BRUCE ROSEMAN, M.D.
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BRUCE ROSEMAN, M.D.
NICOLE LIVESCU, R.N.

Whooping Cough An Epidemic After 5 Deaths
California authorities have declared ‘whooping cough’ an epidemic after at least five infants were killed by the disease. The state appealed to the residents to get vaccinated to prevent the disease. The state announced the disease as epidemic after a sharp rise in the cases of pertussis (scientific name for whooping cough) was noticed. The disease is like common cough and cold and is contagious in nature.
A total of 910 cases have been confirmed with the epidemic and several others are under observation. The authorities fear that if the pace of spreading of disease remains the same, it would be the largest outbreak in past 50 years.

The Deputy Director of the department’s Center for the Infectious Disease, Dr. Gilberto Chavez said that there has been a fourfold increase in the disease as compared to last year. Dr Chavez said that summer is the most sensitive season for this disease to spread. The highest number of cases is usually reported in July and August. Dr Chavez said that these cases are expecting to rise more if prevention is not take on an immediate basis.

It is worth mentioning here that almost 5000-7000 cases of this disease are reported in US every year. The health department is making all efforts to reach out to public. It is spreading the message online and also sending its representatives in person to spread the word about the prevention of whooping cough.


Excess Belly Fat Linked to Insulin Resistance in Kids
Insulin resistance occurs when the body doesn't respond as well to insulin. Insulin, a hormone, is made by the pancreas and allows the body to process glucose, the main type of sugar in the blood. When a person has insulin resistance, glucose is less able to enter the cells and supply energy to the body. Insulin resistance is a problem because it has been linked to the development of type 2 diabetes, as well as a number of other health problems including high blood pressure and heart disease.

In adults, having a lot of fat in the abdomen and a large waist size has been linked to insulin resistance. To help understand the risk of insulin resistance in kids, researchers from the University of Buenos Aires in Argentina studied 84 6- to 13-year-olds. The kids were weighed and had their heights and waist sizes measured. In addition, each child underwent blood tests, blood pressure measurements, and tests to measure the body's ability to process glucose.
Forty of the children in the study were overweight (in the 95th percentile or above in weight for height); 28 of the children in the study were at risk for overweight (between the 85th and 94th percentile in weight for height); and 16 of the children in the study were not overweight or at risk for overweight.

Kids who had larger waistlines tended to have:

    * higher blood pressure measurements
    * abnormal cholesterol levels
    * higher levels of triglycerides, another type of blood fat linked to heart disease
    * a higher risk of insulin resistance

Even after the researchers took into account a kid's height and weight, children with larger waistlines still had a higher risk of insulin resistance.

What This Means to You: Insulin resistance has been linked to the development of type 2 diabetes and heart disease. According to the results of this study, waist measurements could help to identify kids at greater risk for developing insulin resistance.

Children who have insulin resistance are often overweight and may not get much physical activity, but the good news is that eating healthy foods and portion sizes, engaging in regular physical activity, and getting to a healthy weight may help some kids reverse their insulin resistance. If you have questions about your child's weight or insulin resistance, talk to your child's doctor. He or she may recommend that you talk to a registered dietitian if your child needs help managing his or her weight



AUTISM'S FALSE PROPEHTS
By Maggie Fox, Health and Science Editor Maggie Fox, Health And Science Editor Wed Feb 18, 2:41 am ET
WASHINGTON (Reuters) – When the letters and e-mails started to pour in, Dr. Paul Offit braced himself.
The pediatrician and vaccine inventor is a prominent defender of childhood vaccines, tackling those who have argued that immunizations can cause autism.

His book, "Autism's False Prophets," takes on British researcher Dr. Andrew Wakefield , whose now-debunked 1998 study in the prestigious Lancet medical journal linked the measles, mumps and rubella vaccine to autism . It also criticizes organized groups that advise parents to avoid vaccinating their children for fear the vaccines may cause autism.

The issue is at the center of a vociferous and often vicious debate, despite the preponderance of scientific opinion in favor of vaccination.

Offit has endured hate-filled letters, death threats and even a phone call that menaced his children. However, his book was greeted with an outpouring of support from parents of children with autism who had previously remained silent.

"It's actually been exactly the opposite of what I would have guessed," Offit said in an interview.
One mother of an 8-year-old autistic boy wrote: "It really angers me when I hear others vilify you."
Another example: "I am a very unpopular mother at my children's school as I do advocate that children need to get their shots," writes the mother of a 10-year-old boy with autism.
"I would rather deal with autism (even though some days I go bananas) than bury a child to a disease that could have been prevented."

DESPERATE PARENTS
Autism is a brain disorder characterized by problems with social interaction, repetitive behavior and other symptoms.
People with a mild version called Asperger's syndrome usually function relatively well in society, although they have problems relating to others. People with the most extreme symptoms may be unable to speak and may also suffer severe mental illness and retardation.

Surveys by the U.S. Centers for Disease Control and Prevention indicate that one in every 150 children falls into the so-called autism spectrum . No one knows what causes autism, there is no good treatment and parents are understandably often despondent.

Last week a special U.S. federal vaccine court ruled against three families who claimed vaccines caused autism in their children. Offit hopes the ruling, on top of dozens of scientific reports, may reassure parents whose fears about vaccines have caused a plunge in vaccination rates in developed countries.
As a result, childhood illnesses like measles are making a comeback. More than 1,300 measles cases were reported in England and Wales in 2008, and 197,000 people died globally from measles in 2007.
In January, an unvaccinated 7-year-old in the U.S. state of Minnesota died of meningitis caused by Haemophilus influenzae , an infection prevented by a routine childhood vaccine.

These numbers frustrate public health officials , who cite study after study showing no link between vaccination and autism.

Some vaccine doubters believe that doctors and federal health agencies such as the CDC have colluded with vaccine makers to cover up vaccine dangers.

Many have accused Offit of harming children. One caller even threatened Offit's own children.
"The guy said, 'We all want what is best for our children, and you want what is best for your children, Will and Emily, who go to the Kenwood school.' And then he hung up. That scared me," Offit said.
Offit has in particular been doubted because he helped invent the Rotateq vaccine now marketed by Merck and Co to prevent rotavirus.

SHOCKING DEATH
"We were never paid by Merck. Our funding always came from NIH (the U.S. National Institutes of Health)," he said.
His determination to invent a vaccine began in 1979 when, as doctor in training at the University of Pittsburgh, he helped a team struggling to save a 9-month-old baby with severe diarrhea and vomiting from rotavirus.
"I have never seen a child so dehydrated," Offit said. "We tried to get an IV line into her. She never moved," he said.

"We all just stood there in shock that someone had died of viral diarrhea. The mother was outside. Then you have to open the door and tell her to come in and see her dead girl, this previously healthy, 9-month-old girl."
Offit and other experts say that parents today rarely see their children die of diseases that a few decades ago routinely carried off young children, and thus sometimes cannot appreciate the value of vaccines.
They note that every few years the rationale against vaccination changes. First opponents said the measles vaccine somehow caused the mysterious condition; then they argued that it was the mercury-based preservative in some vaccines, and later put forward the idea that some children are somehow predisposed to be hyper-sensitive to vaccines.

Some fear vaccines somehow damage or weaken the immune system. Yet in the vaccines against 14 different diseases now given to U.S. children, there are fewer immunological agents than in two shots given in 1980, Offit said.

"You have living on the surface of your body trillions of bacteria. You are hammered when you are born, and you can handle it. Vaccines are nothing. Vaccines are a drop in the ocean," he said.

Fever and Taking Your Child's Temperature
Most parents have experienced this scenario: You wake up in the middle of the night to find your child standing by your bed, flushed, hot, and sweaty. Your little one's forehead feels warm. You immediately suspect a fever, but are unsure of what to do next. Should you get out the thermometer? Call the doctor?

In healthy kids, fevers usually don't indicate anything serious. Although it can be frightening when your child's temperature rises, fever itself causes no harm and can actually be a good thing — it's often the body's way of fighting off infections. And not all fevers need to be treated. High fever, however, can make a child uncomfortable and aggravate problems such as dehydration.

But it's easy to learn how to correctly take a child's temperature when it's a little higher than usual. Read on for more about fevers, how to measure and treat them, and when to call your child's doctor.
What Is Fever?

Fever occurs when the body's internal "thermostat" raises the body temperature above its normal level. This thermostat is found in the part of the brain called the hypothalamus. The hypothalamus knows what temperature your body should be (usually around 98.6° Fahrenheit, or about 37° Celsius) and will send messages to your body to keep it that way.

Most people's body temperatures even change a little bit during the course of the day: It's usually a little lower in the morning and a little higher in the evening and can fluctuate as kids run around, play, and exercise.
Sometimes, though, the hypothalamus will "reset" the body to a higher temperature in response to an infection, illness, or some other cause. So, why does the hypothalamus tell the body to change to a new temperature? Researchers believe turning up the heat is the body's way of fighting the germs that cause infections and making the body a less comfortable place for them.

What Causes Fever?
It's important to remember that fever by itself is not an illness — it's usually a symptom of an underlying problem. Fever has several potential causes:
Infection: Most fevers are caused by infection or other illness. Fever helps the body fight infections by stimulating natural defense mechanisms.
Overdressing: Infants, especially newborns, may get fevers if they're overbundled or in a hot environment because they don't regulate their body temperature as well as older children. However, because fevers in newborns can indicate a serious infection, even infants who are overdressed must be evaluated by a doctor if they have a fever.
Immunizations: Babies and children sometimes get a low-grade fever after getting vaccinated.
Although teething may cause a slight rise in body temperature, it's probably not the cause if a child's temperature is higher than 100° Fahrenheit (37.8° Celsius).

When Can a Fever Be a Sign of Something Serious?
In the past, doctors advised treating a fever on the basis of temperature alone. But now they recommend considering both the temperature and the child's overall condition.
Kids whose temperatures are lower than 102° Fahrenheit (38.9° Celsius) often don't require medication unless they're uncomfortable. There's one important exception to this rule: If you have an infant 3 months or younger with a rectal temperature of 100.4° Fahrenheit (38° Celsius) or higher, call your doctor or go to the emergency department immediately. Even a slight fever can be a sign of a potentially serious infection in very young infants.
If your child is between 3 months and 3 years old and has a fever of 102.2° Fahrenheit (39° Celsius) or higher, call the doctor to see if he or she needs to see your child. For older kids, take behavior and activity level into account. Watching how your child behaves will give you a pretty good idea whether a minor illness is the cause or if your child should be seen by a doctor.
The illness is probably not serious if your child:
is still interested in playing
is eating and drinking well
is alert and smiling at you
has a normal skin color
looks well when his or her temperature comes down
And don't worry too much about a child with a fever who doesn't want to eat. This is very common with infections that cause fever. For kids who still drink and urinate normally, not eating as much as usual is OK.

How Do I Know if My Child Has a Fever?
A gentle kiss on the forehead or a hand placed lightly on your child's skin is often enough to give you a hint that your child has a fever. However, this method of taking a temperature (called tactile temperature) is dependent on the person doing the feeling and doesn't give an accurate measure of temperature.
Use a reliable thermometer to tell if your child has a fever when his or her temperature is at or above one of these levels:
100.4° Fahrenheit (38° Celsius) measured rectally (in the bottom)
99.5° Fahrenheit (37.5° Celsius) measured orally (in the mouth)
99° Fahrenheit (37.2° Celsius) measured in an axillary position (under the arm)
But how high a fever is doesn't tell you much about how sick your child is. A simple cold or other viral infection can sometimes cause a rather high fever (in the 102°–104° Fahrenheit / 38.9°–40° Celsius range), but this doesn't usually indicate a serious problem. And serious infections may cause no fever or even an abnormally low body temperature, especially in infants.
Because fevers may rise and fall, a child with fever might experience chills as the body tries to generate additional heat as its temperature begins to rise. The child may sweat as the body releases extra heat when the temperature starts to drop.
Sometimes kids with a fever breathe faster than usual and may have a higher heart rate. You should call the doctor if your child is having difficulty breathing, is breathing faster than normal, or continues to breathe fast after the fever comes down.
Different Types of Thermometers
Whichever type of thermometer you choose, be sure you know how to use it correctly to get an accurate reading. Keep and follow the manufacturer's recommendations for any thermometer.
Digital thermometers usually provide the quickest, most accurate readings. They come in many sizes and shapes, are available at most supermarkets and pharmacies, and are available in a range of prices. Although you should read the manufacturer's instructions to determine what method or methods the thermometer is designed for, many digital thermometers can be used for the following temperature-taking methods:
oral (in the mouth)
rectal (in the bottom)
axillary (under the arm)
Digital thermometers usually have a plastic, flexible probe with a temperature sensor at the tip and an easy-to-read digital display on the opposite end.
Electronic ear thermometers measure the tympanic temperature — the temperature inside the ear canal. Although they're quick and easy to use in older babies and children, electronic ear thermometers aren't as accurate for infants 3 months or younger as digital thermometers and are more expensive.
Plastic strip thermometers (small plastic strips that you press against your child's forehead) may be able to tell you whether your child has a fever, but they aren't reliable for taking an exact measurement, especially in infants and very young children. If you need to know your child's exact temperature, plastic strip thermometers are not the way to go.
Forehead thermometers also may be able to tell you if your child has a fever, but are not as accurate as oral or rectal digital thermometers.
Pacifier thermometers may seem convenient, but again, their readings are less reliable than rectal temperatures and shouldn't be used in infants younger than 3 months. They also require the child to keep the pacifier in the mouth for several minutes without moving, which is a nearly impossible task for most babies and toddlers.
Glass mercury thermometers were once common, but the American Academy of Pediatrics (AAP) now says they should not be used because of concerns about possible exposure to mercury, which is an environmental toxin. (If you still have a mercury thermometer, do not simply throw it in the trash where the mercury can leak out. Talk to your doctor or your local health department about how and where to dispose of a mercury thermometer.)
As any parent knows, taking a squirming child's temperature can be challenging. But it's one of the most important tools doctors have to determine if a child has an illness or infection. The method you choose to take your child's temperature will depend on his or her age and how cooperative your child is.
If your child is younger than 3 months, you'll get the most reliable reading by using a digital thermometer to take a rectal temperature. Electronic ear thermometers aren't recommended for infants younger than 3 months because their ear canals are usually too small.
If your child is between 3 months to 4 years old, you can use a digital thermometer to take a rectal temperature or an electronic ear thermometer to take the temperature inside the ear canal. You could also use a digital thermometer to take an axillary temperature, although this is a less accurate method.
If your child is 4 years or older, you can usually use a digital thermometer to take an oral temperature if your child will cooperate. However, kids who have frequent coughs or are breathing through their mouths because of stuffy noses might not be able to keep their mouths closed long enough for an accurate oral reading. In these cases, you can use the tympanic method (with an electronic ear thermometer) or axillary method (with a digital thermometer).

How to Use a Digital Thermometer
A digital thermometer offers the quickest, most accurate way to take a child's temperature and can be used in the mouth, armpit, or rectum. Before you use one, read the directions thoroughly. You need to know how the thermometer signals that the reading is complete (usually, it's a beep or a series of beeps or the temperature flashes in the digital window on the front of the thermometer).
First, turn on the thermometer and make sure the screen is clear of any old readings. If your thermometer uses disposable plastic sleeves or covers, put one on according to the manufacturer's instructions. Remember to discard the sleeve after each use and to clean the thermometer according to the manufacturer's instructions before putting it back in its case.
To take a rectal temperature: Before becoming parents, most people cringe at the thought of taking a rectal temperature. But don't worry — it's a simple process:
Lubricate the tip of the thermometer with a lubricant, such as petroleum jelly.
Place your child:
- belly-down across your lap or on a firm, flat surface and keep your palm along the lower back
- or face-up with legs bent toward the chest with your hand against the back of the thighs
With your other hand, insert the lubricated thermometer into the anal opening about ½ inch to 1 inch (about 1.25 to 2.5 centimeters). Stop if you feel any resistance.
Steady the thermometer between your second and third fingers as you cup your hand against your baby's bottom. Soothe your child and speak quietly as you hold the thermometer in place.
Wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading.
To take an oral temperature: This process is easy in an older, cooperative child.
Wait 20 to 30 minutes after your child finishes eating or drinking to take an oral temperature, and make sure there's no gum or candy in your child's mouth.
Place the tip of the thermometer under the tongue and ask your child to close his or her lips around it. Remind your child not to bite down or talk, and to relax and breathe normally through the nose.
Wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading.
To take an axillary temperature: This is a convenient way to take a child's temperature. Although not as accurate as a rectal or oral temperature in a cooperative child, some parents may prefer to take an axillary temperature, especially for kids who can't hold a thermometer in their mouths.
Remove your child's shirt and undershirt, and place the thermometer under an armpit (it must be touching skin only, not clothing).
Fold your child's arm across the chest to hold the thermometer in place.
Wait until you hear the appropriate number of beeps or other signal that the temperature is ready to be read. Write down the number on the screen, noting the time of day that you took the reading.
Whatever method you choose, keep these additional tips in mind:
Never take a child's temperature right after a bath or if he or she has been bundled tightly for a while — this can affect the temperature reading.
Never leave a child unattended while taking a temperature.
Helping Kids Feel Better
Again, not all fevers need to be treated. And in most cases, a fever should be treated only if it's causing a child discomfort. Here are ways to alleviate symptoms that often accompany a fever:
If your child is fussy or appears uncomfortable, you can give acetaminophen or ibuprofen based on the package recommendations for age or weight. If you don't know the recommended dose or your child is younger than 2 years, call the doctor to find out how much to give. Remember that fever medication will usually temporarily bring a temperature down, but it will not return it to normal — and it won't treat the underlying reason for the fever. (Unless instructed by a doctor, never give aspirin to a child due to its association with Reye syndrome, a rare but potentially fatal disease.) Infants under 2 months old should not be given any medication for fever without being evaluated by a doctor. If your child has any medical problems, check with the doctor to see which medication is best to use.
Giving a sponge bath can make your child more comfortable and help bring the fever down. Use only lukewarm water; cool water may cause shivering, which actually raises body temperature. Never use alcohol (it can cause poisoning when absorbed through the skin) or ice packs/cold baths (they can cause chills that may raise body temperature).
Dress your child in lightweight clothing and cover him or her with a light sheet or blanket. Overdressing and overbundling can prevent body heat from escaping and can cause a temperature to rise.
Make sure your child's room is a comfortable temperature — not too hot or too cold.
Offer plenty of fluids to avoid dehydration — a fever will cause a child to lose fluids more rapidly. Water, soup, ice pops, and flavored gelatin are all good choices. Avoid drinks containing caffeine, including colas and tea, because they can cause increased urination.
If your child also is vomiting and/or has diarrhea, ask the doctor if you should give an electrolyte (rehydration) solution made especially for kids. You can find these solutions at pharmacies and supermarkets. Don't offer sports drinks — they're not designed for younger children, and the added sugars may make diarrhea worse. Also, limit your child's intake of fruits and apple juice.
In general, let your child eat what he or she wants (in reasonable amounts) but don't force eating if your child doesn't feel like it.
Make sure your child gets plenty of rest. Staying in bed all day isn't necessary, but a sick child should take it easy.
It's best to keep a child with a fever home from school or child care. Most doctors feel that it's safe to return when the temperature has been normal for 24 hours.
When to Call the Doctor
The exact temperature that should trigger a call to the doctor depends on the age of the child, the illness, and whether the child has other symptoms with the fever.
Call your doctor if you have an:
infant younger than 3 months with a temperature of 100.4° Fahrenheit (38° Celsius) or higher
older child with a temperature of higher than 102.2° Fahrenheit (39° Celsius)
Call the doctor if an older child has a fever of less than 102.2° Fahrenheit (39° Celsius) but also:
refuses fluids or seems too ill to drink adequately
has persistent diarrhea or repeated vomiting
has any signs of dehydration (urinating less than usual, not having tears when crying, less alert and less active than usual)
has a specific complaint (i.e., sore throat or earache)
still has a fever after 24 hours (in kids younger than 2 years) or 72 hours (in kids 2 years or older)
has recurrent fevers, even if they only last a few hours each night
has a chronic medical problem such as heart disease, cancer, lupus, or sickle cell anemia
has a rash
has pain with urination
Seek emergency care if your child shows any of the following signs along with a fever:
inconsolable crying
extreme irritability
lethargy and difficulty waking
rash or purple spots that look like bruises on the skin (that were not there before the child got sick)
blue lips, tongue, or nails
infant's soft spot on the head seems to be bulging outward or sunken inwards
stiff neck
severe headache
limpness or refusal to move
difficulty breathing that doesn't get better when the nose is cleared
leaning forward and drooling
seizure
abdominal pain

Also, ask your child's doctor for his or her specific guidelines on when to call about a fever.

Fever: A Common Part of Childhood
All kids get fevers, and in the majority of cases, most are completely back to normal within a few days. For older infants and children (but not necessarily for infants younger than 3 months), the way they act is far more important than the reading on your thermometer. Everyone gets cranky when they have a fever. This is normal and should be expected.

But if you're ever in doubt about what to do or what a fever might mean, or if your child is acting ill in a way that concerns you even if there's no fever, always call your doctor for advice.





Teaching Your Child How to Use 911
One of the challenges you have as a parent is to help your child acquire the skills to work through whatever obstacles life presents. Teaching your child how to use 911 in an emergency could be one of the simplest - and most important - lessons you'll ever share.
Talking About 911 With Your Child
Not that many years ago, there was a separate telephone number for each type of emergency agency. For a fire, you called the fire department number. For a crime, you called the police. For a medical situation, you phoned the ambulance or doctor.
In 1968, the U.S. government worked with the phone company to establish 911 as a central number for all types of emergencies. An emergency dispatch operator quickly takes information from the caller and puts the caller in direct contact with whatever emergency personnel are needed, thus making response time quicker.
According to the National Emergency Number Association, 911 covers nearly all of the population of the United States. Check your phone book to ensure that 911 is the emergency number you should use in your area.
Everyone needs to know about calling 911 in an emergency. But children in particular need specifics about what an emergency is. Asking your child, "What would you do if we had a fire in our house?" or "What would you do if you saw someone trying to break in?" gives you a chance to discuss what constitutes an emergency and what should be done if one occurs. Role playing is an especially good way to address various emergency scenarios and give your child the confidence he or she will need to handle them.
For younger children, it might also help to talku about who the emergency workers are in your community - police officers, firefighters, paramedics, doctors, nurses, and so on - and what kinds of things they do to help people who are in trouble. This will paint a clear pictre for your little one of not only what types of emergencies can occur, but also who can help.

