A:  Yikes! It is hard enough to juggle a two year old with a newborn, but to have your older daughter get sick is really challenging.  I have a couple of quick tips for you.

First, yes, you may absolutely use the same rectal thermometer for both children. Cleaning it between uses is wise.  Second, depending on the maturity of your two year old, you should be able to take her temperature under her arm.  The secret to this is holding the thermometer in her armpit until the “beep” and then adding  one degree to whatever you get  to equal a rectal reading.  This is some what inaccurate, but it gives you a good ballpark and is easy to do.  You can sit with your daughter while reading a story and quietly be taking her temperature at the same time. This trick certainly is better than pinning her down for a rectal temp! No two year old likes that at all!

To minimize the risk of spreading infection from one child to another , trying to keep the children apart –as you are already doing– is smart. Another point to remember is that, as you go from one child to the other, you take germs back and forth.  To cut down on this, try wearing a bathrobe (or man’s shirt) while you are with the baby. Leave it in the baby’s room. This way, you can cuddle your older child but protect the baby from her germs. Finally, there is no substitute for washing your face and hands when you go from one child to the next.

All of this requires attention and a lot of extra work when you are already tired with a newborn. But these simple tricks should help keep your family healthy.  Best of luck!  Before long, your girls will be well –and enjoying each other!

Dr. Hippo

Reference:

http://www.aap.org/publiced/BR_Fever.htm

First, the AAP has changed its guidelines for the “regular” seasonal flu that we all have come to expect every winter. 

This year, the AAP recommends that ALL children over age six months be vaccinated against the flu. They say:  “Annual trivalent seasonal influenza immunization is recommended for all children aged 6 months to 18 years of age.”  Please check with your pediatrician about when this vaccine will be available in your area and how soon your children can receive it!

And second, the “new flu” or the “2009 H1N1” is already here!  As Anne Schuchat, MD, Director of the CDC’s National Center for Immunization and Respiratory Diseases writes, “The 2009 H1N1 influenza virus never went away this summer — it’s still around, and we need to pay attention… “

The news is full of stories about college campuses already hit hard with the H1N1 flu, but schools with younger children have already been affected, too.  “The most recent increase in 2009 H1N1 influenza activity appears to be centered in the southeastern states, including Georgia, Mississippi, Alabama, and Florida. On September 4, 24 primary and secondary schools in Georgia, Indiana, Missouri, and Tennessee announced that they had sent home a total of 25,000 students with flu-like illness thought to be caused by the H1N1 strain.”  I have no doubt that these numbers will climb steadily over the upcoming winter months!!

What can you do to protect your child? There are three answers here:

1.     Vaccinate your child when the vaccine against H1N1 flu becomes available. Just approved by the FDA, this vaccine may be ready as soon as three weeks from now. It is expected that one shot will be all that is needed, and the first available vaccines will go to health care workers, pregnant women, and children. It is reassuring that Kathleen Sebelius, U.S. Secretary of Health and Human Services, has said:  “We’ll get the vaccine out the door as fast as it rolls out the production line.” Keep an eye out at your pediatrician’s office about when the vaccine is ready!

2.     Remember that all flu is spread via respiratory droplet. Therefore, the basics of hygiene are critically important:

a.     Cover your mouth with your ELBOW when you sneeze or cough and teach your children to do the same.

b.    Use Kleenex to blow your nose and throw the used tissues away.

c.     Wash your hands before eating and when coming in from “the world”, ie the grocery store, the post office, preschool, etc.

d.  Avoid sick playdates if possible and don’t send your child to school if she is sick!

3.     Do NOT ask for or expect to be given antiviral medicine “just in case” you or your child gets sick.  If you have (or your child has) a chronic illness which puts you at special risk, please discuss the appropriate use of antiviral medicine with your doctor. Note that Dr. Schuchat has said:  “Antivirals are a critical part of our tool kit in countering influenza, both H1N1 and other strains. But a key point is that most children, adolescents, and adults do not need antiviral medication if they develop a flu-like illness. Giving these medications when they are not needed could actually make things worse by promoting viral resistance.”

I hope this helps and will update further as more news comes out.  Sneeze safely and stay well!

Dr. Hippo

References:

1. http://www.aap.org/advocacy/releases/may09swineflu.htm

2. http://www.medscape.com/viewarticle/708580?sssdmh=dm1.526904&src=nldne&uac=138131HG

3. Aap@smartbrief. com September 14^th

A:  You are asking an excellent question about swimming safety, and you have a very smart neighbor!

