Two truths follow. Food is love. People love feeding babies.

Usually at an infant’s four month visit, I’ll get a question parents have been thinking about for some time: “When can we start feeding our child solid foods?”  And, you can be sure that if there is a grandparent present, this will be followed by an echoic, “Yeah, when?”

This is a great question. In some small but important ways, there has been a shift in the thinking of when is best to introduce babies to the so-called “solid foods.” These ‘first feeds’ are pretty mushy actually–there isn’t much that is solid about them– and customarily begin with varieties of cereals, followed by compotes and purees of veggies and proteins.

Historically and until the last couple of years, 4 months of age was considered the go time to begin cereal feeds for full term infants. More recently research suggests infants seem to do better over in their long term appetite regulation and have lower rates of obesity if they begin solids closer to six months.  Lest ye grandparents protest:  the WHO and American Academy of Pediatrics (and a huge body of research) reassure us that  all of a healthy infant’s nutritional needs can be  met by exclusive fluid intake: breastfeeding (ideally) or formula feeding (second best but still ok) for the first six months. Really.

A child who is ready to feed must have achieved certain milestones of strength and coordination and interest  that prepare them to to manipulate thicker, textured stuff in their mouth.   By four months, babies have more strength in their trunk and better head control, allowing them to sit for increasing spells during meals. Some babies, such as premature infants, may have poor head control and may do that bobble -head newborn thing when upright, or they may lack trunk strength. They may need to wait a little longer. A check in with your baby’s primary care provider can help suss out when that time is right.

Around 3-4 months, infants lose a protective newborn reflex to push out substances thicker than breastmilk or formula, presumably as a defense against choking.  Three month olds who are fed baby food, for example, may simply spit back out spoonfuls placed on their tongue. Eager but potentially uninformed parents describe their younger babies as “not liking it.” Not likely. Lastly, babies need to be interested in food.  These babies are hard to miss. Food excites them, and they watch family members with obsessive curiosity as they feed themselves during mealtimes.  Mealtime, people!

And so, how to proceed? As a rule, there aren’t many rules. However, there are a few good ideas to keep in mind.

For starters, keep first feedings short and sweet.  When your nearly/just 6 month old infant appears ready, willing and able to sit up for several minutes, pick  a time of day when he is of a good mood, and customarily hungry (i.e. not naptime). Place the feeding chair in an area without too many distractions (read that as TV, tablet and phone, off). For these first meals, plan on rather short duration–10 or 15 minutes max, and/or until the child’s body language says “all done.” To cultivate long term good feeding behaviors, meals are best kept stress and boredom free. Babies tend to shut down when rushed or forced. And, seriously, you don’t have to stay til the food is all gone. Save that for when they are 12.

Bottomline: the first few meals are more of a dress rehearsal of eating–getting down the steps of the dance, as it were. Food will more be worn than swallowed, at first. That is ok, just don’t wear nice clothes.

More by custom than by necessity, most parents begin with a single ingredient cereal. As I tell folks, pick a grain and go with it: rice, barley, wheat. The order doesn’t matter. Prepare the first feeds as being mostly a small amount of cereal (a teaspoon or two) in one to two ounces of breastmilk or infant formula. It is pretty watery and that is ok, for at this point, it is more about the child mastering the art of eating off a spoon. For tentative babies or nervous parents, it is even fine and dandy to make the first meal or three a session of just spoonfeeding breastmilk or formula. Again, don’t be surprised if most of these calories go down the child’s chin. That is all right.

And, sure enough, if you find yourself speaking in musical and absurdly enthusiastic tones as you scoop up another bit of yumminess, all the better. See? Feeding babies is a hoot, albeit a messy hoot, after all.  After a dozen minutes or when baby pulls away, it is fair and proper to dab the child and top her off by nursing or bottle feeding til she is sated.

Some younger/beginner babies may not yet be ready or willing to try spoonfeeding at first, or they may react with a grimace to certain tastes later (they may in fact, not like it, too).  In such instance, it is fair to back off solid feeding altogether if the child is giving negative signals from the getgo and to try again in a week or two. For the child who has solidly begun, so to speak, but who is reacting with some dislike to a certain item, take it off the menu for a few weeks and reintroduce it later.

Once a child has spent a few days on her first cereal, say rice, it is advisable to add a new/different food to her repertoire every 4-5 days or so, then barley or wheat. In this way, parents can watch for signs of allergy or hypersensitivity to different foods. By adding two new foods at once, or by introducing new foods within 48 hours of each other, makes it hard to tell which was the offending foodstuff in a baby who breaks out in a rash, or who has vomiting or diarrhea.  If you aren’t sure, take an item off the menu for a few weeks and try again. If baby breaks out or has GI upset within minutes to ours, put that on the Do Not Feed list for a couple of months. Sometimes, there is a method to the madness.

After a week or two of cereals, parents customarily begin with purees of the orange-yellow veggies, like carrots, squash and sweet potato.  These are usually well tolerated by babies and go down well. By this time, parents can comfortably add in a second meal.

Feeding your baby can be a true bonding experience, with all that is good and challenging about that. When it goes well, life is good. If there are struggles or difficulty, it can be very stressful. As a pediatrician and as a dad, I appreciate that profoundly.  For any parent concerned their child is struggling or not doing well with feeding, I recommend a prompt consultation with their child’s health care provider.  Best to be reassured, or to identify a problem early.

How much do babies eat? Does the order of first foods matter? Can I give my baby juice or water or sushi(um, no)?  Stay tuned, as my next installment will involve the next steps–and some tasty morsels of wisdom–in advancing the infant’s diet.

Photo above by MandyMarie1201 (http://media.photobucket.com/image/baby%20food/MandyMarie1201/Baby%20Haydn/food.jpg?o=11)

Cartoon below by me

All done, evidently.

The post Performance Art v. Science: Starting Infants On Solids appeared first on The Faster Times.

Something afoot in the head or neck

“His glands are swollen,” said a mom recently in clinic. Warily she measured my reaction and added, “Will you look at them?”

And look I did. Her toddler  giggled as I felt the chains of lymph nodes that run up and down the neck in parallel lines. He’d had a cold for a few days, and in her ministrations, his mom felt something that had gotten her attention. Sure enough, on the right I felt a Rice Krispie-sized series of lumps along the area under his jaw. This “lymphadenopathy” –as it is termed– was enough to convince his mom something terrible was going on.