When to Call 911
Learning what is an emergency goes hand in hand with learning what isn't. A fire, an intruder in the home, an unconscious family member - these are all things that would require a call to 911. A skinned knee, a stolen bicycle, or a lost pet wouldn't. Still, teach your child that if ever in doubt and there's no adult around to ask to always make the call. It's much better to be safe than sorry.
Make sure your child understands that calling 911 as a joke is a crime in many places. In some cities, officials estimate that as much as 75% of the calls made to 911 are nonemergency calls. These are not all pranks. Some people accidentally push the emergency button on their cell phones. Others don't realize that 911 is for true emergencies only. That means it's not for such things as a flat tire or even about a theft that occurred the week before.
Stress to your child that whenever an unnecessary call is made to 911, it can delay a response to someone who actually needs it. Most areas now have what is called enhanced 911, which enables a call to be traced to the location from which it was made. So if someone dials 911 as a prank, emergency personnel could be dispatched directly to that location. Not only could this mean life or death for someone having a real emergency on the other side of town, it also means that it's very likely the prank caller will be caught and punished.
How to Use 911
Although most 911 calls are now traced, it's still important for your child to have your street address and phone number memorized. Your child will need to give that information to the operator as a confirmation so time isn't lost sending emergency workers to the wrong address.
Make sure your child knows that even though he or she shouldn't give personal information to strangers, it's OK to trust the 911 operator. Walk him or her through some of the questions the operator will ask, including:
Where are you calling from? (Where do you live?)
What type of emergency is this?
Who needs help?
Is the person awake and breathing?
Explain to your child that it's OK to be frightened in an emergency, but that it's important to stay calm, speak slowly and clearly, and give as much detail to the 911 operator as possible. If your child is old enough to understand, also explain that the emergency dispatcher may give first-aid instructions before emergency workers arrive at the scene.
Make it clear that your child should not hang up until the person on the other end says it's OK, otherwise important instructions or information could be missed.
More Safety Tips
Here are some additional safety tips to keep in mind:
Always refer to the emergency number as "nine-one-one" not "nine-eleven." In an emergency, your child may not know how to dial the number correctly because of trying to find the "eleven" button on the phone.
Make sure your house number is clearly visible from the street so that police, fire, or ambulance workers can easily locate your address.
If you live in an apartment building, make sure your child knows the apartment number and floor you live on.
Keep a list of emergency phone numbers handy near each phone for your children or babysitter. This should include police, fire, and medical numbers (this is particularly important if you live in one of the few areas where 911 is not in effect), as well as a number where you can be reached, such as your cell phone, pager, or work number. In the confusion of an emergency, calling from a printed list is simpler than looking in the phone book or figuring out which is the correct speed-dial number. The list should also include known allergies, especially to any medication, medical conditions, and insurance information.
If you have special circumstances in your house, such as an elderly grandparent or a person with a heart condition, epilepsy, or diabetes living in your home, prepare your child by discussing specific emergencies that could occur and how to spot them.
Keep a first-aid kit handy and make sure your child and babysitters know where to find it. When your child is old enough, teach him or her basic first aid.



Whooping cough (pertussis)
Reviewed by Dr John Pilinger, GP

What is whooping cough?
Whooping cough (pertussis) is still a very serious disease when it occurs in children under the age of one year old. But thanks to an effective vaccine and prevention against infection, it is now quite rare.
   
Whooping cough is a very serious disease when it occurs in children aged under one year.

Before the vaccination against whooping cough was introduced, three out of four children caught the disease and some died every year. Today only a few get whooping cough.
What causes whooping cough?
Whooping cough is caused by a bacteria (Bordetella pertussis) and is one of the most contagious bacterial infections. If one child in a group of siblings gets it, the other children are extremely likely to become infected if they have not already had the disease or been vaccinated.
This also includes babies. Although infants who are breastfed are usually protected against most common childhood infections, they receive no protection against whooping cough. This is why early vaccination is recommended.
Children with a cold or cough should be kept away from non-vaccinated children as well as women in labour and newborn babies.
How is whooping cough contracted?
The infection is transferred through airborne droplets when an infected person coughs. Anyone who has not been vaccinated is highly likely to contract the disease just by spending time in the same room as an infected person.
Anyone who has been vaccinated or has suffered from whooping cough will have a degree of immunity to the disease. They may contract a mild case some years later but this will not develop into a full-blown attack.
The incubation period - the time between contracting the infection and the appearance of the main symptoms - can vary from 5 to 15 days or even longer.
Whooping cough is infectious from the first sneezes and throughout the course of the disease, which can last for up to eight weeks. This is a much longer period than with other children's diseases.
What are the symptoms of whooping cough?
The disease begins with a cold and a mild cough. After this, the typical coughing bouts set in. The coughing continues until no air is left in the lungs. After this comes a deep intake of breath that produces a heaving, 'whooping' sound when the air passes the larynx (windpipe) that gives rise to the name of the disease.
The patient will eventually cough up some phlegm and these attacks may well be followed by vomiting. The child's temperature is likely to remain normal.
A bout of whooping cough can be very distressing for both the child and the parents who feel unable to help.
Coughing attacks may occur up to 40 times a day and the disease can last for up to eight weeks.
How does the doctor make the diagnosis? The diagnosis is usually made from the symptoms and the history of contact with a person suffering from whooping cough. In case of doubt, the doctor can take swabs from the nose and throat for analysis and have the results in about five days.
Complications While whooping cough is very unpleasant, there may also be other complications, such as bronchitis, pneumonia and ear infections. These complications may cause a high temperature, and change the course of the disease. If one or more of these problems occur, they will usually be treated with antibiotics.
How is whooping cough treated? Most cases of whooping cough require no specific treatment. Infants and small children with other conditions such as asthma require constant monitoring which, at least for a while, is best done in a hospital. The effect of antibiotics is uncertain but they are sometimes used in the early period of the disease.
Vaccination is recommended.
How does one prevent the infection?Just as important as the vaccination, is the necessity to prevent the infection spreading especially to small children. This is especially important for children in nursery school.
If there are infected children in childcare, other infants under the age of one year should not be admitted unless they have had whooping cough or have been vaccinated against it twice, with a period of four weeks between vaccinations.
If the children are more than one year old they may be admitted even if they have not had the disease themselves or been vaccinated. But the parents must be informed of the danger of infection.
If whooping cough occurs at home, no special measures are necessary.
Which medicine can be used?There is no medical treatment against whooping cough as such. However, the infectious period may be reduced by giving certain antibiotics (eg erythromycin).
Who should be vaccinated?The vaccination takes place at the age of two, three and four months as part of the 'triple' Diphtheria-Tetanus-Pertussis (DTP) immunisation. After the first two vaccinations protection is almost 100 per cent. (DTP is now routinely combined with vaccination against Haemophilus influenzae in the UK.)
It is advisable that all children should be vaccinated against whooping cough, as it is important to prevent this dangerous disease.
Based on a text by Dr Hanne Korsholm

Last updated 01.02.2002


FDA Warns Against Codeine for Mothers of Nursing Infants
Emma Hitt, PhD
Medscape Medical News 2007. © 2007 Medscape
August 17, 2007 — Medications containing codeine given to breast-feeding mothers who rapidly metabolize codeine into morphine may cause adverse effects in their infants, according to an alert sent today from MedWatch, the US Food and Drug Administration (FDA) adverse event and reporting program.
Codeine is generally considered safe for use in nursing mothers; however, last year, a healthy 13-day-old breast-fed infant died from very high levels of morphine received through breast milk. The mother was taking codeine at a dose lower than that usually prescribed for episiotomy pain, but genetic testing revealed that the infant's mother was an ultrarapid metabolizer of codeine.
According to the FDA, depending on ethnicity, approximately anywhere from 1 to 28 per 100 individuals rapidly metabolize codeine. Genetic testing is the only way to determine whether someone is a rapid metabolizer; an FDA-cleared test for determining a patient's CYP2D6 genotype is available, but there is limited information about using this test to characterize codeine metabolism. In addition, the test result is insufficient in predicting whether too much morphine will be passed along in a mother breast-feeding an infant.
The FDA recommends that patients be made aware of the signs of morphine overdose. Patients should be told to contact their clinician if a baby shows signs of increased sleepiness (ie, sleeping for more than 4 hours at a time), limpness, or difficulty nursing or breathing.
Healthcare professionals and nursing mothers should report adverse effects that occur while using codeine to the FDA's MedWatch adverse event reporting program by phone at 1-800-332-1088 begin_of_the_skype_highlighting              1-800-332-1088      end_of_the_skype_highlighting.



Circumcision
Whether you're expecting a baby boy or have just welcomed your new little guy into the world, you have an important decision to make before you take your son home: whether to circumcise him.

For some families, the choice is simple because it's based on cultural or religious beliefs. But for others, the right option isn't as clear-cut. Before you make a circumcision decision, it's important to talk to your child's doctor and consider some of the issues.

What Is Circumcision?
Boys are born with a hood of skin, called the foreskin, covering the head (also called the glans) of the penis. In circumcision, the foreskin is surgically removed, exposing the end of the penis.

Approximately 65% of all newborn boys - about 1.2 million babies - are circumcised in the United States each year. The procedure is much more widespread in the United States, Canada, and the Middle East than in Asia, South America, Central America, and most of Europe, where it's uncommon.

Parents who choose circumcision often do so based on religious beliefs, concerns about hygiene, or cultural or social reasons, such as the wish to have their son look like other men in the family.

If you do opt for circumcision, it's best to perform the operation within the first 2 to 3 weeks after birth, as it can become more complicated as a child gets older. But the procedure is usually performed during the first 10 days (often within the first 48 hours), either in the hospital or, for some religious ritual circumcisions, at home. If you decide to have your son circumcised at the hospital, your pediatrician, family doctor, or obstetrician will perform the procedure before you bring your baby home. The doctor should prepare you by telling you about the procedure he or she will use and the possible risks.

In some instances, doctors may decide to delay the procedure or forgo it altogether. Premature babies or those who have special medical concerns may not be circumcised until they're ready to leave the hospital. And babies born with physical abnormalities of the penis that need to be corrected surgically often aren't circumcised at all because the foreskin may eventually be used as part of a reconstructive operation.

The Pros and Cons
On the plus side, studies indicate that circumcised infants are less likely to contract a urinary tract infection (UTI) in the first year of life. About one out of every 1,000 circumcised boys has a UTI in the first year, whereas the rate is one in 100 (at most) for uncircumcised infants.

Circumcised men may also be at lower risk for penile cancer, although the disease is rare in both circumcised and uncircumcised males. Although some studies indicate that the procedure might offer an additional line of defense against sexually transmitted diseases (STDs), particularly HIV, the results of studies in this area are conflicting and difficult to interpret.

It's also easier to keep a circumcised penis clean, although uncircumcised boys can learn how to clean beneath the foreskin once the foreskin becomes retractable (usually some time before age 5). However, some uncircumcised boys can end up with infected foreskins as the result of poor hygiene.

Some people also claim that circumcision either lessens or heightens the sensitivity of the tip of the penis, decreasing or increasing sexual pleasure later in life. But neither of these subjective findings has been proven to be true.

Although circumcision appears to have some medical benefits, it also carries potential risks - as does any surgical procedure. These risks are small, but you should be aware of both the possible advantages and the problems that can be associated with the procedure before you make your decision. Complications of newborn circumcision are uncommon, occurring in between 0.2% to 3% of cases. Of these, the most frequent are minor bleeding and local infection, both of which can be easily treated by your child's doctor.

Perhaps one of the hardest parts of the decision to circumcise is accepting that the procedure can be painful. In the past, it wasn't commonplace to provide pain relief for babies being circumcised, but because studies have indicated that it benefits the infant to receive anesthesia, most doctors will now provide it. Also, the American Academy of Pediatrics (AAP) recommends the use of pain relief measures for circumcision. Even up until recently, though, anesthesia hasn't been universally used, so it's important to ask your doctor ahead of time what, if any, pain relief will be utilized with your son.

Two primary forms of local anesthetic are used to make the operation less painful for your baby:

    * a topical cream (a cream put on the penis) that requires at least 20 to 40 minutes to take its full effect
    * an injectable anesthetic that requires less time to take effect and may provide a slightly longer period of anesthesia

Besides anesthesia, giving a pacifier dipped in sugar water can help reduce your baby's level of stress (and yours). Used together, these methods can decrease your baby's discomfort by more than 50%.

Caring for a Circumcised Penis
Whether you choose circumcision or not, it's important to keep your son's penis clean. It should be washed with soap and warm water every time you bathe him. And you don't need to use cotton swabs, astringents, or any special bath products.

There are also no special washing precautions with newly circumcised babies, other than to be gentle, as your baby may have some mild discomfort after the circumcision. If your son has a bandage on his incision, you might need to apply a new one whenever you change his diaper for a day or 2 after the procedure (put petroleum jelly on the bandage so it won't stick to his skin). Doctors often also recommend putting a dab of petroleum jelly on the baby's penis or on the front of the diaper to alleviate any potential discomfort caused by friction against the diaper.

How you take care of your baby's penis may also vary depending on the type of circumcision procedure your child's doctor performs. Be sure to talk to him or her about what aftercare will be needed.

It usually takes between 7 to 10 days for a penis to heal. Until it does, the tip may seem raw or yellowish in color. Although this is normal, certain other symptoms are not. Call your child's doctor right away if you notice any of the following:

    * persistent
    * bleeding redness around the tip of the penis that gets worse after 3 days
    *
    * fever signs of infection, such as the presence of pus-filled blisters
    * not urinating normally within 6 to 8 hours after the circumcision

However, with quick intervention, almost all circumcision-related problems are easily treated.

Caring for an Uncircumcised Penis
As with a penis that's circumcised, an uncircumcised one should be kept clean. Also, no cotton swabs, astringents, or any special bath products are needed - simple soap and warm water every time you bathe your baby will suffice.

However, you should never forcibly pull back the foreskin to clean beneath it. Instead, gently tense it against the tip of the penis and wash off any smegma (the whitish "beads" of dead skin cells mixed with the body's natural oil). Over time, the foreskin will retract on its own so that it can be pulled away from the glans toward the abdomen. This happens at different times for different children, but most boys can retract their foreskins by the time they're 5 years old.

As your son grows up, teach him to wash beneath the foreskin by gently pulling it back from the glans, rinsing the glans and the inside of the foreskin with soap and warm water, then pulling the foreskin back over the head of the penis.

Making a Circumcision Decision
In addition to the medical issues discussed, religious and cultural beliefs often figure into the equation. Of course, if these are important to you, they deserve to be seriously considered.

Despite the possible benefits and risks, circumcision is neither essential nor detrimental to a boy's health. The AAP and the American Academy of Family Physicians (AAFP) do not endorse the procedure as a way to prevent any of the medical conditions mentioned previously. The AAP also does not find sufficient evidence to medically recommend circumcision or argue against it.

Talk to your child's doctor about the pros and cons of circumcision to help you make the choice that's right for your son.

Updated and reviewed by: Barbara P. Homeier, MD
Date reviewed: January 2005
Originally reviewed by: Steven Dowshen, MD
Study: Circumcision Protects Against AIDS   
Fri Mar 26, 3:28 PM ET    By ROBERT BARR, Associated Press Writer


uncircumcised men were nearly seven times more likely to get the AIDS (news - web sites) virus, giving further support to findings that circumcision .   

The study by Robert C. Bollinger and colleagues from Johns Hopkins University Medical School and the National AIDS Research Institute in Pune, India, was published Friday as a "research letter" in The Lancet medical journal.

"It is now about the ninth study which followed men who are HIV (news - web sites)-negative over a period of months or years. It is the ninth study in a row which has found that the effect (of circumcision) is significant," said Robert C. Bailey, professor of epidemiology and biostatistics at the University of Illinois at Chicago, who was not connected with Bollinger's study.

"The fact that they found no behavioral differences between the two groups is all the more compelling, and indicates that there is a biological factor," Bailey said in a telephone interview.

Bailey, like the authors of the Lancet study, believe that cells in the foreskin may be particularly susceptible to infection.

The association between circumcision and a reduced risk of HIV was noted as early as 1987, when Dr. William Cameron of the University of Manitoba in Canada reported findings from a study in Kenya.

The research published in The Lancet tracked 2,298 men who were being treated at three clinics in Pune, and who were confirmed to be HIV-negative at the start of the study.

The study also found that circumcised men were as much at risk of gonorrhea, herpes simplex and syphilis as the uncircumcised.

The nine studies have all tried to control for variables in behavior, Bailey said. "A randomized control trial is what is necessary now to really nail this down," he said.



Two-Year-Olds Mimic Parents' who smoke and drink
TUESDAY, Sept. 6 (HealthDay News) -- Parents, your children are watching: A new study finds that even 2-year-olds are more likely to "smoke" and "drink" during pretend play if their parents smoke and drink regularly.

Toddlers were also more like to mimic these dangerous adult activities if they were regularly exposed to PG-13 or R-rated movies, the researchers found.

It's not news that parental habits can influence their offspring's smoking and drinking habits, said lead researcher Madeline Dalton, director of the Hood Center for Children and Family Community Health Research Program at Dartmouth Medical School, Lebanon, N.H.

"What is new in this study is really the age," she said.

"Lots of people have looked at the social influences of tobacco and alcohol use. Parental smoking and alcohol use are potent predictors of kids' use," she said, noting that that's been long known for teens. "What we wanted to do was to start looking at younger children."

Reporting in the September issue of the Archives of Pediatrics and Adolescent Medicine, Dalton's team observed 120 children, aged 3 to 6, playing with two dolls. The child was asked to pretend to be one of the dolls while the researcher pretended to be the other doll.

The child was told to pretend he or she was the host and had invited the other doll over to watch a movie and have something to eat.

When the researcher-friend said there was nothing to eat, the child was invited to shop at a doll grocery store as researchers recorded the purchases.

For experiments involving 2-year-olds, the child was simply given one doll and told to take her shopping.

In all, 28 percent of the children bought cigarettes while 61 percent bought alcohol on these "shopping trips." The researchers then compared those buying habits with information they had gathered on the parents' smoking, drinking and movie-viewing habits.

They found that children were nearly four times as likely to buy cigarettes if their parents smoked, and three times as likely to choose wine or beer if their parents drank alcohol at least once a month.

Kids who were allowed to view PG-13 or R-rated movies were five times as likely to choose wine or beer while shopping than kids restricted to watching G-rated movies. According to the researchers, images of drinking adults seen in adult-rated films may be influencing these pro-alcohol "buying" decisions in youngsters.

The study is the first to show that preschoolers have what Dalton calls "social cognitive scripts" of adult social life -- behaviors perceived to be appropriate.

Some of the children even recognized specific brand names of cigarettes, the researchers found, because of the brands their parents smoked. Others role-played the lighting of cigarettes or pouring drinks.

The study findings don't surprise Danny McGoldrick, research director of the Campaign for Tobacco-Free Kids.

"It's an interesting study," he said. "I think it really just points to the social environment that kids grow up in. You see these ads that say 'Talk to Your Kids' [about not smoking]. But the best thing parents can do is not smoke themselves. Smoking has a huge impact on kids, not just with secondhand smoke but with role modeling."

If parents can't quit, McGoldrick said, they should, "at least make the home smoke-free."

The research was an eye-opener for Dalton on a professional and personal level. "It's never too early to talk to your kids about alcohol and cigarettes," she said.

"Certainly there are many instances where it is socially appropriate to use alcohol," she said, "but we need to counterbalance that with a clear message about not misusing it."

Dalton said she realized her habit of offering guests wine or beer when they arrive at her home was giving the wrong message to her young children. "Now, when I have guests, I ask, 'Can I get you something? We have water, we have juice, milk, soda, beer or wine.' Just so [her kids know] it's socially appropriate to choose something else."

Sinusitis Can Strike Kids, Too
It could be the common chronic problem of sinusitis, a condition that is usually associated with adults.

"It is as common in children as in adults, and when sinus problems get worse, asthma and bronchial problems get worse," says Dr. Jordan Josephson, a New York City otolaryngologic surgeon who specializes in pediatric care.

Kids can be particularly susceptible to sinus problems because their sinuses aren't fully formed until age 12, and their sinuses are narrower than an adult's.

If you factor in any allergies a child might have -- as well as environmental triggers like secondhand smoke, air pollution and exposure to bacteria -- that child's susceptibility to sinusitis increases, Josephson says.

Telltale signs of possible sinusitis in a child include a frequent runny nose with yellow mucus, pain near the cheeks or eye areas, and difficulty staying awake in school, Josephson says.

Sinusitis in children -- as well as adults -- can also produce emotional troubles like irritability and a general unhappiness. But a child is often unable to convey this sense of discomfort to a doctor, says Dr. Alexander Chester, an internist at Georgetown University Medical Center.

"It can be really tough for kids who feel poorly but whose illness is not validated by doctors or parents," he says. "A doctor looks at a kid with a runny nose and listlessness and basically tells him to shape up."

Sinusitis is characterized by inflammation of the nasal passages. It can be caused by any number of problems, from a cold to allergies to an infection, doctors say. The inflammation narrows the nasal passages so mucus can't drain properly, causing discomfort and sometimes infection.

Left untreated, sinusitis can become chronic, lasting for anywhere from three to eight weeks, to months or even years, according to the National Institute of Allergies and Infectious Diseases.

Statistics on the prevalence of sinusitis in children are hard to come by. But the National Center for Health Statistics reports that the condition affects about 32 million American adults a year, or approximately 16 percent of the adult population.

Parents should be alert to potential sinusitis symptoms in their children and get them to the doctor.

"If a cold lasts for 72 hours or less, it's nothing to worry about," says Josephson. "But if a child has a runny nose all the time and is home sick once a month, if he's falling asleep in school, getting bad grades or taking his hand and rubbing it up his nose because he can't get relief, you shouldn't dismiss these symptoms."

A pediatrician can prescribe a nasal spray and/or antibiotics if there is a bacterial infection, Josephson says.

"If after two to four weeks the child isn't better, he or she needs to see a specialist," he adds.

