Patients are sometimes confused when doctors differentiate the terms pain and tenderness. The reason we use these words differently is because they mean different things when it comes to making a diagnosis. If something is painful, that means it hurts. If something is tender, that means it hurts when it is touched or moved. A good example of how we use these terms relates to abdominal pain. I could have a horrible stomachache, but if it doesn’t hurt more when someone pushes on my abdomen, I am not tender. Appendicitis always causes a tender abdomen. Similarly, migraine headaches cause severe pain in addition to nausea and photophobia (it hurts to look at lights), but patients with migraine usually don’t have scalp tenderness. If someone has a bad headache associated with scalp tenderness, it’s often due to muscle tension that’s brought on by psychological or physical stress such as carrying a heavy backpack or keyboarding for long periods of time.
Although the human body isn’t perfect, there are lots of awesome ways that it functions. One of these is called the gastrocolic reflex. In this context, “gastro” refers to the stomach and “colic” refers to the colon or large intestine.
When we eat, the stomach stretches and begins digesting our meal. The stomach does this by releasing chemicals and contracting to break down the food we have eaten. At the same time, the “machinery” of the intestinal tract is turned on. The rhythmic contraction of the muscles in the stomach and intestine is called peristalsis. If a child is constipated, the onset of peristalsis within the large intestine (especially the rectum) can cause pain as the intestinal muscles contract against large or hard fecal material. If the pain was because of stool in the rectum, having a bowel movement will usually relieve the pain. If the pain was because of stool higher up in the large intestine, stooling won’t necessarily relieve the pain. Sometimes the pain is so severe that parents may worry their child has an appendicitis.
Constipation isn’t the only condition that can trigger pain after someone eats. Lactose intolerance, overeating and celiac disease can cause similar symptoms. However, 90% of the time pain after eating is due to constipation.
Many childrearing books tell you not to use soap on a baby’s face. One of the reasons for this is because soap may irritate a newborn’s sensitive facial skin. Another is that a newborn’s skin is slightly acidic, which helps prevent infection. Soap can reduce the natural acidity of a newborn’s skin.
The problem with not using soap on a baby’s face is that some of them will be more prone to newborn acne and other rashes because of dead skin, saliva and regurgitated milk that accumulates on their face. The answer to this problem is to wash the baby’s face with a ph-neutral soap substitute like Cetaphil Gentle Skin Cleanser. Using Cetaphil with a washcloth helps remove dead skin, etc. without harming the baby’s skin.
Body temperature varies throughout the day whether you’re sick or healthy. If you take your daughter’s temperature three times a day for a number of days, you will see that the highest readings come in the evening. Similarly, if she is sick, you are more likely to find high temperature at 9pm rather than 9am. This diurnal variation in body temperature causes two problems for parents. First, it’s harder to manage high fevers at night when everyone is trying to get some sleep. Second, if your feverish child wakes up cool, you may think all is well until the fever returns in the afternoon or evening. Although it’s not always clear when a child isn’t contagious, most schools have adopted a 24-hour fever free policy because they know temperatures can come back as the day progresses. That’s why you shouldn’t take your kids to school the morning after a feverish night.
It’s common for people to use baby powder after showering to keep dry, especially during the warmer months. Similarly, parents often use baby powder on their baby’s bottoms after diaper changes. I disagree with the latter use for two reasons. First, I’m not convinced it does any good. Although baby powder may absorb perspiration on an adult, it’s hard for powder to contend with the volume of urine a baby produces in between diaper changes. More importantly, baby powder can be dangerous. A number of reports have been published in medical journals where an older infant had grabbed a container of baby powder while he was lying on his back during a diaper change. Because baby powder containers look like bottles, these infants held the bottles up to their mouths and inadvertently aspirated the powder into their tracheas.
Parents frequently hear that they should never compare children to each other. As a pediatrician, I can unequivocally state that this is one of the dumbest things I’ve ever heard. Not only do we compare our children to each other, but we also compare them to other people’s children. Why? Because it’s instinctive for humans to compare things. We compare which apples to pick at the grocery store. We compare which shampoo to buy. We compare which clothes to wear to work.
So where does this “wisdom” come from? I think it’s derived from the difference between comparing and judging. Things can be different without one being superior to the other. When it comes to children, there is never one thing you are comparing. People are more complicated than apples or shampoo so most parents find they appreciate each child for different things. The flip side of this is also true. Namely, each child can make us crazy in different ways.