But was it? Why do lymph nodes swell up? When should you worry about it?

To answer these questions, one has to understand a little bit how lymph nodes work.

Lymph nodes are sentinels of the network of glands and ducts that run in parallel to our blood vessels. Lymph nodes circulate lymph, a clearish fluid laden with proteins and immune cells that tag and package potentially troublesome materials (bacteria, viruses) to the lymph node. There, legions of white blood cells and antibodies neutralize any potential threat to the body.

When there is a persistent or significant amount of inflammation in one area, (say, the scalp due to ringworm), the lymph nodes in that region respond by increasing the number of immune cells to address the problem. Within hours to days, one or more lymph nodes may recruit extra immune support and double, or even triple in size. Hence, Mr Ringworm could have a few pea-sized benign ‘reactive’ nodes behind his ears due to the rash on his head. That in itself isn’t such a bad thing…and in fact, a slightly enlarged node or two could be busy making someone better.

The size of normal lymph nodes varies across the lifespan.  Newborns have itty bitty lymph nodes that are difficult to feel. From infancy through puberty, it is commonplace to find normal but seemingly impressively sized lymph nodes all over the place. Thereafter, nodes shrink to a smaller size from adolescence into adulthood. In younguns, normal nodes of up to 2 cm in size (think chick pea) can be found in the groin area, or ½ cm to 1 cm sized (grain o’ rice) individual nodes along the sides of the neck or armpit (careful, that tickles!). By contrast, nodes of 2 cm or larger might be considered abnormal in adults. When lymph nodes are bigger than 2-2.5 cm anywhere on the body of a child (or if they are ever felt over the collarbone), the suspicion rises that something abnormal might be going on.

Happily, the vast majority of cases of swollen lymph nodes are a consequence of a short-lived, annoying-but-not-dangerous phenomena. Colds, rashes, canker sores…that sort of thing. As a provider, a careful review of a child’s history and physical exam help us figure out goes a long way in figuring it all out.

Location and Duration. Providers will ask where the large nodes are noted (one side, or both? Just the neck or elsewhere?) and how long they’ve been swollen or painful. (days? weeks?)

Sick contacts or exposures. Have kids been around who are sick that make nodes swell up, such as mononucleosis (aka “mono”), strep throat, or flu? Other entities should be asked about:  Any canker or viral cold sores (herpes), insect bites (tick, mosquito) or animal bites (cats, dog)?  For teens, are they sexually active (Gonorrhea, syphilis, for example)?   Any recent travel to places with potentially exotic, node-inflaming illnesses (plague in the US Southwest, or say, TB from developing countries)?

Other symptoms matter. Throat, dental or ear pain, rashes, swollen joints, weight loss, or fever of any duration may be key to clinching the diagnosis behind a swollen lymph node. In light of the history, a healthcare provider will assess a child’s overall appearance. Well-appearing kids with illness of a brief duration are reassuring. Kids with fever, fatigue, dehydration, pain or severe discomfort may merit a more thorough evaluation including labwork, or imaging studies.  When things are looking complicated (which, again, is rare), a relevant specialist may be consulted, such as an infectious disease doctor, surgeon, or hematologist/oncologist.

When a swollen node is found, one must determine its location, size, and consistency. Further, tweaking and palpating the node assesses if there is tenderness, if it affects more than one gland, and if the lump is a lymph node at all. The trifecta of inflammation for a node known medically by the Latin Rubor, Dolor, Calor (Redness, Pain, & Heat). Ironically, the nodes themselves may become infected, reddened and sore. Lymphadenitis, as this is called, may require antibiotics, and in rarer cases, drainage of abscesses, or collections of pus.

While big nodes are most often due to run-of-the-mill infection or inflammation, cancer–the C word–bears mention. A deeper worry may furrow  the brow of parents with kids with large nodes that something worse–something cancerous–is going on. I urge any parent to voice these concerns upfront, to avoid feeling dismayed if the provider ‘doesn’t say anything about it.’ More than likely, a clinician will have this in mind, but may rule it out as they proceed with their evaluation. Fortunately, leukemia, lymphoma or other malignancies are relatively rare.  These entities may produce unusual symptoms such as unexplained nosebleeds, funky bruising, weight loss and fever for more than a week. Of course, if any parent has such a concern, I recommend they consult their health care provider pronto–for the peace of mind, if nothing else!

And so, all around the world this week, parents will stumble across or perseverate over BB-sized glands in their young child’s neck or groin. Those neck nodes are likely due to a cold, patch dry skin, or those big groin nodes because their child walks barefoot, outside. Hopefully, having a sense of what is normal (that kids have big nodes!) and what is typical (most big nodes return to usual size in 4-6 weeks!) will dispel the alarm. Treatment of swollen glands–if any at all–will depend on whatever is causing them to grow large.

If those big nodes linger, or, if they run with fever or great discomfort, or if you are in doubt, you can always get your charges checked out, right? You node it.

Nice photo above by Bernard Hudson, from a tick bite, BTW(click pic to link)

cartoon below by me.

The post A Cold In Your Node? When Kids’ Glands Get Swollen. appeared first on The Faster Times.

the sea nettle

For those beachgoers among you who don’t already know, jellyfish stings are bummers.

From the days of my sunsplashed summers on the Georgia coast, I can remember how they go. One moment I’d be trodding down the beach barefoot, or wading in the waters just off shore. Suddenly, there’d be a tingling, electric sizzle under my toes or across my leg as the stinging cells on the tentacles, called nematocysts, released their venom. My skin would feel hot for an instant, and a painful itch bloomed, as if I’d brushed nettles with teeth. Within moments, clusters or lines of welts would appear upon my skin, depending on whether I’d stepped upon the jelly, or brushed past a strand of tentacles. Sometimes I’d yell, or I’d practice one of the bad words I was starting to discover.