An otolaryngologist will examine the child in the same way an adult is examined, using CAT scans and maybe an endoscopy. This is a procedure where the doctor, using a slim tube with a camera at the end, can look directly at the sinus passages. Pediatric otolaryngologists have a smaller pediatric endoscope for this purpose, Josephson says. These tests allow the doctor to check for polyps, which can block the nasal passages, or anatomical abnormalities that constrict the natural flow of mucus.

While surgery is rarely performed on children, specialists typically recommend a longer course of antibiotic treatment, usually for a three- to eight-week period, Josephson says.

"Parents are resistant to the idea of an antibiotic for a long period of time," he says. "They often don't want to give kids antibiotics for more than 10 days. But living with an infection for a year isn't good, either. There could be polyp formation and long-term effects of doing poorly in school."


Growing Pains
Your 8-year-old son wakes up crying in the night complaining that his legs are throbbing. You rub them, and soothe him as much as you can, but are uncertain about whether to give him any medication or take him to the doctor. Sound familiar? Your child is probably experiencing growing pains, a normal occurrence in about 25% of children. Read below to find out more about this common problem.
Diagnosis
Growing pains generally strike during two periods: in early childhood among 3- to 5-year-olds and later on in 8- to 12-year-olds. They are what doctors call a diagnosis of exclusion. This means that other conditions should be ruled out before a diagnosis of growing pains is made. A thorough  history and physical examination by your child's doctor can usually accomplish this. In rare instances, blood and X-ray studies may be required before a final diagnosis of growing pains is made.
Causes
No firm evidence exists to show that growth of bones causes pain. The most likely causes of growing pains, therefore, are the aches and discomforts resulting from jumping, climbing, and running pursued by active children during the day. The pains can occur after a child has had a particularly athletic day.
Signs and Symptoms
Although growing pains often strike in late afternoon or early evening before bed, there are occasions when pain can wake a slumbering child. The intensity of the pain varies from child to child, and most kids don't experience the pains every day. "Growing pains are often intermittent, coming once a week or even more infrequently," says Dr. James White, a family practitioner.
Growing pains always concentrate in the muscles, rather than the joints. Most children report pains in the front of their thighs, in the calves, or behind the knee. While joints affected by more serious diseases are swollen, red, tender, or warm, the joints of children experiencing growing pains appear normal.
One symptom that doctors find most helpful in making a diagnosis of growing pains is how the child responds to touch while in pain. Children who have pain for a serious medical disease do not like to be handled, since movement tends to increase the pain. Children with growing pains respond differently; they feel better when they are held, massaged, and cuddled.
Treatment
Massage, stretching, heat, acetaminophen (Tylenol) or ibuprofen (Advil) may help to relieve the pain. Although the pains point to no serious illness, they can be upsetting to a child (or a parent!). Because a child seems completely cured of her aches in the morning, parents sometimes suspect that the child faked the pains. However, this usually is not the case. Support and reassurance that growing pains will pass as children grow up can help them relax.
When to Call Your Child's Doctor
Your child's doctor should be alerted if any of the following symptoms occur with your child's pain: persistent pain, swelling, or redness in one particular area or joint; fever; limping; unusual rashes; loss of appetite; weakness; tiredness; or uncharacteristic behavior. These signs do not accompany growing pains and may be an indication of a medical problem that needs attention. Pains or symptoms localized to the shoulders, arms, wrists, hands, fingers, neck, or back, or pain associated with a particular injury are not due to growing pains, and should be evaluated by a child's doctor.
Updated and reviewed by: Kim Rutherford, MD
Date reviewed: June 2001
Originally reviewed by: Steven Dowshen, MD, and Robert Cooper, MD


dehydration
Following a drinking schedule ensures that your children drink enough to stay hydrated without overdrinking.6 Kids should be well hydrated. For kids less than 90 lbs., it will help to drink 3-6 oz. of fluid one hour before activity. For kids more than 90 lbs., it will help to drink 6-12 oz. one hour before activity. For kids less than 90 lbs., drink 3-5 oz. every 20 minutes.
For kids more than 90 lbs., drink 6-9 oz. every 20 minutes. Drink to make up for any remaining fluid loss if a body weight deficit exists. In general, kids weighing less than 90 lbs. may need to drink up to 8 oz. per 1/2 lb. of weight loss and kids more than 90 lbs. may need 12 oz. per 1/2 lb. of weight loss in the first hour after activity. Learn to drink for individual needs. One kid-size gulp equals about 1/2 oz. of fluid.

When the body is low in fluids because a person is not drinking enough to replace what is lost through sweat.

Common warning signs of dehydration include:
thirst,
headache,
dizziness,
weakness,
irritability,
fatigue
nausea.
Children who are in the “tween” years can lose up to a quart of sweat during two hours of activity on a hot day.1,2 
Children are more susceptible to heat illness than adults when active in hot weather.3 Why?
  – Children produce more metabolic heat per pound of body weight during exercise. They also have a reduced sweating capacity, which lessens their ability to lose heat through sweat evaporation.3 
  – Like adults, children frequently do not have the physiological drive to drink enough water to replenish fluid loss during prolonged exercise.4
Think of fluids as essential safety equipment for sports, like a bike helmet or shin guards—always pack a squeeze bottle for your child’s practice or game. 
Leading health professional organizations recommend kids drink at regular intervals, not just when thirsty. By the time thirst kicks in, they’re likely already dehydrated.
Following a drinking schedule ensures that your children drink enough to stay hydrated without overdrinking.6 
  Kids should be well hydrated. For kids less than 90 lbs., it will help to drink 3-6 oz. of fluid one hour before activity. For kids more than 90 lbs., it will help to drink 6-12 oz. one hour before activity. 
For kids less than 90 lbs., drink 3-5 oz. every 20 minutes.
For kids more than 90 lbs., drink 6-9 oz. every 20 minutes. 
Drink to make up for any remaining fluid loss if a body weight deficit exists. In general, kids weighing less than 90 lbs. may need to drink up to 8 oz. per 1/2 lb. of weight loss and kids more than 90 lbs. may need 12 oz. per 1/2 lb. of weight loss in the first hour after activity. Learn to drink for individual needs. One kid-size gulp equals about 1/2 oz. of fluid.  
A study that offered active kids (ages 9-12) plain water, flavored water and a sports drink showed that they drank 90% more of the sports drink and stayed better hydrated than when drinking plain water.7
1 Iuliano, S. et al. Evaluation of the self-selected fluid intake practices by junior athletes during a simulated duathlon event. Int J Sports Nutr 8:10-23, 1998.
2 Meyer, F. et al. Sweat electrolyte loss during exercise in the heat: effects of gender and maturation. Med Sci Sports Exerc 24:776-781, 1992.
3 Bar-Or, O. Temperature regulation during exercise in children and adolescents. In: Gisolfi C, Lamb DR, eds. Perspectives in Exercise and Sports Medicine, II. Youth, Exercise and Sport. Indianapolis, IN: Benchmark Press; 1989, 335-367.
4 Rivera-Brown A., et al. Drink composition, voluntary drinking and fluid balance in exercising, trained, heat-acclimatized boys. J Appl Phys 86: 78-84, 1999.
5 Adapted from the 2000 National Athletic Trainers’ Association Position Statement: Fluid Replacement for Athletes, J Athletic Training 35(2): 212-224, 2000.
6 Adapted from the American Academy of Pediatrics Position Statement, Pediatrics 106: 158-159, 2000.
7 Wilk B. and Bar-Or, O. Effect of drink flavor and NaCl on voluntary drinking and hydration in boys exercising in the heat. J Appl Physiol, 80: 1112-1117, 1996.
8 Passe, D. et al. Impact of beverage acceptability on fluid intake during exercise. Appetite 35:219-225, 2000.
9 Epstein, Y. Exertional Heatstroke: Lessons we tend to forget. Am J Med Sports 2: 143-152, 2000. 
10 Watts, S. Prevention and treatment of dehydration in athletes. Am J Med Sports 3:286-293, 2001.
*  Scientifically formulated sports drink: a sports drink containing 5-8% carbohydrates (14g per 8oz.), at least 100mg sodium, at least 28mg potassium, no carbonation and no caffeine. (Maughan & Murray Sports Drink. Basic Science And Practical Aspects. Boca Raton: CRC PRESS, 2001, pp. 197-224.)
©2003 S-VC, Inc.
While water is readily available to most kids, research shows active kids don’t always drink enough water to stay fully hydrated.7
Juices have too many carbohydrates, so it takes longer for the fluid to be absorbed into the body.
A scientifically formulated sports drink* helps kids stay better hydrated7 because it:
- Replaces electrolytes active children lose through sweat, helping to maintain the right balance of fluids in the body;2
- Contains flavor and sodium to encourage drinking when active.7,8

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The Test Expectant Moms Shouldn't Skip
Fri Jul 11, 7:02 PM ET    By Kathleen Doheny

FRIDAY, July 11 (HealthDayNews) -- When women visit Dr. William Frumovitz late in their pregnancy, they're probably thinking about bassinettes, baby clothes and breast-feeding.

So the California obstetrician makes it a point to tell them about a very important test they need between their 35th and 37th week of pregnancy -- one that will tell them whether they have a bacterium called Group B streptococcus, which can threaten the life of their newborn.

Also known as GBS, or Group B strep, it is the most common cause of sepsis and meningitis in newborns, according to the U.S. Centers for Disease Control and Prevention (news - web sites) (CDC). Just last year, the CDC revised its 1996 guidelines for GBS testing and now recommends universal screening of all pregnant women at 35 to 37 weeks of pregnancy. In addition, the National Institutes of Health (news - web sites) has declared July as National Group B Strep Awareness Month.

Before the screening guidelines were strengthened, about 8,000 infants in the United States got Group B strep every year, and one of every 20 infected babies died. Those who survive often have long-term problems with hearing, vision and learning.

Problems related to Group B strep, which usually is found around the vagina and rectum, can occur a few hours after birth. Sepsis, meningitis and pneumonia are the most common, the CDC says. But diseases related to Group B strep can also crop up months after birth.

In the past, Frumovitz says, doctors had a choice: Screen at 35 to 37 weeks of pregnancy and decide on a course of action based on the result, or follow a "risk-based" method. That meant identifying women who would be likely to need intravenous antibiotics during labor -- the treatment to prevent transmission -- by their individual risks. These could include delivery before 37 weeks or a fever just before labor.

Like most doctors, Frumovitz has switched to routine screening. The test itself is relatively inexpensive, about $25. And the benefits of catching the bacterium early are immense, says Frumovitz, who is also an assistant visiting professor at University of California Los Angeles' David Geffen School of Medicine.

While not all women who have the bacterium will pass it on to their babies, if they do it can be a life-threatening problem, he says. And treating it is fairly simple.

Awareness about the dangers of Group B strep for newborns is growing, says Dr. Laura Riley, an assistant professor of obstetrics and gynecology at Harvard Medical School (news - web sites) who chairs the committee on obstetric practice for the American College of Obstetricians and Gynecologists. The college also now recommends universal screening of all pregnant women.

While many women have known about the dangers of Group B strep, Riley says, some may not be aware that the guidelines for detecting it have changed.

"Until last year, doctors could culture at 35 to 37 weeks and treat those with a positive culture, or not culture anyone and during labor if risk factors arose those women would get antibiotics," she says.

"Now, we culture all pregnant women between 35 and 37 weeks," says Riley, a specialist in infectious diseases. All women should expect their doctor to give them this test. If they don't, women are encouraged to ask about it.

Riley also tells pregnant women to follow up with their doctor about test results. Don't assume you're fine, she says. Be sure to get the results. Then, if they're positive, you will be advised about getting antibiotics during labor.

"The antibiotics a mom gets during labor decreases the Group B strep in the vagina and the amount the baby comes into contact with," Riley explains.

While the prospect of Group B strep sounds scary, Riley add, it's also important to put it in perspective.

"Twenty to 40 percent of pregnant women will have a positive culture. Of those, a teeny percentage will go on to have a baby who is infected," she says.

   More information

For more on Group B strep screening, visit the American College of Obstetricians and Gynecologists. For information on Group B strep and newborns, check out the U.S. Centers for Disease Control and Prevention.


Recovering From Delivery

Your baby's finally here, and you're thrilled - but you're also exhausted, uncomfortable, on an emotional roller coaster, and wondering whether you'll ever fit into your jeans again. Childbirth classes helped prepare you for giving birth, but not for this.

What to Expect in the First Few Weeks
After your baby arrives, you'll notice you've changed somewhat - both physically and emotionally. Physically, you might experience the following:

sore breasts - Your breasts may be painfully engorged when your milk comes in, and your nipples may be sore.
constipation - The first postpartum bowel movement is typically delayed to the third or fourth day after delivery, and sensitive hemorrhoids and sore muscles may make bowel movements painful.
episiotomy - If your perineum (the area of skin between the vagina and the anus) was cut by your doctor or if it was torn during the birth, the stitches may make it painful to sit or walk for a little while during healing.
hemorrhoids - Although common, hemorrhoids (swollen anal tissues) are frequently unexpected and initially unnoticed.
hot and cold flashes - Your body's adjustment to new hormone and blood flow levels can wreak havoc on your internal thermostat.
urinary or fecal incontinence - The stretching of your muscles during delivery can cause you to inadvertently pass urine when you cough, laugh, or strain or may make it difficult to control your bowel movements, especially if a lengthy labor preceded a vaginal delivery.
"after pains" - The shrinking of your uterus can cause contractions that worsen when your baby nurses or when you take medication to reduce bleeding.
vaginal discharge (lochia) - Heavier than your period and often containing clots (sometimes golf-ball sized), vaginal discharge gradually fades to white or yellow and stops within 2 months.
weight - Your postpartum weight will probably be about 10 pounds (the weight of the baby, placenta, and amniotic fluid) below your full-term weight, before additional water weight drops off within the first week as your body regains its sodium balance.
Emotionally, you may be feeling:

"baby blues" - About 80% of new moms experience irritability, sadness, crying, or anxiety, beginning within days or weeks postpartum. Like the more severe associated syndromes of postpartum depression and postpartum psychosis, these baby blues result from hormonal changes, exhaustion, unexpected birth experiences, adjustments to changing roles, and a sense of lack of control over your altered life as you adjust to your new baby.
postpartum depression (PPD) - More serious than the baby blues, this condition is evident in 10% to 20% of new moms and may cause mood swings, anxiety, guilt, and persistent sadness. Your baby may be several months old before PPD strikes, and it's more common in women with a family history of depression.
postpartum psychosis - Postpartum psychosis is a severe and fairly rare condition that makes it difficult to think clearly or function and may become life-threatening to you or your baby. It's common for women with postpartum psychosis to have thoughts about harming themselves or their babies. If you experience any such feelings, call your doctor immediately.
In addition, when it comes to sexual relations, you and your partner may be on completely different pages. He may be ready to pick up where you left off before baby's arrival, whereas you may not feel comfortable enough - physically or emotionally - and may be craving nothing more than a good night's sleep.

The Healing Process
It took your body months to prepare to give birth, and it takes time to recover. If you've had a cesarean section, it can take even longer because this major surgery requires a longer healing time. If unexpected, it may have also raised emotional issues. Pain is greatest the day after the surgery and should gradually subside. Take sponge baths for several days, and don't scratch the incision. If the incision becomes red and swollen, have your doctor check for an infection. Begin gentle exercises as soon as possible (abdominal tightening, bending and straightening your knees, walking - with assistance at first) to speed recovery and help avoid constipation. Drink eight to ten glasses of water daily. Expect vaginal discharge. Avoid stairs and lifting until you've healed, and don't drive until you can make sudden movements and wear a safety belt properly without discomfort.

Some other things to consider during the healing process include:

birth control - You can become pregnant again before your first postpartum period. If you are exclusively breast-feeding (day and night, no solids, at least every 6 hours), have not had a period, and your baby is younger than 6 months old, you have about 98% protection. If you're not breast-feeding exclusively or want additional protection, discuss your options with your doctor. Many recommend starting low-dose oral contraceptives or injections about 6 weeks postpartum. These methods shouldn't affect milk production or your baby. Barrier methods (condoms, diaphragms, spermicidal jellies, and foams) affect breast-feeding less, but are also less effective than pills or shots.
breast-feeding - You need adequate sleep, fluids, and nutrition. Drink a glass of water whenever your baby nurses. Until your milk supply is well established, avoid caffeine, which causes loss of fluid through urine and sometimes makes babies wakeful and fussy. Your clinic or hospital lactation specialist can advise you on how to deal with any breast-feeding problems. Relieve painful, clogged milk ducts with breast massage, frequent nursing, and warm moist packs applied throughout the day. If you develop a fever and your breast becomes tender and red, you may have an infection (mastitis) and need antibiotics. Continue nursing from both breasts. Drink plenty of fluids.
engorged breasts - They resolve as your breast-feeding pattern becomes established or, if you can't or don't choose to breast-feed, when your body stops producing milk - usually within 3 days.
episiotomy care - Continue sitz baths (sitting in just a few inches of warm water and covering the buttocks, up to the hips, in the bathtub). Squeeze the cheeks of your bottom together when you sit to avoid pulling painfully on the stitches. Use a squirt bottle to wash the area with water when your urinate; pat dry. After a bowel movement, wipe from front to back to avoid infection. Reduce swelling with ice packs.
exercise - Resume as soon as possible to help restore your strength and prepregnancy body, increase your energy and sense of well-being, and reduce constipation. Begin slowly and increase gradually. Walking and swimming are excellent choices.
hemorrhoids and constipation - Alternating warm sitz baths and cold packs help. Ask your doctor about a stool softener. Don't use laxatives, suppositories, or enemas without your doctor's approval. Increase your intake of fluids and fiber-rich fruits and vegetables.
sexual relations - Your body needs time to heal. Doctors usually recommend waiting 4 to 6 weeks to reduce the risk of infection or increased bleeding. Fewer than 20% of couples resume sexual activity in the first month, but 90% do so by 4 months. Begin slowly, with kissing, cuddling, and other intimate activities. You'll probably notice reduced vaginal lubrication (this is due to hormones and usually temporary), so a water-based lubricant might be useful. Try to find positions that put less pressure on sore areas and are most comfortable for you. Tell your partner if you're sore or frightened about pain during sexual activity - talking it over can help both of you to feel less anxious and more secure about resuming your sex life.
urinary or fecal incontinence - This usually resolves gradually as your body returns to its normal prepregnancy state. Encourage the process with Kegel exercises, which help strengthen the pelvic floor muscles. To find the correct muscles, pretend you're trying to stop urinating. Squeeze those muscles for a few seconds, then relax (your doctor can check to be sure you're doing them correctly). Wear a sanitary pad for protection. If the problem doesn't resolve in several months, tell your doctor.
What Else You Can Do to Help Yourself
You'll enjoy your new role - and it will be much easier - if you care for both yourself and your new baby. For example:

When your baby sleeps, take a nap. Get some extra rest for yourself!
Set aside time each day to relax with a book or listen to music.
Shower daily.
Get plenty of exercise and fresh air - either with or without your baby, if you have someone who can babysit.
Schedule regular time - even just 15 minutes a day - for you and your partner to be alone and talk.
Make time each day to enjoy your baby, and encourage your partner to do so, too.
Lower your housekeeping and gourmet meal standards - there's time for that later. If visitors stress you, restrict them temporarily.
Talk with other new moms (perhaps from your birthing class) and create your own informal support group.
Getting Help From Others
Remember, Wonder Woman is fiction. Ask your partner, friends, and family for help. Jot down small, helpful things people can do as they occur to you. When people offer to help, check the list. For example:

Ask friends or relatives to stop by and hold your baby while you take a walk or a bath.
Hire a neighborhood teen - or a cleaning service - to clean once a week, if possible.
Investigate hiring a doula, a supportive companion professionally trained to provide postpartum care.
When to Call Your Doctor
There are times when you should call your doctor about your postpartum health. Be sure to call if you:

experience an unexplained fever of 100.4 degrees Fahrenheit (38 degrees Celsius) or above in the first 2 weeks
soak more than one sanitary napkin an hour or if the bleeding level increases
had a C-section or episiotomy and the incision becomes more red or swollen or drains pus
have new pain, swelling, or tenderness in your legs
have hot-to-the-touch, significantly reddened, sore breasts or any cracking or bleeding from the nipple or areola (the dark-colored area of the breast)
find your vaginal discharge has become foul-smelling
have painful urination or a sudden urge to urinate or inability to control urination
have increasing pain in the vaginal area
develop a cough or chest pain, nausea, or vomiting
become depressed or experience hallucinations, suicidal thoughts, or any thoughts of harming your baby
Reviewed by: Serdar Ural, MD
Date reviewed: August 2001



Looking at Your Newborn: What's Normal
In delivery room scenes on TV and in the movies, the mother-to-be, often a famous actress in full makeup and with every hair in place, "delivers" a baby after a few token grunts and groans. Seconds later, the doctor presents the glowing parents with a picture-perfect, neatly combed and scrubbed, cooing several-month-old infant, who, if he were any older, probably could walk out of the delivery room on his own.

Contrast that picture with how a baby really looks just after emerging from the womb: bluish, waterlogged, covered with blood and cream-cheesy glop, and battered as though he has just been in a fistfight - and lost. Not a pretty sight.

The fact that your newborn doesn't resemble one of those Hollywood "stand-ins" shouldn't come as a great surprise. Remember that the fetus develops immersed in fluid, folded up in an increasingly cramped space inside the uterus. The whole process usually culminates with the baby being pushed forcibly through a narrow, bone-walled birth canal, sometimes requiring the assistance of metal forceps or suction devices.

Still, it helps to remember two things: (1) usually, the features that may make a normal newborn look strange are temporary, and (2) in the eyes of the adoring parent, every infant looks like the "Gerber baby" anyway.

General Appearance of Newborns
When you first get to see, touch, and inspect your newborn may depend on the type of delivery, your condition, and the condition of your baby. Following an uncomplicated vaginal delivery, you should have the opportunity to hold your baby within minutes after the birth. In most cases, infants seem to be in a state of quiet alertness during the first hour or so after delivery. It's a great time for you and your newborn to get acquainted and begin the bonding process. But don't despair if circumstances prevent you from meeting your infant right away. You'll have plenty of quality time together soon, and there's no scientific evidence that the delay will affect your infant's health, behavior, or relationship with you over the long run.