When this topic comes up in my office, I start by telling parents what I just said. I then expand on the topic by reminding them that what you never want to do is to compare your kids unconsciously and not be aware of it. It’s also a bit perilous to censure one child by invoking the more desired attributes of his sibling.
I have two teenagers who are very different. I horse around with and go to movies with my son, but have intellectual conversations with my daughter. I am proud of both of them, but in different ways. Sometimes I wish my daughter and I could do things like I do with my son and visa versa. That is comparing them, but neither one is a better child than the other. The flip side is that they each annoy me in different ways as well.
Comparing your kids to your friend’s kids is a bit trickier because you don’t have all the facts regarding someone else’s children. You may still find that you like certain aspects of your friend’s children more than your own. Just remember that most kids behave better with people other than their parents.
It’s also very important to remember that children have big ears. They love to eavesdrop on their parents because it’s exciting to hear what grownups have to say when they are alone. If my son heard me saying something comparing him to his sister, I am setting myself up for trouble. I can think it, and I can discuss it with my wife. But this should only be done when all children are accounted for.
While every parent hopes his or her teenager will be able to “just say no” when asked to use drugs or alcohol, it’s clear that many adolescents will have difficulty resisting peer pressure. One way to handle this situation is to give teenagers an excuse so it won’t look like they’re not “being cool” when asked to use an illegal substance. Here are some comebacks that may help kids get out of tricky situations:
- “I can’t drink/smoke because I’m taking a medication for my allergies (or some other condition) that interacts badly with alcohol/marijuana.” If someone asks the teen what he’s taking, he can say he doesn’t know because his mom just gives it to him in the morning.
- “I’ve had a stomach ache all day, and the last thing I need is to drink tonight.”
- “I’ve got asthma so I can’t smoke weed.”
- “My parents are planning to buy me a car for graduation, but if they ever catch me doing drugs or alcohol, they told me I can kiss the car goodbye.”
- “My brother/sister/cousin got into a lot of trouble doing alcohol/drugs so I’m not into this stuff.”
- “I’ve got plans tomorrow morning so I need to be clear headed.”
- “I’m the designated driver tonight.”
- “My brother/sister/pet is sick, so I know my parents will be awake when I get home tonight.”
- “I’ve got relatives in town so I need to be straight when I get home tonight.”
- “My dad goes to sleep late every night, so I can never get away with this stuff.”
Have your own tips? Let me know by posting a comment or sending me a note on the contact me page.
Because I’m a pediatrician, most of the spider bites I see happen to children. I have also noted that the ear is the most common place where these bites occur. (The above picture is one of my patients.) I’m not sure why this happens, but I’ve often wondered if it’s because the ear has a large, convoluted surface area that attracts the spider or gives it a place to hide. It’s also possible that the warmth of the ear attracts spiders.
Spider bites usually occur when kids are outside playing or at night while they’re asleep. However, don’t worry that Aragog is stalking your children at night. (Aragog is the name of Hagrid’s spider friend from the Harry Potter books.) The spiders that bite people are tiny ones that are easy to miss even in the daytime.
The typical spider bite presents as a red, swollen area that is warm or hot to the touch, but doesn’t hurt much. In fact, most of the time, they itch more than they hurt.
The bites from black widow spiders and brown recluse spider scan be very dangerous, but in 30 years, I have never had a patient in this region of the country bitten by one of these species.
Parents often give children Benadryl for spider bites assuming the child is having an allergic reaction to the bite. Benadryl doesn’t usually work because the swelling that accompanies spider bites is a local inflammatory reaction to venom rather than an allergy. However, Benadryl may help if the bite itches. The main first aid treatment is to put something cold on the area to reduce the swelling. My favorite remedy is a bag of frozen peas because it conforms to the swollen area.
Kids who get spider bites are often treated with antibiotics because of a concern that the area is infected. Although this is possible, “garden variety” spider bites rarely get infected, possibly because the venom kills any bacteria in the area.
If a spider bite is very swollen, oral steroids may help because they are anti-inflammatory medication.