Like the stings of most North American jellyfish species, these wounds would not be life threatening, but they could sing in their madly itchy, terrible way for minutes to hours.  But… surely the pain of jellyfish envenomation was better than some of the proposed remedies I’d heard then (and since) to deactivate the stingers and their venom: vinegar?(smelly)…meat tenderizer? (weird)…urine? (if anyone ever saw that Friends episode where this was tried… well, enough said). Do these folksy, kitchen cabinet treatments work? Can jellyfish stings be prevented? Why are jellyfish stings on the rise? Let’s see, shall we?

Overfishing of their predators, climate change, and their seeming indifference to pollution or increasingly acidic seas make this a good time to be a jellyfish. We humans (and our offspring) are bound to have ever more frequent encounters with this gelatinous group of organisms as they proliferate in unprecedented numbers globally. Examples abound. In the Philippines, the sheer mass of jellyfish populations recently disabled power stations by clogging intake vents for seawater. In Spain, parts of the Mediterranean coast are rendered unswimmable with summertime jellyfish “blooms.” On the New Hampshire shoreline, over 150 bathers recently suffered stings and discomfort when a lion’s mane jellyfish had strayed from it’s northerly reaches and became beached. To be sure, we’d do best to understand jellyfish (and how to de-zing their sting) better.

In North America, the largest number of jellyfish stings occur in the summer time. Common varieties that cause stings in our waters include the above mentioned lion’s mane common in colder Pacific and Altantic waters, the sea nettle, found along the Eastern seaboard down to Florida, and the Portuguese man o’ war (aka bluebottle) common in Florida and the Gulf of Mexico. In most cases, discomfort from the jellyfish sting is limited to the area stung by the nematocysts. Children may be particularly vulnerable to jellyfish stings, as they tend to be unaware and step on stranded jellies along the tideline, or to be mindful of jellies seen in the water. If stung, some individuals may be prone to more severe allergic reactions to jellyfish venom, or their symptoms may escalate with cumulative effects of large numbers of stings. Diana Nyad, for example, recently had to abandon her Cuba to Florida swim due to repeated stings by Portuguese man o’ wars. Unabated, such exposure can cause severe muscle cramping, chest pain, and breathing problems. Fortunately, deaths from jellyfish stings in U.S. waters are a rare event in adults and children.

To those who travel and hit the beach:  foreign waters may contain nastier varieties. The deadliest jellyfish of all, the teeny box jellyfish off the Australian coast, has been known to have caused nearly 80 deaths, with a potent venom that can kill an adult within minutes to hours of being stung.

So, what to do if a member of your beach party gets stung?

New Research. New recommendations.

A recent article nicely upends our sense of how to treat — and how not to treat — a child or family member if they ever get stung by a jellyfish. Until now, conventional medical wisdom recommended North American beachgoers use vinegar or a baking soda slurry to deactivate the stingers or neutralize jellyfish venom. Not so! Rather, these treatments were derived from research and treatments better suited for the stings of Pacific and Indian Ocean species of jellyfish. In looking at  studies for jellyfish sting treatments in North American and Hawaiian waters, the researchers produced recommendations that are quite different, and in some cases, liberating.

All agree that someone stung by a jellyfish should be removed from the water, if possible, and put on a clean, comfortable spot to check out the exposed area. Anyone offering first aid should take measures to prevent themselves from being stung, remaining watchful that strands of tentacle or active stinging cells may remain on the victim’s skin.  Bits of jellyfish tissue or nematocysts may be removed using the edge of a credit card, and/or by a person wearing protective gloves. Be careful!

The offending jellyfish need not be caught to optimize treatment (in many cases, the perpetrator is never seen, the sting is just felt!). However,  it can be helpful if the type of jellyfish can be identified when possible.

The most effective treatments for North American jellyfish stings? Irrigating or soaking the stung area for several minutes with tolerably hot water, followed by lidocaine cream; a potent (and prescription only) topical anesthetic works best. Unfortunately, these materials are usually in short supply at most beaches. Fortunately, seawater rinses make for a satisfactory next-best option. Room temperature or cool fresh water soaks or rinses may make the situation worse. Vinegar should also be avoided for most jellyfish encountered in U.S. waters as it too may trigger stingers already on the skin. An exception exists to this rule: If Portuguese man o’ war was known to be the source of sting, then vinegar is just the thing.

And, for those of you who’ve been wondering up to now, the recent review found no indication that meat tenderizer or urine have any positive effect on mitigating jellyfish stinging cells or venom. Sorry, Monica.

Once an area has been cleared of stinging cells and properly rinsed, care and comfort measures such as Motrin for pain, Benadryl and periodic applications of ice to the affected skin are a great idea. Hugs and kisses don’t hurt either.

If it ever appears that the stung individual is having more severe discomfort, such as abdominal upset, muscle cramping, or any indication of breathing difficulty, that may mean a more serious reaction is afoot. In such cases, medical attention, including a trip to the ER or calling 911 may be necessary.  If in doubt, get seen!

Can jellyfish stings be prevented? Sorta. Any visitor to the seaside would do well to look online or ask around if there are known jellyfish hazards, or if swim areas offer protective, jellyfishproof netting (really, some places do!). Bathers, snorkelers and scuba divers should get the lowdown before jumping in about what may be in the water.  If there is word of a jellyfish bloom, it might be time for a landlocked pursuit and to come back on another day. For those who love those long walks on the beach, a pair of sandals may lower the risk of stepping on a washed up jellyfish whose tentacles may still hold their fire. Lastly, for those who are more concerned or determined to swim in jellyfish-infested waters, one may invest in so called stinger suits. Hey, they may not be trendy, but they work.

And so, do go forth and enjoy your time at the beach. Be safe, wear your sunblock, and mind your kids as they frolic and splash about. Have a ball. And, be mindful of those ever more present jellyfish adrift in the sunny depths.  They are a picture of silent beauty, but they deserve our caution and respect.

–

Photo 2 by katiebug789 (http://media.photobucket.com/image/jellyfish%20stung/katiebug789/beachmore151.jpg?o=2)

cartoon below by me.

The post Better Than Pee: New Recommendations For The Dreaded Jellyfish Sting appeared first on The Faster Times.