During the first several weeks, you'll notice that much of the time your baby will tend to keep her fists clenched, her elbows bent, her hips and knees flexed, and her arms and legs held close to the front of her body. This position is similar to the fetal position during the last months of pregnancy. Infants who are born prematurely may display several differences in their posture, appearance, activity, and behavior compared with full-term newborns.

Infants are born with a number of instinctual responses to stimuli, such as light or touch, known as primitive reflexes, which gradually disappear as the baby matures. Primitive reflexes include: the sucking reflex, which triggers an infant to forcibly suck on any object put in the mouth; the grasp reflex, which causes an infant to tightly close the fingers when pressure is applied to the inside of the infant's hand by a finger or other object; and the Moro reflex or startle response, which causes an infant to suddenly throw the arms out to the sides and then quickly bring them back toward the middle of the body whenever the infant has been startled by a loud noise, bright light, strong smell, sudden movement, or other stimulus.

Also, due to the immaturity of their developing nervous systems, young infants' arms, legs, and chins may tremble or shake, particularly when they are crying or agitated.

In the first weeks, infants usually spend most of their time sleeping. This may be even more exaggerated during the first day or two of life in newborns whose mothers received certain types of pain medications or anesthesia during the labor or delivery.

Frequently, new parents become concerned about their newborn's breathing pattern, particularly with the increased attention that sudden infant death syndrome (SIDS) has received in recent years. It's normal for young infants to breathe irregularly. They commonly will have periods during which they stop breathing for about 5 to 10 seconds and then start up again on their own. These are known as apneic spells, and they are more likely to occur during sleep. When she's awake, an infant's breathing rate may vary widely, sometimes exceeding 60 breaths per minute, particularly when the baby is excited or following a bout of crying.

Although she won't be talking until later, your newborn will produce a symphony of noises - grunts, moans, high-pitched squeaks - in addition to the obligatory crying. Sneezing and hiccups occur very frequently and don't indicate infection, allergies, or digestive problems in newborns.

Skin
There's little doubt about the origin of the expression "still wet behind the ears," used to describe someone new or inexperienced. Newborns are covered with various fluids at delivery, including amniotic fluid and often some blood (the mother's, not the baby's). Nurses or other personnel attending the birth will promptly begin drying the infant to avoid a drop in the baby's body temperature that will occur if moisture on the skin evaporates rapidly. Newborns are also coated with a thick, pasty, white material called vernix caseosa (made up of the fetus' shed skin cells and skin gland secretions), most of which will be washed off during the baby's first bath.

The hue and color patterns of a young infant's skin may be startling to some parents. Mottling of the skin, a lacy pattern of small reddish and pale areas, is common because of the normal instability of the blood circulation at the skin's surface. For similar reasons, acrocyanosis, or blueness of the skin of the hands and feet and the area surrounding the lips, is often present, especially if the infant is in a cool environment. When she bears down to cry or have a bowel movement, a young infant's skin temporarily may appear beet-red or bluish-purple. Red marks, scratches, bruises, and petechiae (tiny specks of blood that have leaked from small blood vessels in the skin) are all common on the face and other body parts and are caused by the trauma of squeezing through the birth canal or by the pressure from obstetrical forceps used during the delivery. These will heal and disappear during the first week or two of life.

Fine, soft hair, called lanugo, may be present on a newborn's face, shoulders, and back. Most of the lanugo is usually shed in the uterus before the baby is delivered; for this reason, lanugo is more frequently seen on babies born prematurely. In any case, this hair will disappear in a few weeks.

Mongolian spots, flat patches of slate-blue or blue-green color that resemble ink stains on the back, buttocks, or elsewhere on the skin, are found in more than half of black, Native American, and Asian infants and less often in white babies. These spots are of no significance and almost always fade or disappear within a few years.

The top layer of a newborn's skin will peel off during the first week or two. This is normal and expected and does not require any special skin care. Peeling skin may be present at birth in some infants, particularly those who are born past their due date.

Despite what the name says, not all babies come with a birthmark. However, pink or red areas, sometimes called salmon patches, are common. Most frequently found on the back of the neck or on the bridge of the nose, eyelids, or brow (hence the fanciful nicknames "stork bite" and "angel kiss"), they can occur anywhere on the skin, especially in light-skinned infants. They generally disappear within the first year.

Strawberry or capillary hemangiomas are raised red marks caused by collections of widened blood vessels in the skin. These birthmarks may appear pale at birth and then typically become red and enlarge during the first months of life. They then usually shrink and disappear without treatment during the first few years.

Port-wine stains, which are large, flat, reddish-purple birthmarks, will not disappear on their own, and concerns about cosmetic appearance may require the attention of a dermatologist as the child gets older.

Cafe-au-lait spots, so called because of their "coffee with milk" light-brown color, are present on the skin of many infants. These may deepen in color (or may first appear) as the child grows older. They are usually of no concern unless they are large or there are six or more spots on the body, which may indicate the presence of certain medical conditions. Common brown or black moles, known as pigmented nevi, may be present at birth or appear or deepen in color as the child gets older. Larger moles or those with an unusual appearance should be brought to a doctor's attention because some may require removal.

Several benign skin rashes and conditions may be present at birth or appear during the first few weeks. Tiny, flat, yellow or white spots on the nose and chin, called milia, are caused by the collection of secretions in skin glands and will disappear within the first few weeks.

Miliaria - small, raised, red bumps that often have a white or yellow "head" - is sometimes called infant acne because of its appearance. Although miliaria often occurs on the face and may be present on large areas of the body, it's a harmless condition that will go away within the first several weeks with normal skin care.

Despite the frightening sound of its medical name, erythema toxicum is also a harmless newborn rash consisting of red blotches with pale or yellowish bumps at the center, which give the rash a hive-like appearance. This rash usually blossoms during the first day or two after birth and disappears within a week.

Pustular melanosis, a rash present at birth mainly in black infants, is characterized by dark brown bumps or blisters scattered over the neck, back, arms, legs, and palms, which disappear without treatment. Because the fetus can suck while still in the uterus, it's not unusual to see infants born with sucking blisters on the fingers, hands, or arms.

Newborn jaundice, a yellowish discoloration of the skin and white parts of the eyes, is a common condition that normally doesn't appear until the second or third day of life and disappears within 1 to 2 weeks. Jaundice is caused by the accumulation of bilirubin (a waste product produced by the normal breakdown of red blood cells) in the blood, skin, and other tissues due to the temporary inability of the newborn's immature liver to clear this substance from the body effectively.

Head
Because the infant's head is usually the first part through the birth canal, it can be affected by the delivery process. The newborn's skull is made up of several separate bones that will eventually fuse together. This situation permits the large head of the infant to be squeezed through the narrow, rigid-walled birth canal without injury to mother or baby. The heads of infants born by vaginal delivery often show some degree of molding, which is when the skull bones shift and overlap, making the top of the infant's head look elongated, stretched out, or even pointed at birth. This sometimes bizarre appearance will go away over the next several days as the skull bones move into a more rounded configuration. The heads of babies born by Cesarean section or breech (buttocks or feet first) delivery usually will not show molding.

Because of the separation of your newborn's skull bones, you'll be able to feel (go ahead, you won't harm anything) two fontanels, or soft spots, on the top of the head. The larger one, located toward the front of the head, is diamond-shaped and usually about 1 to 3 inches wide. A smaller, triangle-shaped fontanel is found farther back on the head, where a beanie might be worn. Don't be alarmed if you see the fontanels bulge out when the infant cries or strains, or if they seem to move up and down in time with the baby's heartbeat. This is perfectly normal. The fontanels will eventually disappear as the skull bones close together - usually in about 12 to 18 months for the front fontanel and in about 6 months for the one in back.

In addition to looking elongated, a newborn's head may have a lump or two as a result of the trauma of delivery. Caput succedaneum is a circular swelling and bruising of the scalp usually seen on top of the head toward the back, which is the part of the scalp most often leading the way through the birth canal. This will fade over a few days.

A cephalohematoma is a collection of blood that has seeped under the outer covering membrane of one of the skull bones; it usually is caused by the pressure of the head against the mother's pelvic bones during birth. The lump is confined to one side of the top of the baby's head and, in contrast to caput, may take a week or two to disappear. The breakdown of the blood collected in a cephalohematoma may cause these infants to become somewhat more jaundiced than others during the first week of life. It's important to remember that both caput and cephalohematoma occur due to trauma outside of the skull - neither indicates that there has been any injury to the infant's brain.

Face
A newborn's face may look quite puffy due to fluid accumulation and the rough trip through the birth canal. The infant's facial appearance often changes significantly during the first few days as the baby gets rid of the extra fluid and the trauma of delivery subsides. That's why the photos you take of your baby later on at home usually look a lot different than those "new arrival" nursery shots. In some cases, a newborn's facial features can be quite distorted as a result of positioning in the uterus and the squeeze through the birth canal. Not to worry - that folded ear, flattened nose, or crooked jaw usually comes back into place over time.

Eyes
A few minutes after birth, most infants open their eyes and start to look around at their environment. Newborns have good vision, but they probably don't focus well at first, which is why their eyes may seem out of line or crossed at times during the first 2 to 3 months. Because of the puffiness of their eyelids, some infants may not be able to open their eyes wide right away. When holding your newborn, you can encourage eye opening by taking advantage of your baby's "doll's eye" reflex, which is a tendency to open the eyes more when held in an upright position.

Parents are sometimes startled to see that the white part of one or both of their newborn's eyes appears blood-red. Called subconjunctival hemorrhage, this occurs when blood leaks under the covering of the eyeball due to the trauma of delivery. It's a harmless condition similar to a skin bruise that goes away after several days, and it generally does not indicate that there has been any damage to the infant's eyes.

Parents often are curious to know what color eyes their infant will have. If a baby's eyes are brown at birth, they will remain so. This is the case for most black and Asian infants. Most white infants are born with bluish-gray eyes, but the pigmentation of the iris (the colored part of the eye) may progressively darken, usually not becoming permanent until about 3 to 6 months of age.

Ears
A newborn's ears, as well as other features, may be distorted by the position they were in while inside the uterus. Because the baby has not yet developed the thick cartilage that gives firm shape to an older child's ears, it is not unusual for newborns to emerge with temporarily folded or otherwise misshapen ears. Small tags of skin or pits (shallow holes) in the skin on the side of the face just in front of the ear are common. Usually these skin tags can be easily removed.

Nose
Because newborns tend to breathe through their noses and their nasal passages are narrow, small amounts of nasal fluid or mucus can cause them to breathe noisily or sound congested even when they don't have a cold or other problem. Talk with your baby's doctor or health care provider about the use of salt-water nose drops and a bulb syringe to help clear the nasal passages if necessary.

Sneezing is also common in newborns. This is a normal reflex and is not due to an infection, allergies, or other problems.

Mouth
When your newborn opens her mouth to yawn or cry, you may notice some small white spots on the roof of the mouth, usually near the center. These are small collections of cells called Epstein's pearls. These spots, as well as fluid-filled cysts sometimes present on the gums, will disappear during the first few weeks.

In some infants, the frenulum (the membrane underneath the tongue that connects it to the floor of the mouth) appears short and may seem to limit how far the tongue can stick out. Concerns about so-called "tongue-tie" were common in the past, with both doctors and parents worrying that this would interfere with the child's ability to suck or speak. This is almost never the case, and once common surgical "clipping" of the frenulum is rarely performed now.

Occasionally infants are born with one or more teeth already present in the mouth. These may need to be removed, particularly if they are loose, because they can present a choking hazard in an infant. An X-ray may be done to determine if the teeth are "extra" or, as is more commonly the case, if they are part of the normal primary set of teeth (baby teeth) and have come through the gums early.

Neck
Yes ... it's there. Normally the neck looks short in newborns because it tends to get lost in the chubby cheeks and folds of skin.

Chest
Both male and female newborns usually have breast enlargement. This is due to the female hormone estrogen passed to the fetus from the mother during pregnancy. You may feel firm, disc-shaped lumps of tissue beneath the nipples and, occasionally, a small amount of milky fluid (called "witch's milk" in folklore) may be released from the nipples. The breast enlargement almost always disappears during the first few weeks. Despite what some parents believe, you should not squeeze the breast tissue - it will not make the breasts shrink any faster than they will on their own.

Because an infant's chest wall is thin, you may easily feel or observe your infant's upper chest move with each heartbeat. This is normal and not a cause for concern.

Abdomen
It's normal for an infant's abdomen (belly) to appear somewhat full and rounded. When the baby cries or strains, you may also note that the skin over the central area of the abdomen may protrude between the strips of muscle tissue making up the abdominal wall on either side. This almost always disappears during the next several months as the infant grows.

Many parents are concerned about the appearance and care of their infant's umbilical cord. The cord contains three blood vessels (two arteries and a vein) encased in a jelly-like substance. Following delivery, the cord is clamped or tied off before it's cut to separate the infant from the placenta. An antibacterial dye is applied to the remaining stump in most nurseries, which accounts for the blue staining of the cord and surrounding skin. The umbilical stump is then simply allowed to wither and drop off, which usually happens in about 10 days to 3 weeks. You will be instructed to swab the area with alcohol periodically to help prevent infection until the cord falls off and the stump dries up. The infant's navel area shouldn't be submerged in water during bathing until this occurs. The withering cord will go through color changes, from yellow to brown or black - this is normal. You should consult your baby's doctor if the navel area becomes red or if a foul odor or discharge develops.

Sometimes, after the cord falls off, the stump doesn't completely heal on its own and you may note some oozing of blood-tinged fluid, which stains the area of the diaper over the navel. This is usually due to the formation of an umbilical granuloma, a benign condition that your infant's doctor or health care provider can easily treat by swabbing the stump with a small amount of the cauterizing chemical silver nitrate (note: this may cause a harmless, temporary black or gray staining of the skin where it is applied).

Umbilical (navel) hernias are common in newborns, particularly in black infants. A hole in the wall of the abdomen at the site of the umbilical cord/future navel allows the baby's intestine to protrude through when she cries or strains, causing the overlying skin to bulge outward. These hernias are generally harmless and not painful to the infant. The majority of them close on their own during the first few years, but a simple surgical procedure can fix the hernia if it doesn't close by itself. Home remedies for umbilical hernias that have been tried through the years, such as strapping and taping coins over the area, should not be attempted. These techniques are ineffective and may result in skin infections or other injuries.

Genitalia
The genitalia (sexual organs) of both male and female infants may appear relatively large and swollen at birth due to several factors, including the exposure to hormones produced by the mother and fetus, bruising and swelling of the genital tissues related to birth trauma, and the natural course of development of the genitalia.

In girls, the outer lips of the vagina (labia majora) may appear puffy at birth. The skin of the labia may be either smooth or somewhat wrinkled. Sometimes, a small piece of pink tissue may protrude between the labia - this is a hymenal tag and it is of no significance; it will eventually recede into the labia as the genitals grow. Due to the effects of maternal hormones, most newborn girls will have a vaginal discharge of mucus and perhaps some blood that lasts for a few days. This "mini-period" is normal menstrual-type bleeding from the infant's uterus that occurs as the estrogen passed to the infant by the mother begins to disappear. Although it is much more common in boys, swelling in the groin of an infant girl can indicate the presence of an inguinal (groin) hernia.

In boys, the scrotum (the sack containing the testicles) often looks swollen. This is usually due to a hydrocele, a common collection of fluid in the scrotum of infant boys that usually disappears during the first 3 to 6 months. You should consult your baby's doctor about swelling or bulging in your son's scrotum or groin area that persists beyond 3 to 6 months or that seems to come and go. That may indicate the presence of an inguinal hernia, which usually requires surgical treatment. The testicles of newborn boys may be difficult to feel in the swollen scrotum. Muscles attached to the testicles pull them up into the groin briskly when the genital area is touched or exposed to a cool environment. Infant boys also normally experience frequent penile erection, often just before they urinate.

The end of an uncircumcised newborn's penis is usually completely covered by the foreskin. The foreskin remains attached to the tip of the penis in infancy, so you shouldn't attempt to pull it back to clean underneath it. Around age 5, the foreskin of nearly all uncircumcised boys has become retractable. At this point, the boy can be taught to slide the foreskin back and clean the tip of the penis. The opening in the foreskin should be large enough to allow the infant to urinate with a forceful stream. Consult your child's doctor if your son's urine only dribbles out.

Although there may be some health benefits associated with circumcision, it's not medically necessary. If you decide to have your son circumcised, it's best to have it done in the first few weeks when the procedure is simpler. Caring for the penis in the days after circumcision is not complicated or difficult. Immediately after the circumcision has been performed, the tip of the penis is usually covered with gauze coated with petroleum jelly. This dressing will usually come off when the baby urinates. It's not necessary to apply a new dressing as long as the area is gently wiped clean with soap and water when the diaper is changed. Healing is rapid, and any redness or irritation of the penis should subside within a few days. Complications are rare, but if the redness or swelling increases or if pus-filled blisters form, the area may be infected and you should call your son's doctor immediately.

More than 95% of newborns will pass urine within the first 24 hours. If your baby is delivered in a hospital, nursery personnel will want to know if this occurs while the infant is with you. If a newborn does not urinate for what seems like a while at first, it may be that she voided immediately after birth while still in the delivery room. With all the activity going on, that first urination may not have been noticed.

Arms and Legs
Following birth, full-term newborns tend to assume a posture similar to what their position in the cramped uterus had been: arms and legs flexed and held close to their bodies. The hands are usually tightly closed, and it may be difficult for you to open them up because touching or placing an object in the palms triggers a strong grasp reflex. An infant's fingernails can be long enough at birth to scratch her skin as she brings her hands to her face. If this is the case, you can carefully trim your baby's nails with a small scissors.

When their newborn is presented to them, most parents will soon perform a quick finger and toe count, and usually there are 10 of each. However, extra digits are common on the hands, particularly in African-American infants. Although in some cases fully developed extra fingers (or toes) are present, most often the extra digits are little more than pieces of skin, with a partially formed fingernail, dangling from a thin stalk attached to the side of the infant's normal fifth finger. These are of no significance; in fact, one of the infant's parents often has a history of extra digits at birth. Your baby's doctor can usually remove it by simply tying a suture tightly around the thin stalk, which cuts off the blood supply to the extra digit. It will usually wither and drop off painlessly within a few days.

Sometimes parents are concerned about the curved appearance of their newborn's feet and legs. But if you recall the usual position of the fetus in the womb during the final months of pregnancy - hips flexed and knees bent with the legs and feet crossed tightly up against the abdomen - it's no surprise that a newborn's legs and feet tend to curve inward. These are not rigid deformities. You usually can move your newborn's legs and feet into a "walking" position, and this will happen naturally as the infant begins to bear weight, walk, and grow through the first 2 to 3 years of life.

The first days and weeks of a newborn's life are a time of great wonder and delight for most new parents. However, being responsible for such a seemingly fragile creature can be intimidating, particularly if you are unfamiliar with how a normal newborn looks and behaves. If you feel anxious or uncertain about any aspect of caring for your infant, don't hesitate to consult your child's doctor, other health care professionals, or family or friends who have had experience caring for an infant.

Reviewed by: Steve Dowshen, MD
Date reviewed: October 2000


Pacifier Use in the Early Weeks of Life May Interfere with Duration of Breastfeeding
Mothers who wish to encourage their infants to continue breastfeeding should avoid introducing pacifiers or other artificial nipples to their infants during the first few weeks of life, say researchers from the University of Rochester in Rochester, New York, and Children's Hospital Medical Center in Cincinnati, Ohio.
Seven hundred mothers who intended to breastfeed their infants for at least 4 weeks and their newborns were included in the study. The infants and mothers were divided into four groups: The first group of infants received supplemental bottle feedings (only if medically necessary or the mother wanted to supplement) and was introduced to the pacifier at 2 to 5 days of age. The second group of infants received supplemental bottle feedings and was introduced to the pacifier after 4 weeks of age. The third group received supplemental cup feedings but was introduced to a pacifier at 2 to 5 days after birth. The fourth group received supplemental cup feedings but was introduced to the pacifier later than 4 weeks of age. The mothers in the study were interviewed several times over the next year to determine whether their child was still breastfeeding and using the pacifier.
Overall, supplemental cup or bottle feeding was associated with a reduction in the duration that the infant was breastfed. The fewer supplemental feedings given to an infant, the more likely breastfeeding was to continue. Pacifier use was also associated with a reduced likelihood that a child would continue to consume mostly breast milk. Introducing a pacifier earlier rather than later reduced the overall time period that a mother continued to breastfeed.
What This Means to You: The results of this study suggest that, in general, introducing a pacifier earlier and adding supplemental feedings by either bottle or cup may shorten the period of breastfeeding in infants. If you're breastfeeding your infant, lactation experts generally recommend avoiding supplemental feedings shortly after birth and waiting until at least 3 weeks of age before introducing an artificial nipple or pacifier. This waiting period may assist your child in developing the ability to attach to your breast and suckle properly.
Source: Cynthia R. Howard, MD, MPH; Fred M. Howard, MD; Bruce Lanphear, MD, MPH; Shirley Eberly, MS; Elisabeth A. deBlieck, MPA; David Oakes, PhD; Ruth A. Lawrence, MD; Pediatrics, March 2003
Reviewed by: Steven Dowshen, MD
Date reviewed: April 2003



Bringing Your Baby Home
Whether your baby comes home from the hospital right away, arrives later (perhaps after a stay in the neonatal intensive care unit), or comes through an adoption agency, homecoming is a major event you've probably often imagined. Of course, it may or may not turn out to be what you'd expected. Read on to find out how to be prepared in any situation.
Leaving the Hospital
Moms-to-be sometimes pack clothes for the trip home before even going to the hospital - or they may wait and see what the weather brings and have their partner bring clothing for both themselves and baby. Plan loose-fitting clothing for yourself because you most likely won't yet fit into your pre- pregnancy outfits. In selecting your baby's outfit, choose something comparable to what you've picked for yourself.
Babies are frequently overdressed on the trip home. In warm weather, it's practical to dress your baby in a T-shirt and diaper and wrap her in a baby blanket. Hats aren't necessary, but they can be a cute finishing touch. If it's cold, add a snowsuit and an extra blanket. Chances are much better that you'll bring home a calm, contented baby if you don't spend a lot of time at the hospital trying to dress your baby in a complicated outfit that may require pushing and pulling your baby's arms and legs to get her dressed.
Before you leave the hospital, ask when to schedule baby's first checkup. If your baby was premature, it's generally a good idea to get a hearing and vision test before going home. Depending on the circumstances, some babies also go home with a special monitor for breathing and heart rate, and you may be taught infant cardiopulmonary resuscitation (CPR).
The Car Trip
The most important item for the trip home is a proper car seat. Every state requires them because it's one of the best ways to protect your baby. Even for a short trip, it's never safe for one of you to hold your baby in your arms while the other drives. Your baby could be pulled from your arms and thrown against the dashboard by a quick stop.
It's a good idea to purchase, rent, or borrow a car seat before your baby's born, when you have time to choose carefully. There are two kinds of car seats for babies: infant-only seats (which must be replaced when your baby weighs 20 pounds) and convertible seats that accommodate both infants and older children. If you borrow a car seat, make sure that it's not more than 10 years old and was never in a crash (even if it looks OK, it could be structurally unsound). Avoid seats that are missing parts or are not labeled with the manufacture date and model number (you'll have no way to know about recalls). Also, check the seat for the manufacturer's recommended "expiration date." If you have any doubts about the seat's history, or if it is cracked or shows signs of wear and tear, don't use it.
Here are some general tips:
Inquire at your prenatal classes, health care provider's office, hospital, and insurance company about rental or loan programs - they're quite common.
There's not one type of seat that's safest or best, so get one that fits and can be correctly installed in your car.
Higher price doesn't necessarily indicate a seat's quality - it may simply indicate added features that you may or may not want. If you buy a new seat, be sure to register it, so you can be notified of any problems or recalls.
The most common problem involving car seats is improper installation (according to the National Highway Traffic Safety Administration, 80% of all car seats are installed incorrectly. Don't trust illustrations or store displays. Follow the manufacturer's instructions - and hang on to them.
Infants-only seats are designed only for rear-facing use and fit infants better than convertible seats. Infants must be in rear-facing car seats until they are 1 year old and weigh at least 20 pounds. If your baby exceeds that weight before his first birthday, you will need to use a convertible seat designed for bigger babies. Convertible seats face toward the rear until your baby is 20 pounds and 1 year old, and can be turned to face forward after that. (Some convertible seats have higher rear-facing weight limits to accommodate larger babies younger than 1 year.)
Never put a rear-facing infant or convertible seat in the front seat of your car - always use the rear seat. Passenger-side airbags are hazardous for both rear- and forward-facing car seats, and most accidents happen at the front passenger area of the car. When it's cold, strap your baby in snugly first, then put blankets over the baby.
If you're bringing your baby home from the intensive care unit, bring the car seat to the hospital ahead of time, so the staff can see if it will work for your baby. If special health concerns rule out a standard restraint, ask your child's doctor to recommend car seats for children with special needs.
For more information on the proper use of child safety seats, read our article on auto safety.