Watching both swimming and non-swimming children near water is of enormous and potentially life-saving importance.  It is unfortunately taken casually in this country which is why we have so many drownings every year.  Perhaps two pearls will help you make understand your neighbor’s perspective.

First, drowning is silent.  Parents are so used to hearing their children cry when they are hurt (and needing adult help) that they often rely on their ears when “watching” their children.  But, with drowning, a child is unable to cry out for help.  Therefore, you need to really watch a child in the water all of the time.  Drowning is silent and drowning is fast.

Second, the more people at a pool or beach having fun together, the greater the risk of harm to small children.  Parents and older siblings watching the little ones can easily get distracted, and the littlest head can slip under water unnoticed. This is obviously tragic. “Neighborhood” pools are a place where lots of families may gather and where young children may be at special risk. It is the rare family that has a “toddler” pool—with no deep end—at their home; but even a “toddler’ pool can of course prove deadly. A small child near a pool needs to be in “touch” arm’s length away from a grown-up at all times.

Your neighbor’s insistence that your children wear life jackets in her pool is her way of making sure that they stay safe.  This is an excellent idea and one recommended by many pediatric practices: all children  inside pool enclosures should be watched continuously (no texting!) and non-swimming children should have life jackets on.  If they get old enough that this embarrasses them, then it is time to learn to swim!

Thanks for an excellent question in the middle of the summer.

Dr. Hippo

Resources: 1. http://www.aap.org/publiced/BR_WaterSafety.htm

                         2. http://www.aap.org/advocacy/releases/summertips.cfm

A:  Yesterday, the World Health Organization (or WHO) declared that the new H1N1 virus is “unstoppable” and suggested that drug companies all over the world begin to prepare vaccines for what is expected to be an especially bad flu season beginning in the fall.

According to Dr. Marie-Paule Kieny, WHO director of the Initiative for Vaccine Research, “all countries will need access to vaccine.” The WHO has recommended that health care workers be the first to be vaccinated so that they may take care of the sick without becoming ill themselves.  A functional health care system is critical to helping those who do get sick.

We learned last winter that the H1N1 flu affects an unusual group of patients.  Unlike “traditional” seasonal flu infections which affect the elderly and those with chronic illnesses most severely, the new H1N1 flu affects younger people–including healthy children– and healthy adults. Obesity also may put patients at special risk if they get the H1N1flu. Dr. Kieny stated: “Obesity has been observed to be one of the risk factors for more severe reaction to H1N1 — something never before seen…It is not clear if obese people may have undiagnosed health problems that make them susceptible, or if obesity in and of itself is a risk.”

The CDC estimates at least a million people are infected in the United States alone. The United States has documented 211 deaths and WHO counted 429 early last week.

Clearly, we will need to watch the news and keep our eyes out as the fall unfolds! It seems very likely that several vaccines will become available to address the expected H1N1outbreak. Check with your pediatrician and doctor to learn what their recommendations are.  Who should be vaccinated, and when? No one knows yet for sure, but I am confident that we will be advised as early in the flu season as possible about what to expect and what to do.  Stay tuned and stay well!

 Dr. Hippo

Reference:  AAP Smartbrief, July 14, 2009 (Cited Reuter’s article written by Maggie Fox)

The H1N1 Flu (or the swine flu) has faded from the daily papers. But it is still very much with us around the world!!

Recently, the AAP wrote that “ the World Health Organization… is close to declaring a phase 6 alert for the swine flu virus that so far has infected almost 19,000 people, including 117 deaths, in 64 countries. The agency is considering how to address concerns about the mass confusion and panic that could result from declaring a global pandemic. Meanwhile, an 11-week-old boy became the fifth person in New York City to die from the new flu strain.”  One of the many puzzling features of this flu is that—instead of the frail and elderly– it affects the young and healthy!

Keep your eye out for further developments during the summer. I suspect that the flu will quiet down now but re-emerge in the fall when typical flu season begins.  It will be important to learn whether a vaccine has been developed in time for the 2009/2010 winter flu season.

In the meantime, keep washing your hands when you come in from shopping or playing at the park (or whatever) and especially before eating.