Full disclosure #1: Actor Will Smith and his first wife Sheree Fletcher (pictured last on the right) were the first people I ever heard of co-parenting like grown-ups after divorce. Whatever their differences, they kept it civil in the press and made it clear that their son Trey was their top priority. Even though I did not know them personally, they came to mind when I was newly separated and beginning to build a co-parenting partnership with my soon-to-be ex-husband. When Smith married actress Jada Pinkett Smith (whom they call Trey’s “bonus mom”), the Smiths and Sheree did the hard work of continuing along the positive path, a journey Sheree discussed as a guest on a 2010 episode of my “Co-Parenting Matters” show (that’s full disclosure #2).

So when I heard about Sheree’s involvement in VH1′s newest reality show, “Hollywood Exes,” I didn’t cringe. Sheree is a co-parenting hero of mine, and I hope that her presence on the show will reflect the fact that you can survive and thrive after divorce without dragging your ex through the mud and without dragging your kids down in the process. In an interview, Sheree discusses the importance of healing after a break-up and Will’s thoughts about her doing the show (she asked him about it, out of respect, not obligation, and he gave his blessing).

But of course in Hollywood terms, such maturity translates as boring, and sure enough, some Twitter reviews of the show have lamented the lack of dirty laundry being aired. So that can only mean one thing…It’s time to invent some drama! Or rather, in this case, time to drag up years-old drama, dust it off, and try to resuscitate it.

Take a recent post (I won’t dignify it by facilitating additional clicks) that delights in “delicious morsels of drama bubbling up from three years ago!” Actually, the “drama” this post refers to is song lyrics from an album Will Smith released seven years ago. According to some accounts, the song is directed at Sheree and paints her in an unflattering light. But who would click on a headline that read, “Will Smith Disses His ‘Hollywood Ex’ in a Song Released 7 Years Ago!”? Instead, we get “Will Smith Disses His ‘Hollywood Ex’ Sheree Fletcher [AUDIO]“…which makes you think he gave an interview on the subject just yesterday. The “audio”? A YouTube posting of the song featuring the album cover…

I had hoped (in vain) that other media outlets would avoid this kind of reaching (and click-baiting) and let the reality (the real reality, not the kind manufactured for TV) of this particular Hollywood divorce be The Story. Why delight in exes dissing each other, especially when there are children involved? And when said exes have publicly discussed making the conscious decision to move on and get along, why dredge up the past? Presumably, Sheree knows about this song, and if she’s moved past it, shouldn’t we?

Thankfully, most non-Hollywood parents are spared having our less-than-proud post-divorce moments publicly thrown up in our faces 7 years later, or documented for posterity. In real life, we celebrate the journey toward congenial and civil, the journey one member of the CoParenting101 Facebook group described as going “from horrific to joking.” But sadly, this isn’t a reality most people want to see on TV.

I get it. I know drama sells, but I continue to hope that we can become a culture that delights in adults healing and moving forward, not staying mired in and acting out of their pain, anger, and frustration. I continue to hope that we can change the cultural expectation about parenting after divorce to one that involves progressing toward the “delicious morsels” of our best selves.

The post Can’t We All Just…Let Co-Parenting “Hollywood Exes” Get Along? appeared first on The Faster Times.

By the fourth month of life, the salivary glands in the infant undergo a rapid phase of growth, with a corresponding increased output of saliva (once again in medicine, we dignify a condition with a horrible name, “sialorrhea”). While most babies swallow a healthy fraction of this volume, a fair share of slobber tends to cascades out.  As any caretaker of a child who drools knows: chins, and necks, and neck folds tend to be constantly moist and gooey places. Failure to dab or wipe or bib these areas with some regularity can result in the skin becoming irritated and rashy.

Developmentally, healthy children from 4 to 18 months have not yet developed the oral and lip muscles ability to manage all of these secretions.  And, out they come. This problem is magnified by infant’ and toddlers’ tendency to grasp, mouth, and slime whatever graspable object is within their reach. Cute they are, but gooey!

Drooling is considered a normal finding in children up until the age of 2. It really ranges in amount and duration. Some kids drool more (several bibs or costume changes a day!), some less (an occasional swipe will do). Otherwise healthy children who persist in drooling after their second birthday may be simply observed with an expectation that they’ll grow out of it by the age of four. Past that birthday, persistent drooling is considered abnormal.

Drool is saliva (aka spit, slaver, slobber or spittle). Saliva is a remarkable cocktail comprised mostly of water, antibodies and digestive enzymes. Saliva serves a crucial role in moisturizing and protecting the oral cavity from infection, cleansing the teeth, preventing foul breath, assisting in swallowing by moistening foods, and digesting carbohydrates and proteins. Saliva is produced by a network of three paired glands embedded in the lining of the walls and floor of the mouth, with additional spit factories in the tongue and roof of the mouth. No wonder it gets wet in there.

Ideally, children and adults make the saliva they need. Too little saliva ain’t good: children and adults without enough may develop painful mouth infections and sores, suffer increased rates of cavities, and have difficulty eating.

Too much saliva, known as hypersecretion, is relatively rare and is most associated as a side effect of meds, such as seizure drugs or tranquilizers. In older kids who have a drooling problem, the issue is not so much that they produce excessive amounts of saliva, but rather that they are having trouble managing the secretions they produce. Whammo: Drooling happens.

For parents, consulting with their child’s health care provider is key. Each child needs to be considered holistically in such cases, and the evaluation begins with careful history. Do you have a full term child? (preemies have higher rates of oromotor problems) Is there a known neurologic or developmental issue? (rates of drooling can run extremely high in certain populations, such as children with cognitive delay or cerebral palsy, or “CP.” Listen: up to 37% of kids with CP have significant and persistent drooling problems). From a physical exam, a primary care provide can further discern if there are any there any contributing anatomical problems or other related issues.

Acute vs. Chronic: There’s a difference

Children of any age may experience ‘sudden onset’ cases of drooling (or worsening of drooling that they already have)if they develop mouth pain. Oral infections, canker sores, cavities, tooth eruption may underlie a child’s new unwillingness to swallow. A peek inside the mouth by a sunny window is a good idea to see what gives.

A trip to the primary care clinic may be in order if the pain is eluding ‘comfort measures’.  In littler children or children with delays who may be less verbal, one must be sure that drooling has not been triggered by a swallowed, or half-swallowed object. Any perception that something may be stuck in the back of the throat or blocking the airway needs to be evaluated immediately. If a child is having trouble breathing, call 911. STAT.