Medical Issues in Adoption
Being an adoptive parent can be extremely rewarding. And although all parents have concerns about their child's health, adoptive parents may have some special worries. That's why being an active participant in your child's health care is just as important for the adoptive parent as for the biologic one.

Gathering Information Before You Adopt
If you have an open or semi-open adoption - one where you meet the mother and sometimes the father - you should be able to get substantial health information. In an open independent adoption, you may help arrange the birth mother's prenatal care, go with her on doctor visits, and be present for the birth. You can also ask for health records through the agency or attorney who is arranging the adoption.

With an older child living in this country, you may be able to evaluate health issues by spending time with him over weeks or months or by serving as a foster parent before adopting him.

With international adoptions, you are likely to get a picture and perhaps a short video of the child, but health and family information may be scanty or unreliable. If you can afford it, it may be worth making a trip to meet the child before deciding to adopt him, especially if the child is older than 2 or 3 years.

Before you adopt, it can help to have as much medical information as possible, such as:
age, ethnic background, education, occupation, height, weight, and medical condition of the birth parents
diseases or medical conditions that run in the child's family
whether the birth mother or father have other children; if so, their health condition
whether the birth mother drank alcohol, smoked, or used drugs during pregnancy; if so, what and how much
whether the birth mother used any prescription or over-the-counter medications during pregnancy; if so, what and how much
whether the birth mother engaged in sexual conduct that would raise the risk of sexually transmitted diseases
whether the birth mother received prenatal care
the results of any tests done during pregnancy
any problems during pregnancy, labor, or delivery
the child's weight, length, and head circumference measurements since birth
any medical problems the child has had since birth
the results of any medical tests the child has had
development in relation to standard age milestones, such as sitting up, walking, talking, or fine motor skills
a description of his personality and his relationships with others
whether he has been with his birth family, other relatives, in foster care, or in an orphanage or baby home
whether the child has suffered physical, sexual, or emotional abuse

If you adopt through an agency, they probably will ask you what age child you want to adopt and what medical conditions you might be willing to accept in a child. Talking over these questions can help you and your partner clarify your feelings and priorities.

Interpreting Information
Once you have gathered whatever information is available, you need to understand it as accurately as possible. Your adoption agency, if you have one, should help you weigh the information without glossing over any negative factors. It's also wise to get a doctor to help you interpret the child's medical record.

In some cases, it may be a good idea to consult a doctor who has experience with adopted children with the same background as the one you may adopt. This is especially true if you are adopting internationally. Russian medical records, for instance, often contain terms that are unfamiliar to most U.S. doctors but are more familiar to specialists or doctors with more knowledge about that area.

Easing Your Child's Transition
Once you've decided to adopt or provide foster care for a specific child, try to gather more information, especially concerning his daily schedule, his abilities, and his likes and dislikes. Keeping to his usual schedule and providing familiar food can help ease his transition to his new home.

If a child is changing countries and languages, anything familiar can help; for instance, the touch and smell of a favorite toy or an old piece of clothing may help a child sleep. If you are adopting internationally, your trip to pick up your child may be your only chance to ask for this information. But if you are adopting domestically or becoming a foster parent, look for opportunities to continue asking questions, such as:

Which foods does your child like or dislike? When does he eat and how much? Is he allergic to anything? How is he fed or how does he feed himself?
When does he sleep and for how long? Does he have a bedtime routine? Is there anything that helps him sleep?
What kind of diapers does he wear?
Does he use the toilet or potty on a set schedule?
How and when is he washed or bathed? Have his teeth been brushed?
What music has he heard? What are his favorite songs?
What does he usually wear? What does he usually play with? Does he have a favorite toy or blanket?
How is he best comforted?
Can he sit, crawl, or stand? Can he speak, make sentences, or recognize colors, letters, or numbers? If he is in school, at what level is his work?
How does he get along with other children? With adults?
Take pictures of your child's surroundings and friends or caretakers. If he is old enough, you can make arrangements to keep in touch by mail.
Keep track of the names, addresses, and phone numbers of everyone you meet who knows your child in case you need more information later.
Get a record of which vaccinations your child has received and when.
Try to get a copy of your child's medical record or photograph it.
If you are not in touch with the birth mother, try to arrange some way you could contact her if a medical crisis arises.
Children With Special Needs
The term "special needs" is applied to any condition that may make it harder for a child to be adopted. Children with special needs may have a mental, physical, or psychological problem, or they may be older (perhaps 5 or older) or have siblings who must be adopted with them. Sometimes "special needs" may refer to a relatively minor problem such as a large birthmark or eczema. In some cases, toddlers with no special problems may be considered children with special needs if they are of a minority or mixed racial or ethnic background.

Most children with special needs in the United States are adopted through public agencies after being removed from their parents for abuse or neglect and having spent time in one or more foster families. Those who are available for adoption at birth tend to have obvious physical problems. Prospective parents may be required to take courses or get family counseling to prepare for a special needs adoption; therapy for the child may be publicly subsidized. Many foster children have special needs. Children with special needs in other countries may also have been removed from their parents for abuse or neglect or they may have been in orphanages or hospitals since birth.

Health Care When Your Child Comes Home
Soon after your child comes home, he should be thoroughly evaluated by a doctor. If you are adopting through a public agency, it may require that certain tests be done or provide a medical form for your doctor to complete. With a foster child, the agency may be able to tell you where the child has been getting health care so you can either use the same providers or get the records sent to a doctor you choose. This can help your child avoid unnecessary tests. If there have been multiple placements, the record may be fragmented, although some agencies work to improve health care continuity.

If your child is an infant, the examination may consist mostly of taking a history from you and performing a first checkup. If your child was born in another country, and there is any doubt about his vaccinations, he probably should be revaccinated.

Health Problems Your Child May Face
It is often recommended that children be screened for the following conditions. Doctors may check for some or all of these, depending on the child's risk factors and the completeness of his medical records:
anemia
blood lead levels
delays in speech, language, and development
hepatitis B and C
HIV
intestinal parasites
impaired hearing and vision
metabolic disorders
psychological problems (such as attachment problems)
fetal alcohol syndrome or fetal alcohol effects
rickets
syphilis
thyroid conditions
tuberculosis
Don't be surprised if your child becomes ill shortly after arriving in your home. Exposed to new types of germs and coping with a new diet, many adopted children get colds and other respiratory infections, upset stomachs, and diarrhea.

Internationally adopted children, especially those from China and Eastern Europe, often have a number of other immediate medical problems. These may include infections like scabies, lice, and intestinal parasites; rickets and other forms of malnutrition; lead poisoning (especially in children from China); and feeding problems, such as hoarding of food and eating to the point of vomiting (both signs of past food deprivation). These problems usually clear up quickly with treatment and care, and children often experience a spurt of "catch-up" growth.

Similar infections may also be seen in domestically adopted or foster children who have been living in poverty. Among the more troublesome is giardiasis, a parasitic infection that can cause diarrhea, vomiting, gas, and bloating. Even a child who has no symptoms can carry the parasite and spread it through his feces. It is important to be especially careful about personal hygiene, with careful washing of hands after using the toilet or changing diapers and before touching food or kitchen implements.

Talk to your child's doctor if you have any questions about the medical issues surrounding adoption. The more you're able to learn about your child's specific health issues, the better able you'll be to make informed decisions about his medical care.
Note: All information on KidsHealth is for educational purposes only. For specific medical advice, diagnoses, and treatment, consult your doctor.

©1995-2003 The Nemours Foundation. All rights reserved.

Keeping Your Child's Teeth Healthy
When should I schedule my child's first trip to the dentist? Should my 3-year-old be flossing? How do I know if my child needs braces? Many parents have a difficult time judging how much dental care their children need. They know they want to prevent cavities, but they don't always know the best way to do so.
When Should I Start Caring for My Child's Teeth?
Proper dental care begins even before a baby's first tooth appears. Remember that just because you can't see the teeth doesn't mean they aren't there. Teeth actually begin to form in the second trimester of pregnancy. At birth your baby has 20 primary teeth, some of which are fully developed in the jaw.
Running a damp washcloth over your baby's gums following feedings can prevent buildup of damaging bacteria. Once your child has a few teeth showing, you can brush them with a soft child's toothbrush or rub them with gauze at the end of the day.
Even babies can have problems with dental decay when parents do not practice good feeding habits at home. "Putting your baby to sleep with a bottle propped in his mouth may be convenient in the short term - but it is bad news for the baby's teeth," explains pediatric dentist Garrett B. Lyons, DDS.
When the sugars from juice or milk remain on a baby's teeth for hours, they may eat away at the enamel, creating a condition known as bottle mouth. Pocked, pitted, or discolored front teeth are signs of bottle mouth. Severe cases result in cavities and the need to pull all the front teeth until the permanent ones grow in. Parents and child care providers should also help young children develop set times for drinking during the day as well because sucking on a bottle throughout the day can be equally damaging to young teeth.
What Kind of Dentist Should My Child See?
You may want to take your child to a dentist who specializes in treating children. Pediatric dentists are trained to handle the wide range of issues associated with your child's dental health. They also know when to refer you to a different type of specialist, such as an orthodontist to correct an overbite or an oral surgeon for jaw realignment.
A pediatric dentist's primary goals are prevention, heading off potential oral health problems before they occur, and maintenance, ensuring through routine checkups and proper daily care that teeth and gums stay healthy.
How Can I Prevent Cavities?
The American Dental Association recommends that your child's first visit to the dentist take place by her first birthday. At this visit, your child's dentist will explain proper brushing and flossing techniques (you need to floss once your baby has two teeth that touch) and conduct a modified exam while your baby sits on your lap. Such visits can help in the early detection of potential problems. Your child also will become accustomed to visiting the dentist, which means she'll have less fear as she grows older.
When all of your child's primary teeth have come in (usually around age 2 1/2) your dentist may start applying topical fluoride during your child's visits. Fluoride hardens the tooth enamel, helping to ward off the most common childhood oral disease, dental caries, or cavities. Cavities are caused by bacteria and food that are left on the teeth after eating. When these are not brushed away, acid collects on a tooth, softening its enamel until a hole - or cavity - forms. Regular use of fluoride toughens the enamel, making it more difficult for acid to penetrate.
Although many municipalities require tap water to be fluoridated, other communities have no such regulations. "Parents must ask, especially when you move to a new community," Dr. Lyons says. If the water supply is not fluoridated, or if your family uses purified water, ask your dentist for fluoride supplements. Even though most toothpastes contain fluoride, toothpaste alone will not fully protect a child's mouth. Be careful, however, since too much fluoride can cause tooth discoloration. Check with your dentist before supplementing.
Discoloration can also occur as a result of prolonged use of antibiotics. "Some children's medications are almost 75% sugar," says Dr. Lyons. He suggests that parents encourage children to brush after they take their medicine, particularly if the prescription will be long term.
Brushing at least twice a day and routine flossing will help maintain a healthy mouth. Children as young as age 2 or 3 can begin to use toothpaste when brushing, as long as they are supervised. "Children should not ingest large amounts of toothpaste - a pea-sized amount for toddlers is just right," Dr. Lyons suggests. He cautions parents to make sure that the child spits the toothpaste out, instead of swallowing.
As your child's permanent teeth grow in, her dentist can help seal out decay by applying a thin wash of resin to the back teeth, where most chewing occurs. Known as a sealant, this protective coating keeps bacteria from settling in the hard-to-reach crevices of the molars. "Most kids can benefit from sealants, unless the tops of their molars are unusually smooth and flat," explains Constance Killian, DDS, a pediatric dentist and trustee of the American Academy of Pediatric Dentistry.
Although dental research has resulted in increasingly sophisticated preventative techniques, including fillings and sealants that seep fluoride, a dentist's care is only part of the equation. Follow-up at home plays an equally important role. For example, the sealants on a child's teeth do not mean that she can eat sweets uncontrollably or slack off on the daily brushing and flossing. "We can only do so much at the office - parents must work with children to teach good oral health habits," says Dr. Killian.
What Should I Do if My Child Has a Problem?
If you are prone to tooth decay or gum disease, your child may be at higher risk as well. "Dental caries is an infectious disease, so if the parents carry high levels of the disease in their mouths, the kids are at higher risk," Dr. Killian says. Therefore, sometimes even the most diligent brushing and flossing will not prevent a cavity. Be sure to call your dentist if your child complains of pain in her teeth. The pain could be a sign of a cavity that needs to be treated.
New materials have given the pediatric dentist more filling and repair options than ever before. Silver remains the substance of choice for the majority of fillings in permanent teeth. Other materials, such as composite resins, also are gaining popularity. "The beauty of the composite resins is that they bond to the teeth, so the filling won't pop out," Dr. Killian says. "They can be used to rebuild teeth damaged through injury or conditions such as cleft palate."
Tooth-colored resins are also more attractive. But in cases of fracture, extensive decay, or malformation of baby teeth, dentists often opt for stainless steel crowns. "A small amount of decay will destroy a baby tooth very quickly. The crown maintains the tooth while preventing the decay from spreading," Dr. Killian says.
As your child grows older, you may be concerned about her bite and the straightness of her teeth. Orthodontic treatment begins earlier now than it once did. What once was a symbol of preteen anguish - a mouth filled with metal wires and braces - has become a relic of the past. Kids as young as age 7 are now sporting corrective appliances. Efficient, plastic-based materials have replaced old-fashioned metal contraptions. Dentists now understand that manipulation of teeth at a younger age can be easier and more effective in the long run. Younger children's teeth can be positioned with relatively minor orthodontia, thus preventing major orthodontia later on.
In some rare instances, usually when a more complicated dental procedure is to be performed, a dentist will recommend general anesthesia to put the child to sleep. "When there is a severe behavioral problem, for instance, or a child has multiple lesions in the mouth, we will use anesthesia," Dr. Lyons explains.
Parents should make sure that the professional who administers the medicine is a trained anesthesiologist or oral surgeon before agreeing to the procedure. Don't be afraid to question the dentist. "General anesthesia use is relatively safe, as long as licensed, trained professionals follow proper guidelines and maintain appropriate equipment," Dr. Killian says. Giving your child an early start on check-ups and good dental hygiene is an effective way to help prevent this kind of extensive dental work. Encouraging your child to use a mouth guard during sports can also prevent serious dental injuries.
As your child grows, plan on routine dental check-ups anywhere from once every 3 months to once a year, depending on her dentist's recommendations. Limiting intake of sugary foods, and regular brushing and flossing all contribute to your child's dental health. Your partnership with your child's dentist will help keep your child's teeth healthy and her smile beautiful.
Updated and reviewed by: Kim Rutherford, MD
Date reviewed: September 2001
Originally reviewed by: Steve Dowshen, MD, and Garrett Lyons, DDS


Flu Shots For All Tots
Flu season is on its way, and this year that means flu vaccine
time for young children. For the first time, federal health
officials are recommending that all babies aged six months to two
years be vaccinated against influenza, The Associated Press
reports. The new recommendation comes after research has shown
that children under two years old are as likely to be
hospitalized for complications of flu as people over age 65. U.S
health officials say there is no shortage of flu vaccine for this
year. Although flu outbreaks usually start in December or
January, officials recommend that parents start looking into the
inoculations now, since the vaccine formulated especially for
infants has to be administered in two doses, one month apart, the
AP says. Other high-risk people who should get the flu vaccine
include those over age 50, people with medical conditions that
make them more vulnerable to infection, women who will be more
than three months pregnant, children of any age taking aspirin
therapy, health care workers and people who live or work in long-
term care facilities. Healthy people are urged to wait until
November to get a flu shot, the AP says.




Conjunctivitis
Conjunctivitis, better known as Pink Eye, is an infection of the inside of your eyelid. It is usually caused by allergies, bacteria, viruses, or chemicals.
What are the signs and symptoms?
Red, irritated eye.
Some burning and/or scratchy feeling.
There may be a purulent (pus) or a mucous type discharge.
How is it treated?
It depends on what caused the Pink Eye. It may or may not need medication for treatment. If medication is given, follow the directions on the label.
What else do I need to know?
To prevent the spread of the infection:
Wash hands throughly
Before you use the medicine in your eyes.
After using the medicine in your eyes.
Everytime you touch your eyes or face.
Wash any clothing touched by infected eyes.
Clothes
Towels
Pillowcases
Do not share make-up. If the infection is caused by bacteria or a virus you must throw away your used make-up and buy new make-up.
Do not touch the infected eye because the infection will spread to the good eye. IMPORTANT!!!
Pink Eye Spreads Very Easily!

1996 - LSUMC Family Medicine Patient Education Home Page

Common Eye Problems
There are several eye conditions that may affect children. Most of them are detected by a vision screening using an acuity chart during the preschool years.
Amblyopia ("lazy eye") is poor vision in an eye that appears to be normal. Two common causes are crossed eyes and a difference in the refractive error between the two eyes. If untreated, amblyopia can cause irreversible visual loss in the affected eye. (By then the brain's "programming" will ignore signals from that eye.) Amblyopia is best treated during the preschool years.
Strabismus is a misalignment of the eyes; they may turn in, out, up, or down. If the same eye is chronically misaligned, amblyopia may develop in that eye. With early detection, vision can be restored by patching the properly aligned eye, which forces the misaligned one to work. Surgery or specially designed glasses may also help eyes to align.
Refractive errors mean that the shape of the eye doesn't refract, or bend, light properly, so images appear blurred. In addition, refractive errors may also cause eyestrain and/or amblyopia. The most common form of refractive errors is nearsightedness; others include farsightedness and astigmatism.
Nearsightedness is poor distance vision (also called myopia), which is usually treated with glasses.
Farsightedness is poor near vision (also called hyperopia), which is usually treated with glasses.
Astigmatism is imperfect curvature of the front surface of the eye. It is usually treated with glasses if it causes blurred vision or discomfort

If you have a poison emergency
  or a question about poisons

1-800-222-1222
This toll-free number will put you in touch with the poison control center
in your state.
If your  an adult or child has collapsed or is not breathing, call 911.


Splash of Iodine Prevents Early Childhood Cavities
Thu Jun 13, 5:29 PM ET
NEW YORK (Reuters Health) - Swabbing the teeth and gums of infants with a small amount of diluted iodine may keep early childhood cavities away, new study findings suggest.
   
Cavities in the first few years of life can have devastating consequences on the primary teeth of infants, toddlers and young children, according to researchers led by Dr. Lydia Lopez of the University of Puerto Rico Medical Center in San Juan.
Since the primarily culprit responsible for cavities is the bacterium Streptococcus mutans, the researchers note, it stands to reason that suppressing the bug could help prevent cavities.
To investigate, Lopez's team investigated the effectiveness of applying 10% solution of the antimicrobial iodine to the teeth and gums in a study of 83 infants between the ages of 12 and 19 months.
All of the children were healthy, free of cavities and were getting a baby bottle at naptime and bedtime that contained a beverage other than water, such as milk or juice. Such beverages can promote the development of cavities. The children also tested positive twice in a row for the presence of S. mutans, the authors report in the June issue of the journal Pediatric Dentistry.
Iodine was applied every other month for 1 year to the teeth and gums of 39 infants, while the remaining 44 infants, in the "control group," had their teeth and gums swabbed with a solution of unsweetened tea.
Lopez and her team found that 91% of the infants who received the iodine solution were free of cavities after 12 months compared with only 54% of infants in the control group.
"The experimental results of this clinical trial indicate that topical antimicrobial therapy significantly increases disease-free survival in children at high risk for developing early childhood cavities," the authors conclude.
SOURCE: Pediatric Dentistry 2002;24:204-206.