Dr. Hippo

Reference:  AAP Smartbrief (6/7/09)

A: The swine flu is a new influenza A, H1N1 virus strain never before known to exist. It combines elements of previously seen swine influenza, avian influenza and human influenza and appears to be unusual because it can pass directly from person to person like the human flu we are more used to.

People are worried because cases of this flu virus have been have been documented in 10 states and Mexico during the past week. In addition, swine influenza cases also have been reported in Canada, New Zealand, Spain, France and Israel. There is concern that it could spread rapidly throughout the world. This would be a “pandemic”.

It seems at this point as if the symptoms are nearly identical to those of the common flu. If you or your child develops fever with a sore throat and/or a cough., (especially if you have traveled to one of the areas where swine flu has already presented itself) then call your doctor for advice! Please be reassured that many more people get sick with this flu than require hospitalization; and so far, only one American has died.

Although there exists no vaccine for the swine flu, there are several helpful tips to minimize your risk of getting the illness even if exposed. The most important of these is handwashing! While there is so much concern about the swine flu, and while it seems to be popping up in new places every day, it certainly would be smart to wash your child’s face and hands frequently. This would mean: wash her hands and face whenever she comes in from the outside world (school or the grocery store or the library, etc) and especially before she eats. Wash your own face and hands too! Also—a bit more difficult to implement—try to keep your child’s hands out of her mouth, eyes and nose!  If your child does get sick, please notify her doctor and also practice smart respiratory hygiene: teach her to sneeze or cough into her elbow (or sleeve). And keep her home from school so she doesn’t give her illness to her friends.

What is the treatment? There is no vaccine for this flu, but there are two medicines which will work against it. Fortunately, the viral strains tested so far are susceptible to two antiviral medicines called oseltamivir (Tamiflu) and zanamivir (Relenza). Please note that, as with any other viral infection, antibiotics will not be helpful!

We need to be patient while we all learn what we can about this virus. There are at least two critical questions to keep your eye out for in the news: How virulent is this new H1N1 swine flu, ie how sick will it make the people who get it? And, secondly, how contagious is it, what is the risk of “catching” it from other people?  As the answers to these questions emerge, we will all have a better sense of what it is we are up against.

For excellent, current and frequently updated information, visit the CDC Swine Influenza Web site (www.cdc.gov/swineflu/index.htm).This site will be updated at 3:00 p.m. ET daily.

Thanks so much for writing and keep washing those hands!

Dr. Hippo

A: This is a well timed question because there is breaking news from the AAP as of this April!  They now recommend that all children younger than two years old be restrained in rear-facing carseats.  This recommendation has come about because of alarming new data:

• Toddlers from 12-23 months who ride in a rear facing car seat are five times safer than children their age riding in forward facing seats.
• Children under the age of 2 are 75% less likely to die or suffer serious injury (if involved in a car accident) if they are in rear facing car seats rather than facing forward ones.

This is probably a great opportunity to remind all parents that–as children move from infant, to  rear- facing convertible, and then finally to forward facing booster seats– there is one common denominator: keeping children safe within the car! Many parents let children “loose” after they outgrow their booster seats at about age 4.  Children of all ages–like adults–need to be buckled in!

If you have any doubt about the necessity of keeping a five year in a seatbelt all the time without exception, just remember that some day your child will be ten– and then twelve– and then sixteen behind the wheel of a car.  When he is driving (or driving with adolescent friends) do you hope that he will have his seat belt on?  Then make it a habit from the very beginning.

Please buckle up-and thanks for writing!

Dr. Hippo

Reference:  AAP News, April 2009, p. 12. (www.aapnews.org)

A: Let me start by reassuring you that this sounds perfectly normal. In fact, I agree with your daughter:  she doesn’t need a nightly bath!   Kids don’t need nearly as many baths as their parents think they do.

Of course, everyone likes his or her child to be clean, to smell good, and to have shining hair. This is as true for newborns as it is for adolescents.  But the necessity of bathing—the risks and the rewards of bathing—differ with every age.

I put kids into three “bathing boxes” for the sake of simplicity. First, I consider newborns through toilet-training toddlers.  Then come kids who are really out of diapers, fully toilet trained: these are the kids who run around and get into everything all day long.  They are covered in dirt. And then, finally, I look at  adolescents, children who have gone through puberty and who are well on their way to becoming young adults. They exist in a world of their own.