This is a simple tip, but one that makes a big difference when you have to take a medication for 10 days. The basic difference between capsules and pills is that capsules float and pills sink. If you put a capsule in your mouth, take a sip of water and throw your head back to swallow the capsule, it will be hard because the capsule will float on the water and move away from the back of your throat. The best way to take capsules, therefore, is to take a mouthful of water, put the capsule in your mouth and then lean your head forward as you swallow. When you do this, the pill will still float on the water, but now it will be at the back of your mouth and go down more easily.
Because tablets sink, the best way to swallow them is with the opposite maneuver. Take a mouthful of water, put the pill in your mouth and lean your head back when you swallow.
If you have trouble swallowing pills and capsules, I discussed a trick for doing this in an earlier blog.
The most common blood test doctors order is a CBC, which stands for complete blood count. The test provides information about a person’s red blood cells, white blood cells and platelets. We get CBCs for different reasons, but the two most common are to check for anemia (red blood cells) and infection (white blood cells).
Lots of patients ask me what their blood type is. When I tell them this information isn’t important on a day-to-day basis, they often say, “Wouldn’t it helpful if I needed a blood transfusion?” The answer is no.
The basic blood groups that everyone knows about are A, B, AB and O. In addition, blood can be “positive” or “negative.” These designations refer to markers in blood that allow your body to recognize itself. Except for people with AB positive blood, everyone has naturally occurring antibodies to blood types other than their own. Getting transfused with mismatched blood can result in serious or even fatal reactions.
What people don’t know is that we have also minor blood groups in our system. Without getting into details, this basically means that not all A positive blood is the same. Although minor blood group incompatibilities don’t usually cause serious reactions, they can lead to mild transfusion reactions, which should be avoided.
If a person needs a transfusion on an emergency basis, he will always get O negative blood even if he shows up with a blood donation card that says he is A positive. That’s why doctors on TV shows always shout the following order to the closest nurse: “Type and cross the patient and get me six units of O negative blood, STAT!” (If you haven’t seen this before, STAT, means immediately.)
“Typing the patient” means finding out what type blood he has. “Crossing the patient” means cross-matching his blood with similar blood types available in the blood bank. That way, the patient will get the most similar A positive blood on hand, including the minor groups.
Many years ago, I took my 3-year-old son to the Montgomery County Fair. We were having a grand time until I lost sight of Ryan for a second. When I turned around to find him, he was lost in a sea of parents, babies and screaming children. As my heart raced, I vainly tried to find Ryan’s face the crowd. What I noticed instead is that when you’re panicking, all toddlers look alike. Luckily for me, he hadn’t wandered off, but just went to throw a pizza crust in a nearby trashcan.
When I bent down to pick Ryan up, I noticed that he was wearing blue shorts and a bright orange T-shirt. In my three seconds of panic, it would have been easier to look for an orange shirt and blue shorts than my son’s face. From that point on, whenever I was out with one of my kids, I always kept a mental image of what they were wearing in case we got separated.
Most medicine cabinets contain a variety of prescription and nonprescription medication. Some drugs, like allergy medicine, are used intermittently or for long periods of time. Other drugs, like antibiotics, are generally used short-term for an infection. If a doctor prescribes medicine for intermittent use, you’re supposed to keep the pills or liquid on hand for whenever you need it. If a doctor prescribes a drug for acute use, such as a strep throat, you’re supposed to throw away any remaining medicine so you’re not tempted to use it in the future without the doctor’s advice.
All drugs have expiration dates. With nonprescription drugs, the expiration date is printed somewhere on the bottle or tube. With prescription drugs, the expiration date is printed on the instruction label that tells you how to take the medicine.
If the medicine has a short lifespan, the pharmacist will put the appropriate expiration date on the bottle. This is common with antibiotic suspensions that are used with children for ear or sinus infections. However, even if the medicine has a long shelf life, like most pills, the pharmacist is required by law to indicate that the prescription expires one year after it was filled. The reason for this is to reduce the risk that a patient will use the drug inappropriately.
In some cases, it’s okay to use the true expiration date instead of the one listed by the pharmacist. The best example of this situation involves medicine that comes in a tube. In addition to the one-year expiration date provided by the pharmacist, all tubes have the “real” expiration date stamped on the crimp, which is the folded metal part at the bottom of the tube. That being said, it’s always a good idea to check with your doctor before using a prescription medicine.