Chronic drooling may impose a significant challenge to families, careproviders, and educators.  In these instances, children and teens may develop hard-to-treat breakdown of the skin on their faces and necks, soaking of their clothes, communication equipment, and isolation or self-consciousness that makes it difficult for them to connect socially with their peers. In some children with neurologic impairment, excessive drooling may pose additional risks for aspiration and pneumonia. In short, drooling can greatly impair a child and family’s quality of life. I encourage families to convey this concern and not let it be displaced by attention to other issues (braces? wheelchair? growth?) if their child has a lot going on developmentally or medically. It all matters!

Generally, the best approach to abnormal drooling for a child of any age involves a team effort. Consultations may involve the work of specialists, such as pediatric neurologists, dentists, and/or ear, nose and throat surgeons where appropriate. Further, speech pathologists, physical therapists, and occupational therapists collaborate to understand a child’s level of function, and how to optimize it. Oral training and rehabilitation to improve drooling tend to be more effective for children with higher levels of perception and motivation. It can be slow going but well worth it.

Medications offer limited results for children with chronic, excessive drooling. At best, medications lessen the amounts of secretions produced. Unfortunately, many of these meds (e.g. Robinul) come with significant side effects, including making saliva ropey and hard to swallow.  Botox (aka botulinum toxin) has gained attention and renown recently for being effective when injected into the major salivary glands. In studies of treatments applied on kids with drooling results showed some improvement in some of the children—but should be considered as a temporary measure and not a cure.  Radiation and surgical approaches to overactive salivary glands may also be used in grownup populations, but are virtually unheardof in children.

And so, for any parent with an infant, toddler or child who drools a little or a lot: check in with your child’s primary care provider  if you are concerned or have questions. Is it abnormal? It’s worth finding out if therapies can help. After all, not knowing ain’t worth spit.

Photo above by myklang (http://media.photobucket.com/image/drooling%20baby/myklang/drooling.jpg?o=2).

Cartoon below by me.

The post Drooling: Always Gooey, But When Is It Abnormal In Kids? appeared first on The Faster Times.

Migraineur. Sounds like a job for a senior specialist in some artisanal craft, doesn’t it? Such a misleadingly pleasant sounding word. However, ‘migraineur’  describes a more-common-than-you-think  entity affecting an invisible population of child and adult sufferers of the misery that is the migraine headache.  While migraines aren’t entirely understood, migraines in children (child migraineurs!) have been a bit of a mystery til recently.  Do kids get them? (you bet) How are they similar or different than in adults? (excellent question)  When should parents have their children see a health care provider or specialist for them? (Put down that cheese, and read on!).

First, what is a migraine? To paraphrase the International Headache Society’s definition, a migraine is a recurrent headache that occurs sometimes with(or without) a raft of associated sensations called auras, lasting from two to 48 hours.  Migraines are thought to occur as a peculiar cascade of nerve excitement and inflammation over the cortex of the brain, accompanied by changes in blood flow to those areas. All in all, things get funky as migraines come to town, manifesting  in all sorts of ways.

In grownups, migraines are classically felt as dull, pounding pain on one side of the head.  Veterans can feel them coming on, with associations of vision changes, numbness or tingling, pukiness, or unique fogginess prior to the headache onset. Migraine sufferers will often describe their discomfort as medium to extreme, and often runs with associated nausea, and extreme sensitivity to light, and sound.  Health care providers can often discern these headaches by their pattern, triggers and frequency…and by the fact that sufferers almost invariably find solace in a quiet, dark room with the curtains drawn.  Ah, such is the advantage of my adult care provider colleagues!  The diagnosis may be made so much easier by the ability of the migraineur to relate their experience themselves.

Kids are different

In children, migraines present themselves in markedly different ways, and, the developmental status of a child make the detective work a bit more of a veterinary experience. As a classic 1962 study in Sweden found, lots of kids have had headaches (about 40% by 6 years old, and 70% by age 15)  Migraine headaches are the most common type. They occur in 10% of younger children, and about 1/4 of teens.

Clinical pearl: Parents or health care providers should suspect migraines when there are recurring episodes of symptoms that are making kids miserable.   Extra high levels of suspicion should be applied for kids with strong histories of carsickness, or a family history of migraines (up to 70% of young migraineurs have a relative who suffer them!).

Oddly enough, headaches may be a transient, or event absent feature of migraine in children.  While adults may point to a one-sided headache, kids may perceive pain on both sides of their head, and confuse the diagnosis (tension headache? sinus infection?).  Apediatric migraine experience, associated with any number of symptoms, can last up to 3 days. That is a long time to be miserable.  While the particulars may vary from child to child, kids who get these spells tend to look the same each time .

At a migraine’s onset, parents may notice a certain pattern of behavior, including fatigue, irritability or hyperactivity.  These aura type sequences may be important to watch for, as they may offer a window of taking measures or medication to head off (or, in medical parlance, “abort”) a blooming migraine episode. Thereafter, things may progress to pallor, odd facial expressions, confusion, sleepiness, or prolonged bouts of nausea and vomiting. Yeesh.

Parents and kids can often discern activities that trigger migraine ‘attacks.’  As this excellent NYT article suggests, the  zipquick lifestyle of tweens and teens can be a cause of migraines in itself. Insufficient sleep, skipped meals, hydrating poorly, being stressed out or rundown can precipitate an episode. For teen girls, the hormone surges of their periods may bring on migraines. Working with kids to chart or calendar when a headache starts, and what they were doing (eating? exercising? studying for a test?) can help suss out when the triggers are less clear.

In all, medical science is catching up to what families with kids who suffer migraines have long known: Migraines can be extremely debilitating, formative experience. Children may miss significant amounts of school, or perceive that they are different , keeping them from the runnings around of childhood.

Research suggests that the most effective approach migraines is a lifestyle and stress management overhaul.  Getting sufficient sleep, eating and hydrating well, and avoiding triggers (including Xbox, computers, and texting!)  are a great start. Even better: kids learn ways to reduce stress  in a manner suited to a child’s age…This beats medications any day! Yoga, exercise, meditation, massage, or guided imagery are easily adopted techniques that parents can take on with their kids.  Firstline home therapies help too: ibuprofen, rest and chill time (in a dark, quiet room!) will get most children straightened out and flying right.

