lips. Fill a clean container with bath water and pour it over her vaginal tissues. If you don’t have a container, you can splash water in the same direction. Repeat two or three times.
• Have your daughter sit on a toilet with her legs open. Ask her to gently separate her outside vaginal lips. Fill a bottle (the type that has a nozzle) with warm water. Hold the bottle a few inches in front of her vaginal tissues and squeeze. This may tickle, but it should not hurt. Repeat two or three times.

If the circumcision heals properly, the extra skin may develop a thin attachment to the back portion of the glans in early childhood. (Your doctor will be able to tell the difference between a post-circumcision scar and this thin attachment.) It is not necessary to do anything if your child’s penis has a thin attachment because it will resolve over time.

• An older child who likes seeing the doctor.
• A schedule that allows you to bring the older child to the toddler’s visit.
• A doctor who is willing to “examine” the older child first.

It’s common for children to bring a “lovey” to doctor’s appointments to make the visits less stressful. Over the years, I have examined hundreds of stuffed animals from dogs to sharks to giraffes. The purpose of this fake exam is twofold. First, it shows the child you like to play. Second, it empowers the child so the visit is less threatening.

During my 30 years in pediatric practice, I have noticed that an older brother or sister can do an even better job reassuring toddlers that a medical checkup isn’t the worst thing in the world. A cooperative sibling can help in situations where a stuffed animal cannot. Here’s why.

• Toddlers know stuffed animals aren’t real. However, if an older sibling says the ear exam doesn’t hurt, it may carry more weight.
• Younger siblings generally look up to their brothers and sisters and want to be like them. This encourages the toddler to overcome his fear of the examination.
• The presence of the older child may act as a distraction making it easier for the toddler to stay still during the examination.

Although older siblings can help with the medical exam, they are less effective when it comes to blood tests or shots. Consequently, unless you have remarkable kids, I wouldn’t ask the older one to tackle that task.

There are two situations when parents will have difficulty managing their child’s fever with oral medication. First, if the child is unable to keep the medication down because he is vomiting. Second, if he is being uncooperative and won’t take the medication in the first place.

In general, I don’t use my blog to endorse products. However, parents should know about an over-the-counter medication called FeverAll that will come in handy if their child can’t take acetaminophen by mouth. FeverAll is acetaminophen in suppository form. It’s safe to use and works as well as oral acetaminophen. It is worth having FeverAll in your medicine cabinet in case your child gets sick at night or when it would be difficult to buy the medication on an urgent basis.

FeverAll comes in three doses: 80mg, 120mg and 325 mg. You use the same dose as you would with oral acetaminophen. Directions for inserting suppositories into the rectum are included with the packaging.

• Have your child chew a small piece of bread.
• Once the bread is gooey, ask him to push the pill into the center of the bread.
• Next, ask him to move the bread/pill mixture to the back of his mouth and swallow it with a sip of water.
• Have your child practice with small pieces of candy like tic-tacs. Once this has been mastered, she can graduate to M&Ms and capsule-shaped candy like Mike and Ike.
• Once your child has done this a few times, swallowing a pill is usually easy.

I use a variation of this technique for children who take time-release capsules, but can’t learn to swallow the pill. Time-release capsules can be opened and their contents can be mixed into pudding or applesauce. To ensure that children don’t chew the beads, I have them practice with candy sprinkles. Once they have done this a few times, they can accomplish the same thing without crushing the granules of their medication.

Once the child is evaluated, four things may ensue.

1. He may be examined and sent home—with or without lab tests.
2. He may be admitted to the hospital for observation.
3. He may get an abdominal ultrasound and/or CT scan to more definitively make or “rule-out” the diagnosis.
4. He may be taken directly to the operating room.

Except for the first two scenarios, the child’s management will be delayed if he eats or drinks anything before being seen.

• CT scans looking for appendicitis can’t be done unless a child hasn’t had anything to eat or drink for four hours before the procedure.
• Surgeons don’t like to operate unless a person’s stomach is empty.

If the doctor sends your child to the emergency room for a possible appendicitis, do not let him eat or drink anything until he has been “cleared” by the hospital staff.

There is a finding that may occur in uncircumcised children, which can worry parents. Smegma sometimes accumulates under the foreskin before it fully retracts. These accumulations are called “smegma pearls” because they have a round or oval appearance. Most of the time, they are whitish, but on occasion they have a yellowish hue. If this happens, parents may conclude that their child has an infection. There is an easy way to determine if the child has foreskin infection vs. a smegma pearl. The tissue surrounding an infection is red, swollen and tender. If your baby has a white or yellow accumulation under the foreskin that doesn’t look angry and isn’t tender to touch, it’s not likely to be infected. Of course, if you have any questions about this, call your doctor.

I have had two experiences that illustrate an important twist to this scenario. In each case, I put a child on amoxicillin despite the parent’s history of amoxicillin allergy. Both parents inadvertently licked their fingers after giving the medicine to their children. One parent developed an itchy rash that responded to Benadryl. The other parent developed hives that required a trip to the emergency room.

The lesson here is obvious—while it is routine practice to administer medications to children regardless of their parent’s allergy history, be sure that you do not inadvertently ingest the drug yourself.

• frequent colds
• nose picking (and other injuries to the nose)
• dry air (especially in the wintertime)
• allergies

The reason these situations lead to nosebleeds is because they all irritate the lining of the nasal septum (this is the name of the cartilage that separates your nostrils).

The best way to prevent nosebleeds is to deal with the underlying condition. In addition, it helps to moisturize the lining of the nasal septum by rubbing a thin coating of petroleum jelly along the septum. (Some of my ear, nose, and throat colleagues prefer saline gel products that can be purchased without a prescription.) Most kids prefer to do this themselves because they do not want anyone “messing with” their nose. If your child falls into this category, show her how to do this by demonstrating the technique on yourself: the product can be applied with a cotton swab or with an index finger after your child washes his hands. Apply the lubricant once or twice a day as needed to keep the problem under control. If your child continues to get nosebleeds, discuss the situation with your doctor.