Calcium Requirements of Infants, Children and Adolescents

Committee on Nutrition

ABSTRACT. This statement is intended to provide pediatric caregivers with advice about the nutritional needs of calcium of infants, children, and adolescents. It will review the physiology of calcium metabolism and provide a review of the data about the relationship between calcium intake and bone growth and metabolism. In particular, it will focus on the large number of recent studies that have identified a relationship between childhood calcium intake and bone mineralization and the potential relationship of these data to fractures in adolescents and the development of osteoporosis in adulthood. The specific needs of children and adolescents with eating disorders are not considered.

Approximately 99% of total body calcium is found in the skeleton, with only small amounts found in the plasma and extravascular fluid. Serum calcium exists in 3 fractions: ionized calcium (approximately 50%), protein-bound calcium (approximately 40%), and a small amount of calcium that is complexed, primarily to citrate and phosphate ions. Serum calcium is maintained at a constant level by the actions of several hormones, most notably parathyroid hormone and calcitonin. Calcium absorption is by the passive vitamin D-independent route or by the active vitamin D-dependent route.1

Understanding calcium needs for different age groups requires a consideration of the variable physiologic requirements for calcium during development. For example, during the first month of life, the regulatory mechanisms that maintain serum calcium levels may not be entirely adequate in some otherwise healthy infants, and symptomatic hypocalcemia can occur. However, in general, hypocalcemia is uncommon in healthy children and adolescents, and the primary need for dietary calcium is to enhance bone mineral deposition.

Calcium requirements also are affected substantially by genetic variability and other dietary constituents. The interactions of these factors make identification of a single unique number for the calcium "requirement" for all children impossible.2-4 However, several recent dietary guidelines have considered the data about calcium requirements and recommended calcium intake levels that are calculated to benefit most children (Table 1).2,3

In addition to calcium intake, exercise is an important aspect of achieving maximal peak bone mass. There is evidence that childhood and adolescence may represent an important period for achieving long-lasting skeletal benefits from regular exercise.5 For example, Welten et al6 showed in a large Dutch cohort of children that regular weight-bearing activity had a greater influence on peak bone mass than dietary calcium.

IDENTIFICATION OF MINERAL REQUIREMENTS DURING CHILDHOOD

Overview
It is recognized that a very low calcium intake can contribute to the development of rickets in infants and children, especially those consuming very restrictive diets (eg, a macrobiotic diet).7 There are no reliable data on the lowest calcium intake needed to prevent rickets or on the relationship among ethnicity, vitamin D status, physical activity, and diet in the causation of rickets in children fed low-calcium diets.8,9

Recent data support the possibility that a low bone mass may be a contributing factor to some fractures in children. A relationship between the adolescent growth spurt and the risk of fractures has been shown.10,11 Goulding et al12 reported lower bone mass at multiple sites in a group of 100 girls aged 3 to 15 years with distal forearm fractures compared with age-matched girls. For girls aged 11 to 15 years in the study by Goulding et al12 a lower calcium intake was reported for those with fractures compared with the control subjects. Wyshak and Frisch13 similarly reported that high calcium intakes seem to exert a protective effect against fractures in adolescent boys and girls. They also reported a positive relationship between cola beverage intake and bone fracture. Whether this is attributable to a potential effect of excessive phosphorus in the colas impairing bone mineral status or to the lack of calcium intake related to the substitution of colas for dairy products is uncertain. However, a direct harmful effect of a high phosphorus intake affecting the bone mineral status is unlikely in older children and adults.2 Further data on the relationship between calcium intake and fractures are needed before the magnitude of increased fracture risk at different calcium intake levels can be assessed. However, it is reasonable to conclude that low calcium intakes may be an important risk factor for fractures in adolescents. This risk may be an issue that adolescents can more readily relate to than a long-term risk of osteoporosis.

Maintaining adequate calcium intake during childhood is necessary for the development of a maximal peak bone mass. Increasing peak bone mass may be an important way to reduce the risk of osteoporosis in later adulthood.2,14 This is a more difficult end point to identify than the development of rickets or fractures. Therefore, surrogate markers of mineral status are used to assess the consequences of differing levels of calcium intake. The primary surrogates used are optimization of calcium balance or achievement of greater bone mass in children with increased calcium intake.3,14,15

In children with chronic illnesses, fractures may occur during childhood secondary to mineral deficiency associated with the disease process or the effects of therapeutic interventions (ie, corticosteroids) on calcium metabolism.16 However, minimal data generally are not available on the risks and benefits of increasing calcium intake in children with chronic illnesses above current dietary recommendations. Supplementation of vitamin D along with calcium may be necessary for a maximal response.17

Methods
Multiple approaches are used to assess mineral requirements in children. They include the following: 1) measurement of calcium balance in persons with various levels of calcium intake; 2) measurement of bone mineral content, by dual-energy radiograph absorptiometry or other techniques, in groups of children before and after calcium supplementation; and 3) epidemiologic studies relating bone mass or fracture risk in adults with childhood calcium intake.

The calcium balance technique consists of measuring the effects of any given calcium intake on the net retention of calcium by the body. This approach has been the most commonly used to estimate requirement for minerals. Its usefulness is based on the rationale that virtually all retained calcium must be used, especially by children, to enhance bone mineralization. It therefore is reasonable to expect that the dietary intake that leads to the greatest level of calcium retention is the intake that will lead to the greatest benefit for promoting skeletal mineralization and decreasing the ultimate risk of osteoporosis.18,19

The substantial limitations involved in obtaining and interpreting data about calcium balance are well known. These include substantial technical problems with measuring calcium excretion and the difficulty obtaining dietary intake control in children. Both of these are necessary for adequate balance studies. These problems have been partly overcome by the development of stable isotopic methods to assess calcium absorption and excretion.20 Nevertheless, more data are needed to establish the "optimal" level of calcium retention at different ages and the effects of development on calcium balance.6

A major advance in the field during the last 25 years has been the development and improvement of methods to measure total body and regional bone mineral content by using various bone density techniques. Currently, the technique used in many studies is dual-energy radiograph absorptiometry. This technique can rapidly measure the bone mineral content and bone mineral density of the entire skeleton or of regional sites with a virtually negligible level of radiation exposure. Furthermore, recent enhancements in the precision of the technique have made it particularly suitable for assessing the effects of calcium supplementation on bone mass in children of all ages.21

Several groups have directly assessed the effects of calcium supplementation on bone mass by using dual-energy radiograph absorptiometry or similar techniques.22-25 These studies, however, also have limitations. First, most supplementation studies done in children involved relatively short-term supplementation of 1 to 2 years. This period may be inadequate to fully assess the long-term benefits of calcium supplements on bone mineral density. The second is that these studies generally have been done using only 1 level of supplementation, which frequently has been given in pill form. This limited dosing approach makes it difficult to identify an optimal intake level or determine the relative benefits of dietary calcium versus supplements as a method of increasing calcium intake in children.

Several investigators have performed population-based epidemiologic studies relating childhood or adult bone mass or fracture risk to calcium intake in childhood. Although many of these studies are limited by their retrospective design, they have generally shown a positive association between calcium intake in childhood and childhood and adult bone mass. Not all studies have shown a benefit, however, and further data about this relationship are needed.3,26-28

RECOMMENDATIONS BY AGE GROUP

Overview
The specific requirements for calcium intake by infants, children, and adolescents have been extensively reviewed by 2 panels in North America since 1994.2,3 A summary of their recommendations is shown in Table 1.

Infants
The optimal primary nutritional source during the first year of life is human milk. No available evidence shows that exceeding the amount of calcium retained by the exclusively breastfed term infant during the first 6 months of life or the amount retained by the human milk-fed infant supplemented with solid foods during the second 6 months of life is beneficial to achieving long-term increases in bone mineralization. Available data demonstrate that the bioavailability of calcium from human milk is greater than that from infant formulas or cow's milk, although this comparison has not generally been made at comparable intake concentrations, ie, such as found in human milk.29 Nevertheless, it has been deemed prudent to increase the concentration of calcium in all infant formulas relative to human milk to ensure at least comparable levels of calcium retention. Relatively greater calcium concentrations are found in specialized formulas, such as soy formulas and casein hydrolysates, to account for the potential lower bioavailability of the calcium from these formulas relative to cow's milk-based formula. Specific concentration requirements cannot be set readily, but all formulas marketed should have demonstrated a net calcium retention at least comparable to that of human milk. Research data are not available to justify the use of very high levels of calcium in infant formula for full-term infants.

Premature infants have higher calcium requirements than full-term infants while in the nursery. These may be met by using human milk fortified with additional minerals or with specially designed formulas for premature infants.30 After hospitalization, there may be benefits to providing formula-fed premature infants formulas with higher calcium concentrations than those of routine cow's milk-based formulas.31 The optimal concentrations and length of time needed for such formulas are unknown.

Children
Few data are available about the calcium requirements of children before puberty. Calcium retention is relatively low in toddlers and slowly increases as puberty approaches. Most available data indicate that calcium intake levels of about 800 mg/d are associated with adequate bone mineral accumulation in prepubertal children. The benefits of greater levels of intake in this age group have been studied inadequately.20,32 One study found a benefit of calcium supplements to children as young as 6 years of age.16 However, further supporting data are needed for this finding. Perhaps of most importance in this age group is the development of eating patterns that will be associated with adequate calcium intake later in life.

Preadolescents and Adolescents
The majority of research in children about calcium requirements has been directed toward 9- to 18-year-olds. The efficiency of calcium absorption is increased during puberty, and the majority of bone formation occurs during this period.15,20,21,32,33 Data from balance studies suggest that for most healthy children in this age range, the maximal net calcium balance (plateau) is achieved with intakes between 1200 and 1500 mg/d. That is, at intake levels above this, almost all of the additional calcium is excreted and not used. At intakes below that level, the skeleton may not receive as much calcium as it can use, and peak bone mass may not be achieved.2,3,9,15,18-20 Virtually all the data used to establish this intake level are from white children; minimal data are available for other ethnic groups. The exact level that is best for a given person depends on other nutrients in the diet, genetics, exercise, and other factors.

Several controlled trials have found an increase in the bone mineral content in children in this age group who have received calcium supplementation.22-25 However, the available data suggest that if calcium is supplemented only for relatively short periods (ie, 1 to 2 years), there may not be long-term benefits to establishing and maintaining a maximum peak bone mass.34,35 This emphasizes the importance of diet in achieving adequate calcium intake and in establishing dietary patterns consistent with a calcium intake near recommended levels throughout childhood and adolescence. Unfortunately, long-term studies evaluating the consequences of maintaining currently recommended calcium intakes beginning in childhood or early adolescence are not available. Most available epidemiologic data, recently reviewed by the National Academy of Sciences and the National Institutes of Health, support the view that maintaining such a diet will increase peak bone mass and lower the incidence of fractures.2,3

Recent data obtained in African American adolescents suggest a link between lower diastolic blood pressure and increased calcium intake. Further studies are necessary to evaluate this relationship in children of multiple ethnicities and age groups.36

ACHIEVING RECOMMENDED INTAKES

The gap between the recommended calcium intakes and the typical intakes of children, especially those 9 to 18 years of age, is substantial (Table 1). Mean intakes in this age group are between approximately 700 and 1000 mg/d, with values at the higher side of this range occurring in males.3 Preoccupation with being thin is common in this age group, especially among females, as is the misconception that all dairy foods are fattening. Many children and adolescents are unaware that low-fat milk contains at least as much calcium as whole milk.

Knowledge of dietary calcium sources is a first step toward increasing the intake of calcium-rich foods. Table 2 gives typical amounts of calcium for some common food sources. The largest source of dietary calcium for most persons is milk and other dairy products.37 Other sources of calcium are, however, important, especially for achieving calcium intakes of 1200 to 1500 mg/d. Most vegetables contain calcium, although at low density. Therefore, relatively large servings are needed to equal the total intake achieved with typical servings of dairy products. The bioavailability of calcium from vegetables is generally high. An exception is spinach, which is high in oxalate, making the calcium virtually nonbioavailable. Some high-phytate foods, such as whole bran cereals, also may have poorly bioavailable calcium.38-40

Several products have been introduced that are fortified with calcium. These products, most notably orange juice, are fortified to achieve a calcium concentration similar to that of milk. Limited studies of the bioavailability of the calcium in these products suggest that it is at least comparable to that of milk.41 It is likely that more such products will soon become available. Breakfast foods also are frequently fortified with minerals, including calcium. Calcium intakes on food labels are indicated as a percentage of the "daily value" in each serving. This daily value is currently set as 1000 mg/d. Therefore, it is important to instruct families about reading and interpreting food labels.

Several alternatives exist for children with lactose intolerance. Lactose intolerance is more common in African Americans, Mexican Americans, and AsianPacific Islanders than in whites.42 Many children with lactose intolerance can drink small amounts of milk without discomfort. Other alternatives include the use of other dairy products, such as solid cheeses and yogurt, that may be better tolerated than milk. Lactose-free and low-lactose milks are available. Increasing the intake of nondairy products, such as vegetables, may be helpful, as may the use of calcium-supplemented foods.

For children and adolescents who cannot or will not consume adequate amounts of calcium from any dietary sources, the use of mineral supplements should be considered. Although supplements vary in their bioavailability, they may have bioavailability comparable to or greater than that of dairy products.43 Decisions about their use must be made on an individual basis, keeping in mind the usual dietary habits of the person, any individual risk factors for osteoporosis, and the likelihood that the use of the supplement will be maintained.

CONCLUSION

Recent studies and dietary recommendations have emphasized the importance of adequate calcium nutriture in children, especially those undergoing the rapid growth and bone mineralization associated with pubertal development. The current dietary intake of calcium by children and adolescents is well below the recommended optimal levels. The available data support recent recommendations for calcium intakes of 1200 to 1500 mg/d beginning during the preteen years and continuing throughout adolescence as recommended by the National Institutes of Health Consensus Conference2 and the National Academy of Sciences.3 Currently, evidence is inadequate to alter the dietary recommendations for children with chronic illnesses or those taking medications, such as corticosteroids, that alter bone metabolism. However, an effort should be made to achieve at least the recommended intake levels. The provision of adequate vitamin D also may be important for children with chronic illnesses.

RECOMMENDATIONS

  1. Pediatricians should actively support the goal of achieving calcium intakes in children and adolescents comparable to those in recently recommended guidelines.2,3 The prevention of future osteoporosis, as well as the possibility of a decreased risk of childhood and adolescent fractures, should be discussed as potential benefits to achieving these goals. Currently, relatively few children and adolescents achieve dietary calcium intake goals.
  2. To emphasize the importance of calcium nutriture, pediatricians should consider including the following questions about dietary calcium intake.
         * What do you drink, either white or chocolate milk, with your meals?
         * Do you drink milk with meals, snacks, or cereal or any other time during the day?
         * Do you eat cheese, yogurt, or other dairy products such as cottage cheese?
         * Do you drink calcium-fortified juices or eat any calcium-fortified foods?
         * Do you eat any of the following: broccoli, tofu, oranges, or legumes (dried beans and peas)?
         * Do you take any mineral or vitamin supplements?
  3. For children and adolescents whose calcium intake seems deficient, specific information about the sources of dietary calcium should be provided. Adolescents may need to be reminded that low-fat dairy products, including skim milk and low-fat yogurts, are good sources of calcium that are not high in fat.

TABLE 1
Dietary Calcium Intake (mg/d) Recommendations in the United States2,3*
Age      1997 NAS3      1994 NIH2
0 to 6 mo†      210      400
6 mo to 1 y†      270      600
1 through 3 y      500      800
4 through 8 y      800      800 (4-5 y)
             800-1200 (6-8 y)
9 through 18 y      1300      800-1200 (9-10 y)
             1200-1500 (11-18 y)
* Recommended intakes were provided in different forms by each source cited. The Food and Nutrition Board of the National Academy of Sciences (NAS) released Recommended Dietary Allowances until 1997. In 1997, it chose to use the term adequate intake for the recommendations for calcium intake but indicated that these values were to be used as Recommended Dietary Allowances. The NIH Consensus Conference did not specify a specific term but indicated that these values were the "optimal" intake levels. Dietary recommendations by the NAS are set to meet the needs of 95% of the identified population of healthy subjects. The NAS guideline should be the primary guideline utilized. † For infant values, the 1994 NIH Consensus Conference indicated values for formula-fed infants, whereas the 1997 NAS report used the infant fed human milk as the standard.

TABLE 2
Approximate Calcium Contents of 1 Serving of Some Common Foods*
Food      Serving Size      Calcium Content
Milk†      1 cup      240 mL      300 mg
White beans      1/2 cup      110 g      113 mg
Broccoli cooked      1/2 cup      71 g      35 mg
Broccoli raw      1 cup      71 g      35 mg
Cheddar cheese      1.5 oz      42 g      300 mg
Low-fat yogurt      8 oz      240 g      300-415 mg
Spinach cooked‡      1/2 cup      90 g      120 mg
Spinach raw‡      1-1/2 cup      90 g      120 mg
Calcium-fortified orange juice      1 cup      240 mL      300 mg
Orange      1 medium      1 medium      50 mg
Sardines or salmon withbones      20 sardines      240 g      50 mg
Sweet potatoes      1/2 cup mashed      160      44
* Adapted from Raper et al,37 Weaver,38,39 and Weaver and Plawecki.40
† Low-fat milk has comparable or greater calcium levels than whole milk.
‡ The calcium from spinach is essentially nonbioavailable.



Child Behavior: What parents can do to change their child's behavior
What is normal behavior for a child?
Normal behavior in children depends on the child's age, personality, and physical and emotional development. A child's behavior may be a problem if it doesn't match the expectations of the family or if it is disruptive. Knowing what to expect from your child at each age will help you decide what is normal behavior.
What can I do to change my child's behavior?
Children tend to continue a behavior when it is rewarded and stop a behavior when it is ignored. Consistency in your reaction to a behavior is important because rewarding and punishing the same behavior at different times confuses your child. When your child's behavior is a problem, you have 3 choices:
Decide the behavior is not a problem because it's appropriate to the child's age and stage of development.
Attempt to stop the behavior, either by ignoring it or by punishing it.
Introduce a new behavior that you prefer.
How do I stop misbehavior?
The best way to stop unwanted behavior is to ignore it. This way works best when you're able to wait for results. When you want the behavior to stop immediately, you can use the time-out method. Physical punishment is less effective.
Why shouldn't I use physical punishment?
Many parents use physical punishment (such as spanking) to stop undesirable behavior. The biggest drawback to this method is that although the punishment stops the bad behavior for a while, it doesn't give the child an alternative. If the child doesn't know a good behavior, he or she is likely to return to the bad behavior. Physical punishment becomes less effective with time and can cause the child to behave aggressively. It can also be carried too far--into child abuse. Other methods of punishment are preferred and should be used whenever possible.
How do I use the time-out method?
Decide ahead of time the behaviors that will result in a time out--usually tantrums, or aggressive or dangerous behavior. Choose a time-out place that is uninteresting for the child and not frightening--usually a chair, a corner or a playpen. When you're away from home, consider using a car or a restroom as a time-out place.
When the unacceptable behavior occurs, tell the child the behavior is unacceptable and give 1 warning that you will put the child in time out if the behavior doesn't stop. Remain calm and don't look angry. If the child goes on misbehaving, take him or her to the time-out area.
Set a timer so the child will know when time out is over. Time out should be brief--generally 1 minute for each year of age--and should begin immediately after reaching the time-out place or after the child calms down. You should stay within sight or earshot of the child but don't talk to him or her. If the child leaves the time-out area, gently return him or her to the area and consider resetting the timer. When the time out is over, let the child leave the time-out place. Don't discuss the bad behavior but look for ways to praise good behavior later on.
How do I encourage a new, desired behavior?
One way to encourage good behavior is to use a reward system. This way works best in children over 2 years of age. It can take up to 2 months to work. Keeping a diary of behavior can be helpful to parents, to show gradual changes in their child.
Choose 1 to 2 behaviors you would like to change (such as bedtime behavior, toothbrushing or picking up toys). Choose a reward your child would enjoy. Examples of good rewards are an extra bedtime story, delaying bedtime by a half hour, a preferred snack or, for older children, earning points toward a special toy, a privilege or a small amount of money.
Explain the desired behavior and the reward to the child. For example, "If you get into your pajamas and brush your teeth before this TV show is over, you can stay up a half hour later." Request the behavior only 1 time. If the child does what you ask, give the reward. You can help the child if necessary but don't get too involved. Because any attention from parents, even negative attention, is so rewarding to children, they may prefer to have parental attention instead of a reward at first. Transition statements, such as, "In 5 minutes, play time will be over," are helpful when you are teaching your child new behaviors.
This system helps you avoid power struggles with your child. However, you must live with your child's choice. If your child chooses not to behave as you ask, the child is not punished; he or she simply does not get the reward.
What are some examples of this method?
Beat the Clock (best method for a dawdling child)
Ask the child to do a task. Set a timer. If the task is done before the timer rings, the child gets a reward. To decide the amount of time to give the child, figure out the child's "best time" to do that task and add 5 minutes.
The Good Behavior Game (good when you're trying to teach a new behavior)
Write a short list of good behaviors on a chart and mark the chart with a star each time you see the good behavior. After the child has earned a small number of stars (depending on the child's age), give him or her a reward.
Good Marks/Bad Marks (best method for difficult, highly active children)
In a short time (about an hour) put a mark on a chart or on the child's hand each time you see him or her performing a good behavior. For example, if you see your child playing quietly, solving a problem without fighting, picking up toys or reading a book, you would mark the chart.
After a certain number of marks, give the child a reward.
You can also make negative marks each time a bad behavior occurs. If you do this, you only give the child a reward if there are more positive marks than negative marks.
Developing Quiet Time (often useful when you're making supper)
Ask the child to play quietly alone or with a sibling for a short time (maybe 30 minutes).
Check on the child frequently (every 2 to 5 minutes, depending on the child's age) and give a reward or a token for each few minutes the child was quiet or playing well.
Gradually increase the intervals (go from checking the child's behavior every 2 to 5 minutes to checking every 30 minutes), but continue to give rewards for each time period the child was quiet or played well.
What else can I do to help my child behave well?
Make a short list of important rules. Avoid power struggles and no-win situations. Try not to go to extremes. When you think you've overreacted, it's better to use your common sense to solve the problem, even if you have to be inconsistent just this once.
Accept your child's basic personality, whether it's shy, social, talkative or active. Basic personality can be changed a little, but not very much. Try to avoid situations that can make your child cranky, such as becoming overly stimulated, tired or bored. Don't criticize your child in front of other people. Describe the child's behavior as bad, but don't label the child as bad. Praise your child often when he or she deserves it. Touch your child affectionately and often.
Develop little routines and rituals, especially at bedtimes and meal times. Provide transition remarks (such as, "In 5 minutes, we'll be eating dinner."). Allow your child choices whenever possible. You can ask, "Do you want to wear your red pajamas or your blue pajamas to bed tonight?"
As children get older, they enjoy becoming involved in household rule making. Don't debate the rules at the time of misbehavior but invite the child to participate in rule making at another time.
Children who learn that bad behavior is not tolerated and that good behavior is rewarded are learning skills that will last them a lifetime.
(Rev.October 2000)

This handout provides a general overview on this topic and may not apply to everyone. To find out if this handout applies to you and to get more information on this subject, talk to your family doctor.
Visit familydoctor.org for more useful information on this and many other health-related topics.


