H1N1 Virus
Q: What do we need to know about the H1N1 flu (swine flu)?
First of all, H1N1 is a virus not a bacteria. It is a combination of human, bird and swine flu. Therefore, the term “swine flu” is no longer acceptable. It can not be treated with antibiotics. In most cases, it is a benign (non-life threatening) disease treated with rest, good nutrition and liquids. For those “at risk” due to underlying diseases such as diabetes, asthma or immune compromised individuals, as well as those appearing overly ill, treatment with anti-virals such as Tami-flu® or Relenza® is recommended. We will provide the H1N1 vaccine when it becomes available utilizing national guidelines.
The symptoms of H1N1 are similar to the common cold, which makes it difficult for parents to know when to seek treatment. The symptoms of H1N1 most commonly include: cough, fever, muscle aches, runny nose, loss of appetite and/or activity. You should be aware that vomiting and diarrhea may also be associated with H1N1 but are not an absolute indication of this disease. Because of the increasing prevalence of H1N1 disease, we recommend if your child is experiencing any of these symptoms that they be evaluated and possibly tested for H1N1. Treatment is most effective if begun within the first 48 hours of the illness.
Avoidance of the H1N1 disease is better than treating it and is best accomplished by avoiding obviously ill people and frequent hand washing. This means washing your hands with soap and water. The American Academy of Pediatrics (AAP) recommends the following for appropriate hand washing:
1. Use liquid soap, disposable towels, and warm water that is comfortable. Lather hands for 10 seconds and rinse hands until they are free of soap and dirt. Washing for a full 10 seconds is the hardest part; count, sing a song that lasts 10 seconds, or use a timer to make sure this happens. The warm water doesn't necessarily remove more germs, but it helps you to wash your hands longer. Dry hands with the clean, disposable paper or single use cloth towel.
2. If you don't have running water available, you can use wipes or hand sanitizers, but always follow-up with proper hand washing as soon as you can. Research shows that hand sanitizers, wipes or foams are not as effective against germs as soap and water.
3. Once your hands are clean, remember not to touch something that is not clean. Throw out diapers, put soiled clothing in bags, and toss the garbage before washing your hands. If the water does not shut off automatically, let it run while you dry your hands and then turn the taps off with a towel.
For additional information on the AAP recommendations about hand washing go to http://www.healthychildcare.org/ENewsApr06.html#handwashing.
Breast Feeding
Q: What are the advantages of breastfeeding?
First, we are happy to support our patients' mothers with whatever feeding choice they make. Still, breast milk has been associated with numerous health benefits for both the baby and the mother. To quote the American Academy of Pediatrics policy statement of February 2, 2005: “Research in developed and developing countries of the world, including middle-class populations in developed countries, provides strong evidence that human milk feeding decreases the incidence and/or severity of a wide range of infectious diseases including bacterial meningitis, bacteremia, diarrhea, respiratory tract infection, necrotizing enterocolitis, otitis media, urinary tract infection, and late-onset sepsis in preterm infants. In addition, postneonatal infant mortality rates in the United States are reduced by 21% in breastfed infants.” Also, breast milk is less expensive, breast feeding mothers have lower rates of breast cancer later on in life, and the cuddling and bonding between mother and baby can be beneficial for both.
Q: What can I do if I am having trouble or pain with breastfeeding? Where can I get help & support?
In general, it is virtually always a way to work it out so breastfeeding can be successful and without pain. Many resources are available: Our patients can always call our office for advice.
Q: My baby looks yellow, should I be concerned?
In general, whether jaundice (yellow skin color due to high levels of a substance called bilirubin in a baby's bloodstream) is a problem or not must be decided on a case by case basis. Although the overwhelming majority of cases of jaundice are completely benign, occasionally jaundice signifies or represents an urgent medical problem. We urge our patients to call us immediately if they notice jaundice.
Q: How can I tell if I'm making enough milk?
Expect to see the baby stooling and urinating frequently. Most women can also feel the breast engorged before a feed and empty after. But if you are not sure if your baby is feeding well the best thing is to weigh the baby accurately. If babies feed well they gain weight (after the first few days of life when they lose weight.) You can call for an appointment to have the baby examined and weighed at any time.
Q: The baby is sleeping more and more and eating less and less.