For any parent concerned their child may have a migraine should consult with their child’s health care provider.  A careful history and an examination of the child help make the diagnosis, and therapies can be suggested that are appropriate and safe. Ideally, parents and provides can develop a Migraine Plan, including how to prevent episodes, and what to do at home or school if an episode is suspected. Children with more complicated symptoms (vision loss, or muscle weakness during migrainous episodes, or severe symptoms that don’t respond to first line therapies) may require a consultation with a neurologist or migraine treatment center.

For the younger migraineur, take heart. About half of all children of elementary school age or younger will see their symptoms cease at the onset of puberty. For kids who develop migraines during their teen years, tend to have them into adulthood, with their severity and frequency waning over time. For all kids and teens with migraines, we parents and care providers will do well to respect the fact that migraines affect children of preschool age and older (at least)…and that they deserve our attention and efforts to prevent them.

photo above by snarkist [/link http://media.photobucket.com/image/migraine/snarkist/migraine.jpg?o=15]

Cartoon below by me.

Dr Obvious rides again

The post Kiddie Migraines: A Headache in Your Stomach? appeared first on The Faster Times.

Don’t let those hiccups get you down!

Hiccups are like divine comedy, aren’t they? In seconds, a paroxysmal hurk can render a child most serene, or an adult most stern into something hilarious. While they rarely pose anything more than a sociodietary awkward moment, hiccups do cause their concerns. Parents of infants understandably ask if the hiccoughs of their newborns need to be addressed somehow (more on that below). Why do we hiccup anyway? (great question) And, do any remedies work…and should I use them? (hold your breath, have a sip from the far rim of a cup and we’ll see).

The hiccup is known in medical parlance as the singultus, an apt Latin word for the hitching way one catches their breath while sobbing.  The iconic hic! sound of hiccups results from some funky physiology. Each hiccup is a sudden, involuntary spasm of the diaphragm muscles at the floor of the chest cavity, and the intercostal muscles that sling around the rib cage. The rapid inhalation of air pulls the glottis home at the top of the airway with a snap, producing that musical noise we love so well.

Hiccups usually occur at a rate of 4-60 times a second. The vast majority of cases subside within a minute or three.  In some blessed individuals, we note, hiccups can be heralded by simultaneous other phenomena, such as burping, sneezing or breaking wind. We celebrate their musicality, but the root cause of such prodigious synchrony is beyond the scope of this article.

Meanwhile, what is going on here? Why do hiccups occur? In short, we’re not entirely sure. Hiccups begin in the third trimester of pregnancy and become an undignified fact of life in the first few months after birth. Hiccups are thought to arise due to irritation of the vagus or phrenic nerves connected to the stomach and diaphragm, among other things. In most cases, distension of the tummy from a large meal, swallowing of air with eating (so called, aerophagia), sudden changes in temperature (externally), or ingestion of cold or warm fluids (internally), or emotional excitement or stress  trigger hiccuppy signals from the nerves to the respiratory centers in the brain and back again. Presto! Hiccuptime.

Hiccups manifest differently across childhood and beyond. Newborns and infants with their rather unique physiology, are very sensitive to stimuli and stresses in general. Babies’ tendency to hiccup would seem (and is) rather inevitable. Simply feeding or retaining unreleased burps can trigger a bout of infant singulti. Mild spittiness or acid reflux,  common in babies, can also be the culprit. In the words of an attending who taught me early in my training: hiccups tend to bother the parents a whole lot more than the baby. Mercifully, hiccups just about never pose a problem in the youngest of the pediatric age set, and resolve on their own.

In older kids, scarfing food too quickly, drinking carbonated beverages, or dining on fatty foods can precipitate a hiccup attack. In teens and adults, transient cases of hiccups may be triggered by other lifestyle habits, including smoking or consuming alcoholic beverages (Not a myth after all: all those old bugs bunny cartoons were right!).  Parents take note: if your adolescent arrives home from a party suddenly hiccupping a bunch, it may be wise to inquire about what they’ve been up to.

And, you might ask, why do we hiccup at all? There is no clear or current evolutionary advantage to our species having hiccups. They aren’t fetching, cool or distracting to predators, that’s for sure. One theory suggests that hiccups may be a primitive (and, to be sure, rather lame) response to choking on food. Rhythmic lurching with rapid inhalation, the theory goes, would dislodge an offending item allowing one to sort of auto-Heimlich oneself. Nifty, perhaps, but not terribly effective.

Seriously, Chronic Hiccups?

About 1 in 100,000 hiccups will become a longer term plight. Cases lasting more than 48 hours are called persistent hiccups. (Yikes) Intractable hiccups last more than a month. (Ok, that’d just suck).  When an individual hiccups for a longer haul, the index suspicion that some underlying cause is at work goes way, way up.

Generally, a health care provider sees chronic hiccups in a more grown up population.  As one article nicely summarizes (link below) chronic hiccups fall into three main groups: nerve injury or inflammation (such as a nicked nerve after surgery, a neck mass or swollen gland, laryngitis, or even a hair tickling an eardrum); brain issues (infections, strokes, concussion, or a brain injury); or metabolic problems or medication side effects (e.g. diabetes, kidney disease, alcohol, steroids, or other drugs).

Any case would require a careful review of the story of the hiccups, when they started, and what triggered them, followed by a full physical exam. Here’s a gem: hiccups that occur during sleep or that last for days to weeks almost always suggest a more complex problem is afoot. Blood tests or imaging would be done depending on an individual’s story or area of concern.  In the end, addressing the underlying condition may be key to ending the hics.

Treatment…if at all.

And so, for the rest of us and our children, what to do for the everyday, acute case of here-we-go-again variety of hiccups?  Every family and culture I’ve met seems to have a slightly different, sworn by cure-all for the problem. The variety of treatments is staggering, and ranges from benign and inventive, to bizarre, or  unwise.  What research there is suggests that hiccup remedies are at best mildly effective.  The mechanisms to end hiccup bouts work  possibly by either mildly raising the carbon dioxide levels in the blood, or by stimulating the vagal nerve. Let’s them these treatments up quickly.