Pinworms and Your Child
What are pinworms?
Pinworms are a type of worm that can get inside your body. They live in your intestines and eat some of the nutrients from your food. Usually this infection is annoying but not dangerous.
Pinworm infections are common in families with small children. If your child has pinworms, you may notice your child moving around a lot in bed at night or being unable to sleep because of an itchy bottom. The itching is caused by a female pinworm that comes out of the rectum to lay eggs around the anus (the opening to the rectum). Sometimes tiny worms (shorter than 1/2 inch) may be seen on the child's bottom at night or they may show up in the child's bowel movement.
How do people get pinworms?
Pinworms are easy to get. Pinworms are usually spread from child to child, and the eggs can be picked up on children's fingers when they are playing. If the eggs are on their hands or toys, and they put their fingers or toys in their mouth, the tiny eggs can enter their bodies. The eggs are very small and can only be seen with a microscope. The eggs stay in the upper part of the intestine until they hatch. After they hatch, the worms move down the length of the intestine, trying to get out to lay eggs. When the children scratch their itchy bottoms, the tiny eggs can get under their fingernails. As the children move around the house, the eggs may be spread, and other family members may become infected. Sometimes adults breathe in the eggs when the bed covers are shaken. Children easily infect each other while they are playing. Pets do not spread pinworms, although they may carry their own kinds of worms.
How are pinworms detected?
Because pinworms usually crawl out of the anus while a child sleeps, the tape test is an easy way to find pinworms. To do the tape test, your doctor will give you a tongue depressor with a piece of clear tape on it. You will press the end of the tongue depressor--with the tape on it--against your child's anal skin. Then the tape is placed sticky-side down on a glass slide. It is best to do this test right after your child wakes up in the morning, before moving around or washing. If your child has pinworms, your doctor will be able to see the eggs with a microscope.
How do we get rid of pinworms?
Fortunately, most pinworm infections are mild and easily treated. Your doctor may prescribe a single chewable tablet of a medicine called mebendazole (brand name: Vermox). About 2 weeks later, a second tablet is taken. Or your doctor may recommend another kind of medicine, pyrantel (brand names: Pin-X, Pin-Rid). This is also taken in 2 doses about 2 weeks apart.
Even if only one child in a family has pinworms, it is very important that everyone in the household be treated with the pinworm medicine at the same time, even if they don't have any signs of pinworms. All the sheets, blankets, towels and clothing in the house should be washed in hot water, and everyone's fingernails (which might hold the worm eggs) should be carefully cleaned and cut short.
If you get treatment from your doctor right away and keep everything in the house very clean, your family's encounter with pinworms will soon be over.

This handout provides a general overview on this topic and may not apply to everyone. To find out if this handout applies to you and to get more information on this subject, talk to your family doctor.
Visit familydoctor.org for information on this and many other health-related topics.

Does Your Child Have Obsessive-Compulsive Disorder?
"What if I forget to bring my homework to school? Did I remember to feed my goldfish? I know I turned off the TV, but let me check to make sure."

All children have worries and doubts. But when your child can't stop thinking about them, they begin to hamper his ability to function. No matter how stressful the worries are, no matter how silly they may seem, and no matter how much your child wants them to go away, they do not subside on their own. In association with this anxiety, your child may begin to perform certain rituals, behaviors that are performed in a certain way over and over again. If these behaviors persist, your child may be diagnosed with obsessive-compulsive disorder (OCD).

It is reported that approximately 1 million children and adolescents in the United States suffer from OCD. This translates to one in 200 children. OCD is more prevalent than many other childhood disorders or illnesses, but it is often hidden because it causes pain and embarrassment to the child.

In the years when most children want to fit in with their peers, the discomfort and stress brought on by OCD can make them feel scared, out of control, and alone.

What can you do to help? Keep reading to learn more about OCD and how you can help your child.

What Is OCD?
OCD is an anxiety disorder in which the brain gets stuck on a particular thought or urge and can't let go. OCD manifests itself in obsessive thinking or beliefs that tell a child: "If you don't do X, then something uncomfortable or even life-threatening will happen." (In younger children, compulsive behaviors may be evident without the "if...then" thinking.) The rise in anxiety or worry is so strong that the child must perform the task or dwell on the thought, over and over again, to the point where it interferes with everyday life. OCD can become extremely embarrassing and overwhelming for both the child and his family.

Experts aren't sure how OCD gets started, but it should never be viewed as the child's fault or something he can stop if he just tries harder. OCD is a disorder, just like a sleep disorder or dyslexia - it's not something the child can control. Experts do know that OCD tends to run in families, and just like in children, OCD in adults is often kept private so that most families are not aware of this disorder in their family histories.

OCD is best viewed as a "short circuit" in the brain's "worry computer," says John March, MD, author of OCD in Children and Adolescents: A Cognitive Behavioral Treatment Manual. This worry computer inappropriately and repeatedly cues the child to fear that something will happen. These cues are commonly called obsessions.

Obsessions are repeated thoughts or impulses that are out of place - they cause the child to experience anxiety or distress. They are out of the child's control, and they are different from normal thoughts. A child with these thoughts usually attempts to ignore or suppress obsessive thoughts or impulses by neutralizing them with another thought or action - a compulsion. For example, a child who is plagued with doubts about having turned off the stove might compulsively check the stove, again and again, to ensure that it is off.

Compulsions, or rituals, are the deliberate and repeated behaviors a child with OCD performs to relieve the anxiety caused by the obsessive thoughts. For example, a child who has a fear of germs may repeatedly wash his hands until the skin becomes raw; a child who has an obsession with neatness will redo her test paper so many times that she may tear a hole in it from constant erasing. Other times, compulsions might seem less clearly related to the obsessive thought.

Common OCD Behaviors in Children
OCD can make daily life difficult for children and families. The behaviors often take up a great deal of time and energy, making it more difficult to complete tasks such as homework or chores or enjoy life. In addition to feeling frustrated or guilty for not being able to control their own thoughts or actions, children with OCD also may suffer from low self-esteem because the disorder can lead to shame or embarrassment. Children often involve their parents in their rituals (for example, asking about a potential illness they think they have), leading to increases in family stress.

Children with OCD may feel pressured because they don't have enough time to do everything. They might become irritable because they have to stay awake late into the night or miss an activity or outing to complete their rituals. They might have difficulties with attention or concentration because of the intrusive thoughts.

In addition, obsessions and compulsions related to food are common. These can lead to abnormal eating habits (such as eating only one kind of food), thus compromising nutrition.

Studies of children and adolescents with OCD have revealed that the most common obsessions include:
fear of dirt or germs
fear of contamination
a need for symmetry, order, and precision
religious obsessions
preoccupation with body wastes
lucky and unlucky numbers
sexual or aggressive thoughts
fear of illness or harm coming to oneself or relatives
preoccupation with household items
intrusive sounds or words

The following compulsions have been identified as the most common in children and adolescents:
grooming rituals, including hand washing, showering, and teeth brushing
repeating rituals, including going in and out of doorways, needing to move through spaces in a special way, checking to make sure that an appliance is off or a door is locked, and checking homework
rituals to undo contact with a "contaminated" person or object
touching rituals
rituals to prevent harming self or others
ordering or arranging objects
counting rituals
hoarding and collecting things
cleaning rituals related to the house or other items
Signs of OCD


Recognizing OCD in children is often difficult because they become adept at hiding the behaviors. It's not uncommon for a child to engage in ritualistic behavior for months, or even years, before parents know about it. Also, many children do not engage in their rituals at school, so parents may think that this is just a phase their child is going through.

"Kids try to contain their thoughts or behaviors, and this creates anxiety," says David Sheslow, PhD, a pediatric psychologist. "Children experience embarrassment and sometimes feel like they are 'going crazy.' They try to keep it quiet and to blend it into the normal routine of their lives until they can't contain it anymore. This is when the parents become concerned. Even then, parents typically know of only some of their child's ritual thoughts and behaviors.

"The child may ask the parent to join him in the ritualistic behavior: first the child has to do something and then the parent has to do something else. If a child says, 'I didn't touch something with germs, did I?' the parent might have to respond, 'No, you're OK,' and the ritual will begin again for a certain number of times," Dr. Sheslow explains. "Initially, the parents might not notice what is happening. Tantrums, overt signs of worry, and difficult behaviors are common when parents fail to participate in their child's rituals. It is often this behavior, as much as the OCD itself, that brings families into treatment."

Parents can look for the following possible signs of OCD:

raw, chapped hands from constant washing
unusually high rate of soap or paper towel usage
high, unexplained utility bills
a sudden drop in test grades
unproductive hours spent doing homework
holes erased through test papers and homework
requests for family members to repeat strange phrases or keep answering the same question
a persistent fear of illness
a dramatic increase in laundry
an exceptionally long amount of time spent getting ready for bed
a continual fear that something terrible will happen to someone
constant checks of the health of family members
reluctance to leave the house at the same time as other family members
Environmental and stress factors can signal the onset of OCD. These can include ordinary developmental transitions (such as starting school) as well as significant losses (such as the death of a loved one or moving).

Diagnosing OCD
In screening for OCD, your child's doctor or mental health professional will ask about obsessions and compulsions in language that your child will understand, such as the following questions:

Do you have worries, thoughts, images, feelings, or ideas that bother you?
Do you have to check things over and over again?
Do you have to wash your hands a lot, more than most kids?
Do you count to a certain number or do things a certain number of times?
Do you collect things that others might throw away (like hair or fingernail clippings)?
Do things have to be "just so"?
Are there things you have to do before you go to bed?
Because it can be normal for children to answer yes to any of these questions, your child's doctor will also ask about your family's history of OCD, Tourette syndrome, and other motor or vocal tic disorders. OCD has a genetic component, which means that children whose family members have had any of these disorders may be more prone to OCD.

Tic disorders often resemble OCD symptoms: approximately 35% to 50% of people with Tourette syndrome also have OCD (but only a small percentage of children with OCD also have Tourette syndrome).

Disorders that frequently occur with OCD include other anxiety disorders, depression, disruptive behavior disorders (attention deficit hyperactivity disorder and oppositional defiant disorder), learning disorders, trichotillomania (compulsive hair pulling), and habit disorders such as nail biting or skin picking.

Treating OCD
The most successful treatments for children with OCD are behavioral therapy and medication. Cognitive-behavioral psychotherapy (CBT) helps children learn to change their thoughts and feelings by first changing their behavior. CBT involves exposure, or exposing the child to his fears to decrease his anxiety about it. For example, a child who is afraid of dirt might be exposed to something he considers dirty until he no longer fears it.

For exposure to be successful, it is often combined with response prevention, in which the child's rituals or avoidance behaviors are blocked. For example, the child who fears dirt must not only stay in contact with the dirty object, he also must not be allowed to wash repeatedly. Some treatment plans involve having the child "bossing back" the OCD, giving it a nasty nickname, and visualizing it as something the child can control.

Behavioral treatment with children works best when the whole family is involved, according to Dr. Sheslow. "Treating children from a behavioral perspective requires a high degree of cooperation," he says. "Without a considerable amount of family support, you won't have a high rate of success. Because cognitive behavioral treatments often provoke considerable anxiety, a good deal of support is needed. As well, it is important to find a therapist who knows about how to treat OCD. OCD can worsen if not treated in a consistent, logical, and supportive manner."

Medication is often combined with CBT to get more complete and lasting results. Research shows that selective serotonin reuptake inhibitors (SSRIs) are most effective in children with OCD. These include medications such as fluoxetine, fluvoxamine, paroxetine, and sertaline. Another medication that may be prescribed is clomipramine. Most experts agree that medication should be used to treat children as a second choice to CBT. "Medication often can reduce the impulse to engage in ritualistic behavior. Therapy will help the child and family learn strategies to manage the waxing and waning of OCD symptoms," Dr. Sheslow says.

"Many children can do well with CBT alone, others will need a combination of behavioral therapy and medication. It's important to use the treatments appropriately to avoid the long-term adverse effects of OCD on children's development," Dr. March says.

How Can I Help My Child?
Parents and children should understand that OCD is never the child's fault. Once a child is in treatment, parents are encouraged to participate, to learn more about OCD, and modify their expectations and be supportive. You need to realize that kids get better at different rates and day-to-day comparisons of your child's behaviors should be avoided. Small improvements should be recognized and praised.

"It is rare to find a child with OCD without finding a family with OCD," Dr. Sheslow says.

Your entire family should be educated and supportive at all times. The more personal criticism can be avoided, the better. Members of your family should keep in mind that it's the OCD that is causing the problem, not the child. Family routines should be kept as normal as possible, family members should learn strategies to approach members with OCD, and if your child is on medication, the regime should never waver.

It's not surprising that many people keep this disorder hidden. "This is not something that people want to advertise; there's an embarrassment about it," says Dr. Sheslow, who explains that OCD is different from other disorders, such as a fear of dogs, for example. Other disorders are easier for people to talk about than OCD.


Warning On Walkers
Put your baby in a walker and you may end up running to the
emergency room. That's a warning the American Academy of
Pediatrics is reiterating this week in an updated policy
statement. The AAP is calling for a ban on manufacture and sale
of all mobile baby walkers, saying that the devices offer no
clear benefits for children but pose considerable risk of injury
and even death. For example, walkers put infants in a position
where they can grab potentially dangerous items from tabletops
and allow infants to move faster than they are equipped to
handle, resulting in falls down stairs and other injuries even
when the children are supervised, according to an InteliHealth
News Service report. In addition, studies have found that
walkers don't help with coordination or learning to walk, and may
actually delay normal development, InteliHealth reports. The AAP
urges parents to throw away or destroy any baby walkers they
might have. The organization notes that new stationary activity
centers, which look like walkers but have no wheels, are a safer
alternative for infants.


Obese Kids, Heart Disease Link r

  CHICAGO (AP) - Overweight children as young as 8 have been found to have a
  smoldering type of bloodstream inflammation that in adults has been linked to heart
  disease.

  The new study may help explain why people who were overweight as children run a
  higher risk of cardiovascular problems and diabetes in adulthood, regardless of their
  adult weight.

  The study, published in the January issue of the journal Pediatrics, is the first to link
  childhood weight and inflammation. The research was led by Marjolein Visser, an
  epidemiologist from Vrije University in Amsterdam.

  The researchers looked at 3,561 U.S. children ages 8 to 16 and found that overweight
  youngsters were three to five times more likely than those of normal weight to have
  inflammation, as marked by the presence of a substance called C-reactive protein, or
  CRP, in the bloodstream.

  Dr. Michael Steelman, past president of the American Society of Bariatric Physicians, a
  group of doctors specializing in obesity, said the finding is a major reason for concern.

  "When we can start documenting the physical changes occurring at that age, it's just like
  a time bomb just below the surface of their skin that's going to go off someday,"
  Steelman said.

  The study does not address whether inflammation in children poses any short- or
  long-term risks. But Visser said previous research has linked elevated CRP levels in
  overweight adults with the development of heart problems.

  In Visser's study, 7 percent of the boys and 6 percent of the girls showed signs of CRP
  inflammation. Elevated white blood cell counts, another sign of inflammation, were also
  far more common in overweight children.

  Previous research has suggested that elevated CRP levels may stem from artery
  inflammation during the early stages of heart disease. The body may respond to plaque
  buildup the same way it responds to infection - by releasing disease-fighting cells that
  cause inflammation.

  Aspirin, because of its blood-thinning properties, is sometimes recommended for adults
  at increased risk of heart disease. But because aspirin is also known to reduce
  inflammation, some experts have suggested this benefit may be the real reason it helps
  reduce the risk.

  Visser said the findings are too preliminary to recommend aspirin for overweight
  children with elevated CRP levels.

  "If the relationship between obesity and elevated CRP levels is causal, weight loss would
  be the recommended treatment for overweight children," said Visser, who worked with
  the U.S. National Institute on Aging on the study.





What are sacral dimples?
My wife and I had a boy at 26 weeks gestation due to PIH and HELLP syndrome. The baby has had minor complications, but the newest one is what was described as a sacral dimple. It is very small. The doctor so far has only suggested that he will do a kidney work-up closer to discharge, ruling out neural tube defect's or spina-bifida. The baby did have sepsis on and off for the first few weeks of life, and I have heard that UTI's can cause this sacral dimple. Is this true? Should we get a second opinion?

Robert Steele
Robert W. Steele, M.D., is a board certified pediatrician at St. John's Regional Health Center in Springfield, Missouri.

Incidence of dermal lesions in the sacral region = 3% of all normal babies.
1.4% have a sacral dimple (Base visible)
1.2% have a sinus or a pit without clearly visible base
0.6% have a lump, tag, vascular nevus or other malformation
One study group collected 94 babies who each had any type of sacral skin lesion. Spinal ultrasound was obtained on all the study babies. NONE of the babies with diffusely hairy lower backs, shallow pits, or sinuses (78/94 or 83% of the study babies) had spinal cord or vertebral anomalies. Seven of the 94 cases (7%) had an abnormality on ultrasound, but the skin lesions were swellings, tags, or nevi or a pit with a hair growing out of it.
   
Sacral pits, dimples or hairiness are not indicative of abnormal vertebrae or cord. They do not require work-up. (Normal if in gluteal crease)
   
Tags, swellings or unusual lesions are associated with spine or cord anomalies, and the baby should have a spinal u/s before discharge from the newborn nursery.
   
Spinal ultrasound is as sensitive as MRI at detecting spine or cord anomalies in the newborn period. Therefore, ultrasound is the study of choice for initial work up.
   
Ultrasound can be performed with good results until the baby is 6-12 weeks old. After that, MRI is the best study.
Sacral dimples refer to the divots found on the lower backs of some infants. It is estimated that at least two percent of infants have these dimples or pits most of which are located in the middle of the back just above the buttocks. To understand what the significance of these dimples are (if any) it is helpful to realize the basic way the spinal column develops while the baby is in mom.

During the first eight weeks or so of development, the fetus develops the rudimentary structure of the spinal column called the neural tube. This tube forms sort of in the same manner as when the edges of a flat piece of paper are brought together to form a tube. When the edges or a portion of these edges do not meet, a "neural tube defect" occurs. But it gets a little more complicated. Now picture this tube forming from several sheets of paper that are placed on top of each other. To form a complete neural tube, all the edges of all the layers must meet to be complete. If the outer most paper has edges that meet, the tube may look complete from the outside, but when you look inside, it is possible that the other sheets of paper inside the tube got crumpled and do not have the edges meeting.

This is generally what can occur as the spinal column is forming. If the inner tissues of the tube become malformed, the outer layer including the skin may not be smooth. All the other permutations may be true as well. The outside layer may form with some dimples in it which have no effect on the inner layers. And there may be malformation of the inner layers which have no effect on the outer ones. To put it simply, a dimple in the lower back along the spine may be a simple divot in the skin which causes no problems whatsoever, or it may be the sign of malformation in lower layers including the spine and spinal cord.

The problem with this is that, as I stated above, at least two percent of babies may have these pits. That's one in every 50 babies. And almost all of these pits are insignificant when it comes to serious problems or involvement of deeper tissues. Therefore, what do doctors look for to decide who ought to have additional tests to examine the deeper tissues? There are a number of things, but some of them include:

Can the floor of the pit or dimple be easily visualized? Divots in which the bottom portion cannot be seen may be evidence of a neural tube that never closed completely.
Does the pit have a tuft of hair growing from it? This again make a pit suspicious for deeper involvement.
Is the neurologic exam normal? If there is significant involvement of the spinal column, there may be weakness in the legs.
How high up on the back is the dimple? Most dimples very low on the back (just above the buttocks) are of little concern. The higher the dimple is, the more likely it is to be associated with defects in deeper tissues.
Are there signs of any other defects? The brain, spinal column, kidneys, as well as other structures form at the same time the neural tube closes. Therefore, if there are any malformations in any other parts of the body, it becomes more concerning that the neural tube may be involved as well.

Antidepressants and Pediatric Depression — The Risk of Doing Nothing
David A. Brent, M.D.        Volume 351:1598-1601           October 14, 2004           Number 16

The editors asked two members of the Psychopharmacologic Drugs and Pediatric Advisory Committees of the Food and Drug Administration to comment on the committees' recent recommendations regarding the use of antidepressant medications in children and adolescents.

Their responses follow.
There is great concern that antidepressants used in children and adolescents may paradoxically increase their risk of suicidal thoughts and behavior. Is this concern valid, and if so, how should it modify our clinical approach to pediatric depression?

Twenty-five years ago, long before the introduction of selective serotonin-reuptake inhibitors (SSRIs), the adolescent suicide rate was increasing rapidly, having tripled over the previous two decades, but the risk factors involved were unknown. Adolescents who committed suicide were regarded as misunderstood teenagers who had been under too much stress. There was debate about whether depression could occur in children, and the prevailing view was that moodiness was normal in adolescents. Furthermore, even if we could have diagnosed depression and recognized young people who were at risk for suicide, there were no empirically validated treatments to offer.

Eventually, we learned that depression did indeed affect children and adolescents. Through retrospective interviews with family members and friends, this disorder emerged as the single most important risk factor for adolescent suicide,1 although it often acted in concert with substance abuse and impulsive aggression. Adolescents who committed suicide frequently had a history of suicidal thoughts or behavior, disclosed only to a friend who was sworn to secrecy. Most commonly, adolescents killed themselves with a gun, and guns were much more frequently available to those who had died by suicide than to those who had attempted suicide but lived.