This downhill cycle of poor feeding, increased sleeping and poor milk production can often be avoided or reversed with vigorous, frequent attempts at feeding (such as waking for feeds, feeding every 2-3 hours until feeding is well established, etc.) Often babies like this have to be examined and weighed to determine if they are becoming dehydrated.
Q: When should I introduce cereal and other foods?
In a 2005 policy statement the American Academy of Pediatrics stated it's general recommendation for exclusive breastfeeding (no complementary foods, such as juice, water, or baby or other solid foods) for the first 6 months of life. The Academy does recognize individual differences in feeding needs and behaviors. It is acceptable that some children will begin such foods as early as 4 months or as late as 8 months.
Q: What foods should I begin with?
Most parents begin with rice cereal. For the first feed or two it is customary to "extra dilute" the cereal with breast milk or formula. It is equally acceptable to begin with other cereals, strained fruits or vegetables. Breast milk is still the most important part of nutrition, so we recommend beginning with small feeds only once or at most twice a day until the baby is older.
Q: When should I begin to give fruit juice and water?
It is our opinion that children usually do not need any fruit juice or water when they are babies. Of course, on a hot summer day or if you just want to give something extra a little water given here or there is perfectly okay. Small babies usually do fine with breastmilk and no other liquids at all.
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Infant Formula
Q: Which formula do you recommend for bottle fed babies?
The choice whether to breast feed or bottle feed is yours. Although we encourage breast feeding, we respect a woman's right to choose which method to feed her own child. In cases of choice or circumstance (such as adoption, women not comfortable with or able to breast feed, various life circumstances, etc.) we recommend cow's milk based formula supplemented with iron for the average healthy full-term newborn. Examples of such formulas are Similac® Advantage and Enfamil® Lipil. We do not recommend "Low Iron" formulas.
Q: When should I change from formula to milk?
In general at about one year old. Some parents switch all at one from formula to whole cow's milk and others do this more gradually. Most parents switch all at once, although a gradual transition to cow's milk probably makes it somewhat less likely that problems will occur.
Q: Will cereal in the bottle before bed help my baby sleep through the night? Does feeding before bed help a baby sleep through the night?
No to both questions. First: No, it is usually a bad idea to put cereal in the bottle before bed. This may lad to children waking up at night with gas and stools. It may also lead to a baby learning to become dependant on having a "full belly" to fall asleep. Also, cereal is only "empty calories" for babies under 4 to 6 months old, with little nutritional value except in older babies. Second, feeding before bed usually does not help a child sleep though the night (at least, in most babies over two or three months old.) Feeding to sleep can lead to dentition, so called bottle caries. Maybe sometimes feeding before bed helps a baby under two or three months old sleep through the night, but it often leads to problems as listed above. For older babies it rarely helps them sleep through the night, and often leads to dependence on feeding before bed that can lead to tooth decay, obesity, and sleep problems that begin at nine to twelve months of life. In short, when kids get in the habit of feeding to sleep, it's very hard to break them of that habit. Also, feeding with a bottle in bed can lead to recurrent ear infections.
Q: Which is best: ready-to-feed, concentrate or powder?
50-50-50. The choice should depend upon cost, convenience, and the quality of the local water supply.
Q: When should I introduce cereal and other solid foods?
The American Academy of Pediatrics recommends introducing solid foods (baby cereal, fruits, vegetables, etc.) beginning at 6 months of age. Here is a link to the policy statement from 12/1/97.
Q: What foods should I begin with?
Most parents begin with rice cereal. For the first feed or two it is customary to "extra dilute" the cereal with breast milk or formula. It is equally acceptable to begin with other cereals, strained fruits or vegetables. Many parents overfeed in the beginning. Breast milk is the most important part of nutrition, so we recommend beginning with small feeds only once or at most twice a day until the baby is older.
Q: Can I give occasional baby cereal or fruit in small amounts to a crying 2 or 3 month old?
Not our first choice, although it usually doesn't cause any problems as long as you don't feed much and don't feed at bedtime.. The food must be of soft texture, be carefully given in small amounts occasionally, and you must understand that there is some association between early feeding and likelihood of developing allergies later on in life. Of course, the risk of aspiration of food into the lungs is greater with higher texture food introduced earlier in life.