My general feeling is that children who are in diapers—almost no matter how old they are, newborn to three-ish—need to have some kind of bathing daily. They primarily need to have their bottoms cleaned with mild soap and water in order to prevent unpleasant odors from developing and skin breakdown from occurring in the diaper area.

Many babies just have sponge baths, and there is no earthly reason that this can’t suffice for toddlers, too.   But, as babies turn into toddlers, water play becomes a favorite past-time, and the bath tub has tremendous allure.  This is great and offers parents time to wash their child while she is happily distracted with floating toys and endless pouring.  But these children are young enough to be at risk for drowning if ever left alone in or near a bath. Please do not leave your child for a minute!

Hair washing often becomes a bugaboo for parents with kids in this age range.  This is not a daily requirement by a long shot and is often most easily accomplished simply by pouring a cup of water over the child’s head while she is tips her chin up to look at the stars (or stickers) on the ceiling. Another trick that works beautifully is to wash your child’s hair in the kitchen sink as if she were in a beauty parlor,  lying her on the counter and just leaning her head  into the sink far enough for you to use the kitchen spigot.  Kids like this because they do not have to get all wet, and the risk of getting soap in their eyes is fairly small. They just need a toy to keep their hands busy.

For  kids who are toilet trained and prepubertal (roughly age 3 to 12), the need for daily baths vanishes.  These are kids who get dirty day in and day out, and parents want to keep them clean and fresh and sweet smelling—but there is no medical need to do so.  Yes, kids should certainly wash their hands frequently and especially before they eat. And they need to bathe often enough to maintain clean bottoms free from broken down skin. But there is no overarching need to bathe them daily.

In fact, there are at least two problems associated with over bathing in this age group: bathing paradoxically dries out the skin, leading to or exacerbating eczema; and little girls frequently develop urinary tract infections from too much bubble bath.  Thus, it is better for their skin to bathe less frequently rather than more!

The relative lack of need for bathing in this age group is a godsend for many parents because they—like you—find that their child, who once bathed with great abandon and delight, now shuns the tub and indeed the whole process.  This is okay.  Baths can be infrequent (once a week?) and your child will be fine.  Sponge baths, showers, baths on her terms, are fine.  Our three children went for weeks without full baths! It is a battle you simply do not have to fight.

Finally, puberty arrives and with it all kinds of physical changes that wreak havoc on your household.  Fortunately, most children are fascinated by their changing bodies and are only too happy to shower frequently.  They may request privacy earlier than you think necessary, but you should delight in their emerging independence and honor their requests.   Show your pre-teen daughter respect for her new body, and let her be.  Adolescents tend to shower more than they need to and for longer than they need to:  getting them clean is rarely the issue. Getting them out while there is still hot water in the house is more likely to be your complaint!

You also asked about your daughter’s new fear of the water.  I suspect that this is a developmental issue really quite separate from her baths.  Kids her age can become frightened of all kinds of things (monsters under the bed and in the closet come to mind.) Give her some space—decrease the frequency of her baths—and give her time. She will outgrow it before long. If her fear of water persists or becomes more pronounced with time rather than evaporating, then do discuss it with your pediatrician.

I hope this helps!  Thanks for writing.

Dr. Hippo

A: In a word, the answer is: “No.”

When we were growing up, many of us had mothers who made us drink our orange juice at breakfast.  Maybe this is why Moms  across this country believe that juice is important for their children and unwittingly give them more juice than is healthy.  Or maybe we all do this because of the successful marketing campaigns of juice producers!

The truth is that children do not need any juice. The only nutrient in juice is vitamin C, and this is readily available for children in  fruit itself. Note that fruit is entirely natural, is not processed, and is filled with fiber shown to be increasingly important in the diets of people of all ages.  Reaching for fruit instead of juice is a wonderful-life long habit to teach your child!

But there are millions of “juice drinkers” amongst American children.  I have taken care of a great many of them and have observed that they often drive their parents crazy! “Juice drinkers” quickly prefer juice to milk and soon refuse milk altogether–unless it is sweetened with chocolate or strawberry flavoring.  Parents have asked me time and again how to avoid this problem.  The answer–or at least one of them–is simple: don’t begin.  If a child is offered milk or water from the very beginning of her life, guess what she loves to drink?  Milk and water.  Unlike juice, milk is indeed filled with a great many nutrients of which the most important is calcium. Children do need milk and lots of it! Why are juice producers putting calcium into their juice?  To make juice more like milk. You are better off to stick with milk.