Better approaches: #1 Benign neglect (letting them run their course)! Otherwise, try  burping an infant or positioning her to relieve gas or abdominal distension. In older children, drinking a cool glass of water, or holding their breath.

Interesting approaches (not for infants and young toddlers!): Placing sugar or honey on the tongue, sipping fluid from the far side of a cup, having someone apply ‘traction’ to the tongue.

Not so wise approaches (i.e Don’t!): pressing on the eyeballs, pushing on an infant’s fontanel, startling infants or the elderly, sticking a finger in the ear, or pressing on the palate.

In short, if hiccups are bothering you (or your child) that much, I recommend you run it by a health care provider to be sure that all is well. Just as we say don’t scare kids with the hiccups, don’t let hiccups scare you. And, will a better treatment for them come along anytime soon? Don’t hold your breath.

Photo above by Ashgo . Cartoon below by me.

Nice summary article: http://www.emedicinehealth.com/hiccups/page5_em.htm#Hiccups%20Treatment

Treatment worse than the disease?

The post The Lowdown On Hiccups appeared first on The Faster Times.

The bumps that occur on kids’ eyelids are not the most commonly encountered phenomena in pediatrics, but they sure do generate lots of parental anxiety (ranging from “ooh, to eww!”) and an awful lot of questions. Now, the eyelid is an artful piece of anatomy, serving to protect, lubricate, and insulate our precious eyeballs against the big wide world. What is it about them that lets styes happen? ….feeling stymied?

Right there, at the tip of your eyelid, you’ll find the eyelashes. These coarse hairs serve as a first line of defense to keep the eye from grit, bugs, debris and moisture as we go through our days. The roots of the eyelashes emerge from the outer margin of the eyelid, where twin glands (glands o’ Zeis on the outside and the meibomian glands on the inside) secrete oils mix with the body’s tears and keep them from evaporating too quickly. Blinking sweetly reapplies a sheen of tear solution to the delicate surface of the eye, while sweeping debris and moisture to the tear ducts on the lower lid. Normally, tears drain unnoticed into the nasal cavity. When the they eye becomes inflamed, the tear ducts becomes blocked with mucus, or if you get a good cry on,   teariness may be noticed. So then, what are styes?

A stye is a hordeolum, but is not a chalazion.

For most folks, a red, painful bump on their child’s eyelid is a stye. Before we, um, lump them all together, there are different types of those tender BB-sized nodules. Who knew?

Styes—also known by the unfortunate term, “hordeolums”– are itty bitty abscesses of the eyelash follicle and nearby oil glands. Styes usually arise spontaneously, as kids or parents note the sudden arrival of a small, tender lump on one eyelid. What’s in there? Pus, dead white blood cells, bacteria, and some clogged gland material, mostly. (Hey, you asked). Typically, styes will last for 1-2 weeks, and will either drain (yes, like a pimple!), or will quietly resorb and go away.

The chalazion. Painless, but a pain.

Chalazions are longer lived cousins to the stye: As one article says in gorgeous medicospeak a chalazion is a “sterile nodular lipogranulomatous inflammation of a meibomian (or Zeis) gland.” Right. Gotcha. Put differently, a chalazion is what a stye becomes if it hangs around long enough. When conditions allow, and the eyelid’s oil glands become blocked, they can form a persistent and eventually painless little fibrous bump that can last for months. Chalazion city.

What to do? In the vast majority of cases, home treatment is the best treatment for these eye bumps–styes and chalazions inclusive!  Parents may apply comfortably warm (not hot!) compresses–perhaps best with a towel moistened with water– to an affected eyelid several times a day. Over time, this may help break up the inflamed goo and help things clear up, and even drain.  And, for those who favor makeup, it’s best to avoid applying it until the eyelid’s inflammation has resolved. While tempting, parents and kids should specifically try NOT to squeeze the little buggers. Such action may make styes worse, and cause more pain and inflammation in the process. No one needs that. So then, when does a stye or chalazion require medical evaluation?

Very occasionally, styes and chalazions cause a significant amount of pain, or concern for spreading infection. If parents perceive that the usual approaches (compresses, Motrin) are not enough, and if kids are persistently uncomfortable OR if one sees spreading redness across the eyelid, then it is time to get checked out. If there is some local irritation and drainage, a clinician may recommend some topical antibiotic ointment or drops. Oral antibiotics are deployed when the infection spreads to the surrounding skin, a so-called peri-orbital cellulitis. That is a higher (and rarer!) grade of problem, and merits treatment and close followup.

A very small subset of children, teens or adults develop recurrent styes or chalazions that do not respond to home therapy or medical treatments. If these folks are sufficiently uncomfortable,  or if they find the lesions distracting or problematic, then an evaluation by a specialist may be due. Which type of specialist seen may vary regionally, but surgical removal or drainage could be done by an Ophthamologist, Plastic Surgeon, or Dermatologist. Whomever one’s primary care provider feels is sufficiently expert in working on the complex anatomy in that part of the body is probably a good bet.

And so, back to those questions from the start:

Styes are like pimples on your eyelid, right? Kinda.  We should squeeze those bumps there, and get out the stuff inside, and that’ll help them get better, won’t it? No. No. No.

If a stye goes on long enough, it could damage a kid’s vision, couldn’t it? Possibly, but unlikely. Seriously, are they called “pigstyes?”  Some people do call them that, albeit incorrectly.

Lastly, to remember the difference in these bothersome eye bumps on our eyelids, I submit the world’s first “stye-ku”, if you will

A chalazion

Is an ol’ hordeolum

Both’re gross eye bumps.

Photo 1 by http://commons.wikimedia.org/wiki/File:Stye02.jpg

Photo 2  by http://upload.wikimedia.org/wikipedia/commons/a/a3/Chalazion_sup_02.jpgabove by

Cartoon below by me

Stye vs. Sty

The post Spy A Stye In A Little Eye? Here’s Why. appeared first on The Faster Times.

When I took the three-week consulting job in another country, I thought I could handle it. Actually, I thought it would be great. Uninterrupted sleep (my daughter still wakes two, three times a night), quiet mornings reading in bed before work, the freedom to go out at night without consulting anyone. It was great for a few days, but now I’m having nightmares that my child has gone missing, and waking each day and pathetically imagining she’s crawled into bed for a morning snuggle.