Q: What are the most "hypo-allergenic" formulas?
Pregestimil® and Neocate®, but this is unnecessary and far too expensive and for most babies. In general, Alimentum® and Nutramigen® are very hypoallergenic compared to other soy and cow's milk based formulas. They are also expensive and most parents dislike the smell of both formulas, but they are hypoallergenic.
Q: When should I begin to give fruit juice and water?
Children usually do not need any fruit juice or water when they are babies. Most babies usually do fine with breastmilk or formula and no other liquids at all.
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Dr. Bob's FAQs (Or, what should I do when?)
Q: When should I give Tylenol® (acetaminophen) to my child for a fever?
Generally for a temperature of 102 F or more, I would recommend treatment simply to make
your child feel better. A fever is a good thing, not bad, it’s an indication that the immune system is working and
it helps to control bacteria and viruses.
The general dosage for acetaminophen is 15 mg/kg every 4 to 6 hours as needed. I do not recommend switching back and forth
between acetaminophen and ibuprofen.
Q: Is it better to use Advil® (ibuprofen) or Tylenol® (acetaminophen) when my child is not feeling well?
Either one is acceptable for a fever or pain, theoretically, ibuprofen would be a better choice is there is inflammation, such as swelling, present. I do not recommend routine interspersing of ibuprofen and acetaminophen. There have been no studies showing that this regimen works better than either one alone. In fact, there are studies showing that alternating these medications can actually cause damage to the kidneys.
Q: What should I do if my toddler refuses to eat?
Generally,the best approach is to show your child that he has control over whether he will eat, but not over when and what he will eat. So you put a little bit of each food you have prepared in front of him and when the rest of the family is done, you remove the food and he will get nothing more to eat until the next meal except water. This will show your child that he has control over whether he will eat, but you control when and what. He will not starve, but he will be hungry the next meal.
You should not make special meals for him or feed him in between meals, except for a scheduled snack. The alternative is that you will raise a child who is a “grazer” and more prone to obesity.
Q: My child would like to get her tongue pierced. I am opposed to this, but she feels that I am being too “old fashioned”.
Medically, what are your thoughts?
Aside from the aesthetics of seeing a foreign body attached to the tongue and the difficulties with speech, the main problem is dealing with infection. The tongue is a muscle; therefore, it has a very good blood supply. While it heals rapidly, it can become seriously and chronically infected due to the foreign body effect. Any infection of the tongue could go directly to the heart and lungs, causing a severe systemic infection. Although the risk of severe infection is probably small, if your child is going to have such a piercing, then excellent mouth care is essential – good brushing and cleansing of the tongue should be completed after each meal and at bedtime. In addition, most dentists believe that a foreign body in the tongue could be detrimental to the enamel on the teeth due to damage of the teeth from the tongue jewelry.
Q: Why does my baby strain so much when having a bowel movement? Is he constipated? How to I help alleviate this problem?
As long as the stools are soft, this is not constipation. Infants do not have control over their sphincter muscles that allow defecation. The inner muscle opens when there is stool in the rectal vault. The outer muscle may spasm and the baby will push and push and seem to be in pain from straining. You can alleviate the problem, but pressing gently on the anus which relieves the spasm and allows the baby to pass the stool.
If the stools are hard, then adding extra water to the diet will usually be helpful. Using white grape juice or pear juice mixed ½ and ½ with water, giving 2 to 4 ounces a day will usually clear the problem.
Q: What causes ear infections?
Middle ear infections (otitis media) usually occur 3 to 5 days into a cold. This swelling from the viral illness blocks the Eustachian tube running from the middle ear to the throat and allows pressure to build and bacteria to enter, which causes an infection.
Using salt water drops in the nose 4 to 6 times a day when cold symptoms begin will decrease the risk of an ear infection by almost 50%. The salt water rinses out the bacteria and the mucous thereby decreasing the risk of infection.
“Swimmer’s Ear” (otitis externa) occurs when water gets trapped in the ear canal, usually by wax, and allows infection to occur.
You can often differentiate between a middle or outer ear infection by pressing on the tragus at the opening of the ear or pulling on the ear (pinna) itself. If pain is illicit by pulling on the pinna or pressing on the tragus, then it is probably an external ear infection, or “Swimmer’s Ear”.
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