Another complaint that parents have brought into me is that their “juice drinker” never eats anything! Children who drink lots of juice (2 or more bottles/glasses a day) tend to fill up on it, and they have no room for their meals: many children have plenty of calories for the day from just their juice, and so they feel full!  But what about all of those nutritious foods you wanted them to have? A juice drinker tends to get most of her calories from one food only-juice. If you cut back on her juice to the single glass (about 4-6 oz per day) recommended by the AAP, your child will get hungry again! Hooray!!

What about teeth?  Juice is terrible for teeth, offering a quick route to decay if children are given bottles of juice all day-or left to sleep with them at night.  In this regard, milk and juice are similarly bad actors.  A child needs to go down to sleep after a bottle, not with it. Or,  at the very least, make sure to take the bottle away once your child is asleep.  And sippy-cups filled with juice in the car, or in front of the TV,  or “just anytime” , increase the risk of cavities, too!

The juice habit is good to avoid if you can.  But, if your child is already “hooked”, there are some easy pediatric tips for getting her “off” of juice. I will address these soon, so please check back.

Thanks for writing!

Dr. Hippo

Reference: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/5/1210

A: These are great questions! They are addressed in an excellent article in a recent New England Journal of Medicine (March 5, 2009) about illnesses caused by a variety of bacteria and found in a variety of foods. Such staples as spinach and peanut butter have been affected!

“Coming to Grips with Food borne Infection,” by Dr. Dennis G. Maki offers a succinct and clear review of the problem and also describes some steps we can take to minimize it.  He suggests that “we must ask ourselves how food borne disease can……cause 350,000 hospitalizations and 5000 deaths annually.” What are we doing wrong?

Dr. Maki explains that the increase in food borne illness we are experiencing has many causes, and he cites recent clinically significant examples:  Californian spinach was contaminated with the bacteria, E. coli 0157:H7 two years ago; last summer, tomatoes were suspected and then peppers proven to be responsible for a major outbreak of illness caused by a different bacteria called Salmonella Saintpaul; and then, in February 2009, peanut butter from a single producer in Georgia has proven responsible for an outbreak of Salmonella Thyphimurium. This last outbreak is ongoing, has sickened 600 people in 44 states(!), and has already resulted in hundreds of hospitalizations.  Eight people have died.

As our population has grown in America, the ways in which we produce our food has grown and changed correspondingly.  Now, very little of our food is produced on local farms; the great majority is grown and processed on a “vast industrial scale”.  Much is also imported, coming to us from all over the world. Dr. Maki explains: “With centralized production and transcontinental distribution of commercially produced foods, unusually heavy contamination of a basic foodstuff–or a failure to remove contaminants in a single production step– can result in the shipment of contaminated food to millions of consumers.”

What can we do? Dr. Maki suggests several steps, as noted below. The comments which follow in parentheses are my additions.

1. The Federal Government needs to commit more money to monitoring the safety of our food. There are ways to improve the regulation of our food production -but they cost money.

2. Animals should not be given antibiotic enriched feeds. (You as a consumer should try to purchase meat labeled “antibiotic free.”)

3. We should aim to eliminate all unnecessary use of antibiotics in human and veterinary medicine. (You as a parent can and should question the need for antibiotics in the care of your child. They are sometimes necessary!! But use them wisely: as directed, and for the entire length of time prescribed.)

4. Food handling at home and at restaurants can be improved. (Wash thoroughly all that you eat raw–veggies and fruit–and cook thoroughly all that needs to be cooked!)

5. Support the routine incorporation of food irradiation into the food we produce. Dr. Maki writes: “Irradiation kills bacteria…without impairing the nutritional value of food or making it toxic, carcinogenic, or radioactive.” Food irradiation has been approved by such organizations as the World Health Organization, the CDC, the FDA, the USDA, and the American Medical Association. (Keep an eye out for more irradiated foods at the store. They are coming!)

The above tips should help to keep you and your family healthy and hopefully able to avoid food borne infections.  Thanks for sending in your question!

Dr. Hippo

Reference: Maki, D.G. Coming to Grips with Food Borne Infection-Peanut Butter, Peppers, and Nationwide Salmonella Outbreaks. N Engl J Med 2009;360:949-53.