We talk frequently via Skype, but it seems to make matters worse – especially for me. She’s confused. “Mommy, why are you in that room in the computer?” Foolishly I try to answer sincerely.

The first time she asked, I explained that it wasn’t a room in the computer but that the technology allowed her to see me in a room in a hotel in another country. “Hotel” didn’t ring any bells, nor did “another country”. She asked if I could come back to our room in our house. The next time I explained that I would be home soon and missed her very much. She blew me a kiss and ran out of the room. The third time, I swore never to be away so long again and then made an excuse to go so I could cry.

My friend Monica who lives in Georgia, the country where I’m working, gave me a book. The Business Traveling Parent offers more than 100 ideas on how to stay connected to your kids when you’re traveling on business. It’s full of clever tips that I will one day use: gifts you hide for your kids to find after you’ve left, airport tours, farewell meals and bedtime stories together. The ideas are wonderful, but I’m already far away and when a child is three it’s tricky to keep their attention via a computer screen.

While the work has gone well – largely because there are no distractions – I’m failing on the emotional front. On Skype, I’m like a distant relative talking to a child for the first time. I ask banal questions about her day and then sit quietly waiting for her to do something adorable.

My daughter, on the other hand, seems to know just what to do. She blows me kisses, dances around the room and sings me songs she’s learned at school. Just when I’m thinking maybe she doesn’t miss me that much, she’ll do something unforgettable like press her palm against the screen and ask me to do the same so we can hold hands.

Even on the day before I left, she seemed to know just what I needed. I had dropped her off at school and was standing at the gate talking to her teacher. In a made-for-TV-kind-of-moment, my daughter raced out of the classroom and flung her little arms around my neck. “Mommy, I forgot to kiss you goodbye,” she said, before kissing me and running back inside.

If only I were as emotionally together as my child.

Image by Camila L. Oliveira (Flog da Mila)

The post Business Travel and the Lonely Mom appeared first on The Faster Times.

One of the great (and, I’m sure, unintentional) ironies of the Fox hit is that the show preaches “Don’t stop believing” while presenting scenarios that make doing so virtually impossible.

For example: Are we really supposed to believe that a group that includes the hunky quarterback and several beautiful cheerleaders could really be targets of constant “slushy” attacks? Or that our dedicated Glee-clubbers, after traveling across the country for the most important competition of the year, would not only show up in New York with nothing prepared but then decide to write original songs the day before the big event? Head-scratchers, indeed.

Then again, this isn’t the History Channel here. It’s Glee, right? We can handle a little suspension of disbelief.

And so, on a recent episode, when Will Schuester (Matthew Morrison), in a soaking wet white tux, literally walked across the high school swimming pool and asked his girlfriend Emma Pillsbury (Jayma Mays) to marry him, as the climax of a hastily-constructed-yet-impossibly-intricate synchronized swimming number, I rolled with it.

Because to me, the truly “cry-foul” development happened earlier in that same episode, when Mr. Schue asked Finn Hudson (Cory Monteith)—a high school senior—to be his best man.

As a high school teacher myself, I’ve always been a little suspicious of Mr. Schuester—and not because he once planted marijuana in Finn’s locker to blackmail him into joining the Glee club. Reportedly a Spanish teacher, Mr. Schue has been spotted in the actual classroom maybe three times. He’s rarely seen correcting tests or essays. And he spends an inordinate amount of time during the school day in the choir room, which raises the question, “Where do McKinley High’s actual music teachers hang out?”

In fact, Mr. Schue’s lack of interest in teaching Spanish became so obvious that even the writers had to acknowledge it. And so, in the recent Ricky Martin episode, Mr. Schue admitted he doesn’t even know how to speak Spanish that well and decided to teach social studies instead. (Yeah, because switching disciplines is that easy!)

In short, only his seemingly endless supply of snazzy Cardigan sweaters prevents me from giving Will a failing grade as an educator. But asking Finn to be the best man? Come on. What, Will has no other relatives or, you know, friends his own age who could do the job? It’s beyond unrealistic; it’s inappropriate, bordering on creepy.

Am I saying teachers can’t have important relationships with the kids? Of course not. Those relationships make the job meaningful and worthwhile. After all, no one goes into teaching because the prospect of spending an entire weekend correcting Othello essays sounds oh-so-appealing. You go into it because of the kids. Truly, the kids make the job.

Nor am I saying that teachers can’t ever see students outside of the classroom. Over the past ten years, I’ve gone to many, many plays and games and recitals and graduation parties—not because I have to, but because I want to. I care for these kids and want to support them.

But we’re not peers. My students and I don’t “hang out.” And as much as I respect many of them and enjoy their company, I would never even invite one of my current students to my wedding, let alone ask him to be my best man. It just crosses the line.

Now, to all the Gleeks out there: I’m not hatin’ on poor Mr. Schue. I know he means no harm. He legitimately cares for Finn (the whole “planting marijuana in his locker” incident notwithstanding), and considering Finn doesn’t have a father, that relationship is significant. In fact, if Finn asked Will to be his best man, I absolutely would have accepted that.

Moreover, I also know Will Schuester is a fictional character. But here’s the thing: there are real-life Mr. Shues out there, well-meaning high school teachers who don’t break any laws themselves but have the misfortune of sharing the profession with people who do.

Every day, it seems, you hear another story about some deviant teacher who has sex with his (or her) students or plays beer-pong with them or does all sorts of brazenly inappropriate activities with them. (Case in point: Idina Menzel’s Glee character Shelby Corcoran sleeps with the seventeen-year-old Puck—although she apparently suffers no consequences for this indiscretion.)

Granted, the number of kind and decent teachers in the world far, far exceeds the number of monsters, but the monsters get all the press. They’re the ones who ruin it for the Mr. Schuesters of the world.

Is asking a student to be your best man at all comparable to those other crimes I mentioned? No way. But you don’t ever want to be even remotely painted with the same brush as those guys.

So, if Will Schuester were my colleague, I would have to tell him this: Enjoy the kids. Believe in them. Advise them. Respect and admire them. Write them college recommendations and celebrate with them when they get in. But when it comes to social functions like weddings, leave them off the invite list.

Oh, and maybe refrain from serving slushies at your reception. It could get ugly.

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