It’s common knowledge that people are usually diagnosed with mononucleosis (mono) during adolescence. This is the reason it’s often referred to as the “kissing disease.” What lots of people don’t know, however, is that about 20 percent of children get mono before age ten.
The explanation for this fact lies in the way the human body responds to infections. When a person comes down with an illness, his immune system produces antibodies to help kill the invading microorganism. The first antibodies the body produces are in the IgM class. These antibodies are present for about three months after which they disappear from the circulation.
A month or so after the body starts producing IgM antibodies, it makes IgG antibodies to the same viral or bacterial agent. However, IgG antibodies are produced continuously and will remain in a person’s bloodstream for life. The reason you don’t get the same infection more than once is because IgG antibodies are always around, and they prevent the infection if you are exposed to the virus or bacteria in the future. This is what it means to be “immune” to something.
Antibody production also explains how immunizations work. When you get a vaccine, your body is injected with a tiny amount of a killed or weakened biologic agent. Your body then makes antibodies to that microorganism so if you get exposed to the germ at a later time, you won’t get sick or you will have a milder form of the illness. In most cases, the body’s immune system is superior to vaccinations in terms of conferring future immunity. That’s why vaccines are not 100 percent effective. A notable exception is whopping cough, which is better prevented by vaccines than natural infection.
Okay, back to mononucleosis. When I draw blood to check for mono, I always test for IgM and IgG antibodies to the virus. If the patient’s IgM antibodies are positive, that means he currently has mono. However, if the IgM antibodies are negative, but the IgG antibodies are positive, that means he had mono at some point in the past, but does not have it now, i.e., the current infection is due to another virus. If the patient has a negative test for IgM and IgG antibodies that means he doesn’t have mono now and did not have it in the past either.
Parents almost never recall a preteen child having had mononucleosis because this age group does not get the classic mono symptoms: fever, swollen lymph nodes, horrible sore throat and fatigue. Instead, they usually have a fever that lasts for four or five days.
It’s important to make sure your baby has had all of his standard immunizations before travelling. However, some foreign destinations require special vaccines, many of which cannot be given to infants. Similarly, some countries require preventive medication during travel, e.g., malaria prevention, or insect repellent to reduce the risk of mosquito-borne illness. Most preventive anti-malaria medications are not approved for infants. Further, the American Academy of Pediatrics (AAP) does not recommend using DEET-containing insect repellents in the first two months.
Although most babies are healthy, you need to consider the medical facilities that would be available if your baby became ill while you were away. Pediatricians are particularly concerned if a baby develops a fever in the first two to three months of life. Dealing with a sick infant is difficult enough when you’re at home. Having to contend with an illness while you are away is even harder.
Babies are creatures of habit and travelling can easily disturb their feeding and sleep schedules. This is particularly true if you have to take multiple planes to reach your destination or if you are moving from one time zone to another.
Altercations between young children are common. If parents are around to witness the squabble, they usually ask the aggressor to say he’s sorry. This is a reasonable thing to do because adults are supposed to teach children how to behave in social circumstances. However, most parents have been in the situation where one child does not want to say he’s sorry to the other. What should you do then, especially if your child was the one who wouldn’t say he was sorry?
Not only are you likely to be embarrassed if this happens, but you may also feel a strong sense to force your child to apologize. Encouraging kids to say they’re sorry is logical. Forcing them is not. In some cases, a parent will threaten to take away TV, dessert or other privileges if the child refuses to say he’s sorry.
Although I appreciate the motivation to encourage your child to apologize, if it’s not sincere, it’s not clear that anything will be gained by forcing the issue. My recommendation, in this situation, is to model the appropriate behavior for your child instead of turning it into a showdown. Make eye contact with the victim and say something like this: “I’m so sorry, Henry. We don’t allow hitting in our house, and I don’t know why Ryan did that to you.” You might also consider ignoring your child for a moment and hugging the child who was hurt.
Children learn by experiencing the consequences of their actions. In the above example, you ignored your son and gave positive attention to the child who was wronged. This is only half of the intervention. For the next five or ten minutes, you would watch your son like a hawk so you could give him positive attention for appropriate behavior. Psychologists call this process, “catching them being good.”
About twice a month, I see a child who has been urinating very frequently during the day. It usually occurs in children under the age of eight, and the pattern is remarkably similar. Rather suddenly, the child starts making frequent trips to the bathroom to pee. She feels an urgent need to go but once she gets to the toilet, only a small amount of urine comes out. It doesn’t hurt when she pees. The child goes back to what she was doing only to feel the same urge five to ten minutes later. The feeling disappears when the child goes to sleep only to resume again the next morning.
The bladder is basically a pouch made of muscle. The lining of the bladder contains a complex system of nerves that’s designed to keep us dry and alert us when we need to go. Most of the time, the bladder signals that it’s time to urinate when it’s about halfway full. This is accomplished by “stretching” nerves that sense increased pressure within the bladder.
The situation I described above is called daytime frequency syndrome. It’s not clear what causes the condition, but in some cases, it may be due to stress. The symptoms usually resolve in a week or two. There is no treatment for the problem other than to reassure children and let them go to the bathroom when they feel the urge. When I see kids in my office with this problem, I give them a quick anatomy lesson and then explain that their bladder is being silly by signaling them to go when it’s not full.
If you think your child has daytime frequency syndrome, you should talk to your doctor to make sure something else isn’t causing the problem. Doctors consider the following conditions anytime a child presents with frequent urination:
- Urinary tract infection: If a child has a UTI, she will usually have a fever, abdominal pain or burning when she urinates.
- Diabetes: If a child has diabetes, she will usually produce a normal to large amount of urine each time she goes. In addition, they commonly wake up at night to pee or start wetting the bed.
- Constipation: Most parents don’t know what’s going on with their children’s bowel movements once they are toilet trained. Constipation can present with large, hard or infrequent stools that may or may not be associated with tummy aches. The only way to be sure your child isn’t having a poop problem is to look at her stools for a few days.
Car seats are designed to keep babies safe in the event of a motor vehicle accident. They are not meant to be a substitute crib. However, everyone knows that babies commonly fall asleep during car rides. This happens because the vibrations and sounds inside a motor vehicle often lull the baby to sleep. The same thing happens when parents rock and shush their babies to help them relax.
Because babies commonly fall asleep in the car, parents may let them finish napping in the car seat once they have arrived home. Although most doctors would not argue with the adage, “Never wake a sleeping baby,” it is important for parents to be aware of the dangers associated with sleeping in car seats.
There are three reasons why most doctors discourage sleeping in car seats.
- It can make stomach reflux worse. If a baby refluxes while he is in a car seat, he is more likely to choke because he cannot extend his neck to clear the refluxed material.
- A baby can fall out of a car seat if he is not strapped in correctly. Also, an older sibling might accidentally push the car seat off a table or other raised surface.
- When a baby is strapped into a car seat, his head can fall forward onto his chest. If this happens, the baby’s airway may become compromised making it harder for him to breathe. A 2005 study showed that oxygen levels dropped in 18% of newborns who were strapped in car seats.
Interestingly, parents worry about different things than doctors. Although no one has researched this question, my own patients worry about the following:
- Sleeping in a car seat for a long period of time may hurt the baby’s back or neck. This is an unnecessary concern. Babies are so flexible they do not get aches and pains after being in a car seat.
- A baby can become conditioned to sleep in a car seat. As a result, he may be unable to sleep in a crib when he gets older. There is an element of truth to this concern, especially when you consider that parents typically let babies sleep in car seats because they don’t like their crib.
If your baby does not like sleeping in his crib, try the following techniques before putting him in a car seat to sleep:
- Keep your baby next to your bed so you can comfort him if he stirs during the night.
- Swaddle your baby.
- Give your baby a pacifier.
- Turn on a ceiling fan or a sound machine to help soothe your baby.
Children are encouraged to get regular checkups. In addition to answering a parent’s questions, these visits are meant to reinforce a healthy lifestyle and to screen for certain conditions based on the child’s age. For babies and toddlers, screening questions focus on nutrition, growth and development, and safety. For school-aged children, this focus is broadened to include exercise, academic readiness, and the management of common childhood problems. Adolescents need more independence and should spend some time alone with the doctor.
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.
The American Academy of Pediatrics (AAP) recommends breastfeeding for the first year. Most mothers are unable to breastfeed their babies for the entire year because of work or family situations. This is perfectly acceptable.
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:
- 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.
- 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:
- 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.
- 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.