These findings suggested some straightforward approaches to prevention. Although it had been thought that people who talk about suicide don't kill themselves, these results showed that previous suicidal behavior and current suicidal thoughts are potent risk factors for suicide and must be taken seriously. The association between the availability of guns and their use in suicides suggested that guns should be removed, or at least secured. Finally, the development and testing of treatments for pediatric depression should be given high priority.

Today, we are able to identify young people who are at high risk for suicide and to offer empirically validated treatments for depression.2 It is ironic that concern about the risks posed by antidepressants has arisen now, when the adolescent suicide rate has been decreasing for a decade (see Figure), for the first time in more than half a century. This trend is accounted for primarily by a drop in the rate of suicide by means of firearms, suggesting that more restrictive gun-control laws may be partially responsible.3 A portion of the decrease may be related to better detection of depression and suicidality (suicidal ideation, behavior, or both) and the dissemination of validated treatments. There is some ecologic evidence that increases in the number of prescriptions for SSRIs for adolescents are associated with a decrease in adolescent suicide.4

Nevertheless, given findings showing a relationship between suicidality and completed suicide, one must take seriously the possibility that antidepressants might increase the risk of suicidality. And yet the concern about SSRIs in pediatric depression that has been aroused by the British Medicines and Healthcare Products Regulatory Agency (MHRA) (http://medicines.mhra.gov.uk/ourwork/monitorsafequalmed/safetymessages/ssrioverview_101203.htm) is based, in my opinion, on an overestimation of risk and an underestimation of benefit.

Current clinical practice with regard to SSRI use for pediatric depression is based on six published studies, although five unpublished studies were much less favorable. There is the most incontrovertible evidence of efficacy for fluoxetine, which had positive results in three clinical trials. For sertraline, the results were positive but modest, with a 10 percent difference in response between drug and placebo. One study of citalopram was positive and one negative, but the latter involved both inpatients and outpatients and had a very high dropout rate. There were two negative trials of venlafaxine, but the doses used were often well below the minimal therapeutic dose for adults, and when the results were stratified according to age, venlafaxine was superior to placebo among adolescents. There have been three clinical trials of paroxetine, of which only one was positive.

In addition to questioning the benefit of these drugs, the MHRA and the Food and Drug Administration (FDA) focused attention on a possible increase in the likelihood of suicidality. In response, the MHRA declared that all antidepressants except fluoxetine were contraindicated in pediatric depression. The FDA initially advised against the use of paroxetine only, since there was some evidence of efficacy for sertraline and citalopram. More recently, the FDA labeled all antidepressants with a warning about their possible potential for inducing suicidal thoughts or behavior. The FDA also recently commissioned a blind independent review of these adverse events by a consensus panel of international experts.

With regard to the main outcome, suicidality (the combination of new suicide attempts, new-onset suicidal ideation, and worsening of existing suicidal ideation), the FDA analysis, presented to an advisory committee in a public hearing September 13 and 14, 2004, found an increase by a factor of 1.8 associated with drug treatment, which translates to a difference of 1.7 percentage points between drug and placebo (3.8 percent vs. 2.1 percent). Although the difference is small, it seems likely that the effect is real, because the findings were statistically significant in aggregate and are consistent across multiple studies of various agents.

Although the initial MHRA report and the FDA analysis found that fluoxetine treatment was not associated with suicidality, an FDA analysis of a new clinical trial found otherwise — but the results help to put the benefits and risks into perspective.3 In this study, cognitive–behavioral therapy and fluoxetine treatment, alone and in combination, were compared with each other and with placebo. Fluoxetine was much more likely than placebo to result in a significant clinical improvement (in 61 percent of cases vs. 35 percent) but, according to the FDA analysis, was associated with a significant increase by a factor of 4.6 in the rate of suicidal events (8.3 percent vs. 1.8 percent). Once a suicidal event was detected, the patient was withdrawn from the trial. Although depression and suicidality are both significant risk factors for suicide, depression improved in these patients four times as frequently as suicidality developed, which seems to represent an acceptable risk–benefit ratio. Fluoxetine plus cognitive therapy was not superior to fluoxetine alone according to most measures of depression, but the combination was superior to all other treatments in reducing the intensity of suicidal thoughts. This finding suggests that the optimal treatment for suicidality in a depressed patient may be multimodal — a logical approach, given the multiple risk factors for suicide.

In light of these concerns, why use SSRIs at all? Although cognitive–behavioral therapy appears to be more effective than other psychosocial treatments for depression, this comparison between it and medication found it inferior to fluoxetine therapy. And although the risk–benefit ratio is best for fluoxetine, nearly 40 percent of depressed adolescents do not have a response to this drug, and others cannot tolerate it. Other agents with some evidence of efficacy should be considered for these patients.

In addition to increasing the risk of suicidality, SSRIs are twice as likely as placebo to result in agitation and hostility. The FDA could not test whether hostility and suicidality were linked, but the drugs most closely associated with one were also most closely associated with the other. In addition, treatment with antidepressants is much more likely to unmask an underlying bipolar disorder in children or adolescents than it is in adults,5 which can result in the induction of a mixed manic and depressive state — a condition that carries a very high risk of suicidal behavior.

As SSRIs have gained in popularity, their ease of use and relatively favorable side-effect profile may have led to an overly casual approach to the treatment of depression. All depressed patients who are treated with antidepressants must be closely monitored for emergent suicidality, hostility, agitation, and mania. Families and patients must be informed about the benefits and risks of these drugs and should be educated about monitoring for emergent side effects, as recommended in recent public statements and labeling changes made by the FDA. Because children and adolescents generally metabolize antidepressants more rapidly than adults, they must receive doses adequate to achieve a clinical response. Suicidality in depressed patients may be best treated by a combination of psychotherapy and medication.

The FDA's recent analysis suggests that the risk of emergent suicidality in children and adolescents receiving SSRIs is real — but small. The FDA's advisors recommended stronger warnings in labeling and better information for patients and caregivers, but they stopped short of recommending contraindications for these drugs. However, many participants in the public hearing seemed convinced that the pharmacologic treatment of pediatric depression should be banned or severely curtailed. That would turn the clock back 25 years, to a time when the only thing we could offer the families of suicide victims was the hope that someday we would have effective treatments. Ideally, the FDA, families, and clinicians will find the right balance between the risk of suicidality and another, greater risk: the risk that lies in doing nothing.


Source Information

From the Western Psychiatric Institute and Clinic, Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh.

References

   1. Brent DA, Perper JA, Goldstein CE, et al. Risk factors for adolescent suicide: a comparison of adolescent suicide victims with suicidal inpatients. Arch Gen Psychiatry 1988;45:581-588.[Abstract]
   2. March JS, Silva S, Petrycki S, et al. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents With Depression Study (TADS) randomized controlled trial. JAMA 2004;292:807-820.[Abstract/Full Text]
   3. Webster DW, Vernick JS, Zeoli AM, Manganello JA. Association between youth-focused firearm laws and youth suicides. JAMA 2004;292:594-601. [Erratum, JAMA 2004;292:1178.][Abstract/Full Text]
   4. Olfson M, Shaffer D, Marcus SC, Greenberg T. Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 2003;60:978-982.[Abstract/Full Text]
   5. Martin A, Young C, Leckman JF, Mukonoweshuro C, Rosenheck R, Leslie D. Age effects on antidepressant-induced manic conversion. Arch Pediatr Adolesc Med 2004;158:773-780.[Abstract/Full Text]




NEW BABIES
NORMAL KID STUFF
NUTRITION
VACCINES

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Two-Year-Olds Mimic Parents' who smoke and drink
TUESDAY, Sept. 6 (HealthDay News) -- Parents, your children are watching: A new study finds that even 2-year-olds are more likely to "smoke" and "drink" during pretend play if their parents smoke and drink regularly.

Toddlers were also more like to mimic these dangerous adult activities if they were regularly exposed to PG-13 or R-rated movies, the researchers found.

It's not news that parental habits can influence their offspring's smoking and drinking habits, said lead researcher Madeline Dalton, director of the Hood Center for Children and Family Community Health Research Program at Dartmouth Medical School, Lebanon, N.H.

"What is new in this study is really the age," she said.

"Lots of people have looked at the social influences of tobacco and alcohol use. Parental smoking and alcohol use are potent predictors of kids' use," she said, noting that that's been long known for teens. "What we wanted to do was to start looking at younger children."

Reporting in the September issue of the Archives of Pediatrics and Adolescent Medicine, Dalton's team observed 120 children, aged 3 to 6, playing with two dolls. The child was asked to pretend to be one of the dolls while the researcher pretended to be the other doll.

The child was told to pretend he or she was the host and had invited the other doll over to watch a movie and have something to eat.

When the researcher-friend said there was nothing to eat, the child was invited to shop at a doll grocery store as researchers recorded the purchases.

For experiments involving 2-year-olds, the child was simply given one doll and told to take her shopping.

In all, 28 percent of the children bought cigarettes while 61 percent bought alcohol on these "shopping trips." The researchers then compared those buying habits with information they had gathered on the parents' smoking, drinking and movie-viewing habits.

They found that children were nearly four times as likely to buy cigarettes if their parents smoked, and three times as likely to choose wine or beer if their parents drank alcohol at least once a month.

Kids who were allowed to view PG-13 or R-rated movies were five times as likely to choose wine or beer while shopping than kids restricted to watching G-rated movies. According to the researchers, images of drinking adults seen in adult-rated films may be influencing these pro-alcohol "buying" decisions in youngsters.

The study is the first to show that preschoolers have what Dalton calls "social cognitive scripts" of adult social life -- behaviors perceived to be appropriate.

Some of the children even recognized specific brand names of cigarettes, the researchers found, because of the brands their parents smoked. Others role-played the lighting of cigarettes or pouring drinks.

The study findings don't surprise Danny McGoldrick, research director of the Campaign for Tobacco-Free Kids.

"It's an interesting study," he said. "I think it really just points to the social environment that kids grow up in. You see these ads that say 'Talk to Your Kids' [about not smoking]. But the best thing parents can do is not smoke themselves. Smoking has a huge impact on kids, not just with secondhand smoke but with role modeling."

If parents can't quit, McGoldrick said, they should, "at least make the home smoke-free."

The research was an eye-opener for Dalton on a professional and personal level. "It's never too early to talk to your kids about alcohol and cigarettes," she said.

"Certainly there are many instances where it is socially appropriate to use alcohol," she said, "but we need to counterbalance that with a clear message about not misusing it."

Dalton said she realized her habit of offering guests wine or beer when they arrive at her home was giving the wrong message to her young children. "Now, when I have guests, I ask, 'Can I get you something? We have water, we have juice, milk, soda, beer or wine.' Just so [her kids know] it's socially appropriate to choose something else."

Sinusitis Can Strike Kids, Too
It could be the common chronic problem of sinusitis, a condition that is usually associated with adults.

"It is as common in children as in adults, and when sinus problems get worse, asthma and bronchial problems get worse," says Dr. Jordan Josephson, a New York City otolaryngologic surgeon who specializes in pediatric care.

Kids can be particularly susceptible to sinus problems because their sinuses aren't fully formed until age 12, and their sinuses are narrower than an adult's.

If you factor in any allergies a child might have -- as well as environmental triggers like secondhand smoke, air pollution and exposure to bacteria -- that child's susceptibility to sinusitis increases, Josephson says.

Telltale signs of possible sinusitis in a child include a frequent runny nose with yellow mucus, pain near the cheeks or eye areas, and difficulty staying awake in school, Josephson says.

Sinusitis in children -- as well as adults -- can also produce emotional troubles like irritability and a general unhappiness. But a child is often unable to convey this sense of discomfort to a doctor, says Dr. Alexander Chester, an internist at Georgetown University Medical Center.

"It can be really tough for kids who feel poorly but whose illness is not validated by doctors or parents," he says. "A doctor looks at a kid with a runny nose and listlessness and basically tells him to shape up."

Sinusitis is characterized by inflammation of the nasal passages. It can be caused by any number of problems, from a cold to allergies to an infection, doctors say. The inflammation narrows the nasal passages so mucus can't drain properly, causing discomfort and sometimes infection.

Left untreated, sinusitis can become chronic, lasting for anywhere from three to eight weeks, to months or even years, according to the National Institute of Allergies and Infectious Diseases.

Statistics on the prevalence of sinusitis in children are hard to come by. But the National Center for Health Statistics reports that the condition affects about 32 million American adults a year, or approximately 16 percent of the adult population.

Parents should be alert to potential sinusitis symptoms in their children and get them to the doctor.

"If a cold lasts for 72 hours or less, it's nothing to worry about," says Josephson. "But if a child has a runny nose all the time and is home sick once a month, if he's falling asleep in school, getting bad grades or taking his hand and rubbing it up his nose because he can't get relief, you shouldn't dismiss these symptoms."

A pediatrician can prescribe a nasal spray and/or antibiotics if there is a bacterial infection, Josephson says.

"If after two to four weeks the child isn't better, he or she needs to see a specialist," he adds.

An otolaryngologist will examine the child in the same way an adult is examined, using CAT scans and maybe an endoscopy. This is a procedure where the doctor, using a slim tube with a camera at the end, can look directly at the sinus passages. Pediatric otolaryngologists have a smaller pediatric endoscope for this purpose, Josephson says. These tests allow the doctor to check for polyps, which can block the nasal passages, or anatomical abnormalities that constrict the natural flow of mucus.

While surgery is rarely performed on children, specialists typically recommend a longer course of antibiotic treatment, usually for a three- to eight-week period, Josephson says.

"Parents are resistant to the idea of an antibiotic for a long period of time," he says. "They often don't want to give kids antibiotics for more than 10 days. But living with an infection for a year isn't good, either. There could be polyp formation and long-term effects of doing poorly in school."


Growing Pains
Your 8-year-old son wakes up crying in the night complaining that his legs are throbbing. You rub them, and soothe him as much as you can, but are uncertain about whether to give him any medication or take him to the doctor. Sound familiar? Your child is probably experiencing growing pains, a normal occurrence in about 25% of children. Read below to find out more about this common problem.
Diagnosis
Growing pains generally strike during two periods: in early childhood among 3- to 5-year-olds and later on in 8- to 12-year-olds. They are what doctors call a diagnosis of exclusion. This means that other conditions should be ruled out before a diagnosis of growing pains is made. A thorough  history and physical examination by your child's doctor can usually accomplish this. In rare instances, blood and X-ray studies may be required before a final diagnosis of growing pains is made.
Causes
No firm evidence exists to show that growth of bones causes pain. The most likely causes of growing pains, therefore, are the aches and discomforts resulting from jumping, climbing, and running pursued by active children during the day. The pains can occur after a child has had a particularly athletic day.
Signs and Symptoms
Although growing pains often strike in late afternoon or early evening before bed, there are occasions when pain can wake a slumbering child. The intensity of the pain varies from child to child, and most kids don't experience the pains every day. "Growing pains are often intermittent, coming once a week or even more infrequently," says Dr. James White, a family practitioner.
Growing pains always concentrate in the muscles, rather than the joints. Most children report pains in the front of their thighs, in the calves, or behind the knee. While joints affected by more serious diseases are swollen, red, tender, or warm, the joints of children experiencing growing pains appear normal.
One symptom that doctors find most helpful in making a diagnosis of growing pains is how the child responds to touch while in pain. Children who have pain for a serious medical disease do not like to be handled, since movement tends to increase the pain. Children with growing pains respond differently; they feel better when they are held, massaged, and cuddled.
Treatment
Massage, stretching, heat, acetaminophen (Tylenol) or ibuprofen (Advil) may help to relieve the pain. Although the pains point to no serious illness, they can be upsetting to a child (or a parent!). Because a child seems completely cured of her aches in the morning, parents sometimes suspect that the child faked the pains. However, this usually is not the case. Support and reassurance that growing pains will pass as children grow up can help them relax.
When to Call Your Child's Doctor
Your child's doctor should be alerted if any of the following symptoms occur with your child's pain: persistent pain, swelling, or redness in one particular area or joint; fever; limping; unusual rashes; loss of appetite; weakness; tiredness; or uncharacteristic behavior. These signs do not accompany growing pains and may be an indication of a medical problem that needs attention. Pains or symptoms localized to the shoulders, arms, wrists, hands, fingers, neck, or back, or pain associated with a particular injury are not due to growing pains, and should be evaluated by a child's doctor.
Updated and reviewed by: Kim Rutherford, MD
Date reviewed: June 2001
Originally reviewed by: Steven Dowshen, MD, and Robert Cooper, MD
 
 
 
ROBOT.TXT
Autism and MMR Vaccine Study an 'Elaborate Fraud,' Charges BMJ

January 6, 2011 — BMJ is publishing a series of 3 articles and editorials charging that the study published in The Lancet in 1998 by Andrew Wakefield and colleagues linking the childhood measles-mumps-rubella (MMR) vaccine to a "new syndrome" of regressive autism and bowel disease was not just bad science but "an elaborate fraud."

According to the first article published in BMJ today by London-based investigative reporter Brian Deer, the study's investigators altered and falsified medical records and facts, misrepresented information to families, and treated the 12 children involved unethically.

In addition, Mr. Wakefield accepted consultancy fees from lawyers who were building a lawsuit against vaccine manufacturers, and many of the study participants were referred by an antivaccine organization.

 
Dr. Fiona Godlee 

In an accompanying editorial, BMJ Editor-in-Chief Fiona Godlee, MD, Deputy BMJ Editor Jane Smith, and Associate BMJ Editor Harvey Marcovitch write that there is no doubt that Mr. Wakefield perpetrated fraud. "A great deal of thought and effort must have gone into drafting the paper to achieve the results he wanted: the discrepancies all led in 1 direction; misreporting was gross."

A great deal of thought and effort must have gone into drafting the paper to achieve the results he wanted: the discrepancies all led in 1 direction; misreporting was gross.
Although The Lancet published a retraction of the study last year right after the UK General Medical Council (GMC) announced that the investigators acted "dishonestly" and irresponsibly," the BMJ editors note that the journal did not go far enough.

"The Lancet retraction was prompted by the results from the [General Medical Council] hearing and was very much based on the concerns about the ethics of the study," Dr. Godlee told Medscape Medical News.

"What we found was that it was definite fraud and that is a very important thing for the world to know. This article shows that the science was falsified and should be discounted," continued Dr. Godlee.

This evidence "should now close the door on this damaging vaccine scare," the editorial authors add.

Damage to Public Health

Although it included only 12 patients, faced almost immediate criticism, and never had its findings replicated, the study received wide media coverage and set off a panic among parents, with the result that MMR vaccinations decreased dramatically.

The 2003 to 2004 vaccination rate of 80% has now recovered slightly in the United Kingdom, but it is still well below the recommended 95% level recommended to ensure "herd immunity." A measles epidemic was also declared in England and Wales in 2008.

"Perhaps as important as the scare's effect on infectious disease is the energy, emotion, and money that have been diverted away from efforts to understand the real cause of autism and how to help children and families who live with it," the editorialists write.

 
Mr. Brian Deer 

Mr. Deer did his first investigative stories on the Wakefield paper in 2004 for the Sunday Times in London and a UK television network. On the basis of his findings, the GMC's Fitness to Practice panel convened in 2007 and heard from 36 witnesses during a period of 2 and a half years.

At the end of January last year, as reported by Medscape Medical News , the panel used strong language in condemning the study's methods and noted that Mr. Wakefield and 2 other colleagues had broken guidelines.

The Lancet issued its retraction 5 days later, citing the panel's findings that the participants were not consecutive patients seeking treatment and that the study had falsely reported being approved by an ethics committee.

Although the GMC later found that Mr. Wakefield and coauthor John Walker-Smith committed serious misconduct and struck them off the medical register, Mr. Wakefield has repeatedly denied doing anything wrong. In addition, he was not among the 10 of 13 coauthors who disavowed the study's findings in 2004.

"Instead, although now disgraced and stripped of his clinical and academic credentials, he continues to push his views. Meanwhile, the damage to public health continues," the editorialists write.

Multiple Discrepancies Found

Last spring, the BMJ went to Mr. Deer to ask if there was more to this story. In this newest article, he reports that "multiple discrepancies" were found, including the following:

•Only one of the studied 9 children actually had clear regressive autism and 3 did not have a diagnosis of any autism type;
•Five had preexisting development concerns — although all 12 were classified in the study as "previously normal"; and
•The exclusion of important allegations helped create "the appearance of a 14-day temporal link."
In addition, none of the 12 patients were "free of misreporting or alteration," he writes.

It cost a tremendous amount of time and money to penetrate the veil of confidentiality that surrounded just these 12 children. So how on earth would anybody penetrate the veil over other larger medical research? When Wakefield did what he did, it was on the assumption that no one would ever be able to find out the truth.
"My number 1 takeaway is that it cost a tremendous amount of time and money to penetrate the veil of confidentiality that surrounded just these 12 children. So how on earth would anybody penetrate the veil over other larger medical research? When Wakefield did what he did, it was on the assumption that no one would ever be able to find out the truth," Mr. Deer told Medscape Medical News.

BMJ fact-checked Mr. Deer's article against the 6 million–word transcript of the GMC panel's hearing. Dr. Godlee said she is now calling for reexamination of all of Wakefield's past studies to determine whether others should be retracted. "Past experience tells us that research misconduct is rarely isolated behavior," she writes.

But how did a small case-control study like this set off such a panic in the first place? "I think a lot of people would like to know the answer to that," said Dr. Godlee.

"I think Andrew Wakefield is a terrifically good publicist. He managed to convince his institution to run a press conference for this very small piece of research. The media attention for this grew, and concerns were raised with his subsequent publications."

In addition, she said that many parents have questions about why their children have developed autism and are looking for reasons to explain the onset of its behavioral symptoms. "MMR is a very common intervention, it seemed to fit the picture, and it's very hard to prove that something is safe despite overwhelming evidence that there is no link.

"If you're looking for an explanation, this may seem plausible, although the science is nonsense. Overall, I think it's a combination of very desperate parents looking for answers and a very clever man who was willing to lie and cheat, who was willing to try to advance his own career and financial benefits," noted Dr. Godlee.

Editor's Dread

With questions raised almost from the start, how culpable is The Lancet? And how can other journals protect themselves from publishing falsified studies?

"That is the dread of any editor," said Dr. Godlee. "I think editors' main responsibility is to make sure that what is published is valid in terms of being good research. And I think The Lancet's decision to publish this is the first place was a very questionable decision, especially as it dealt with such a serious issue.

"Why publish research that is not going to advance science and is going to create a vaccine scare? I think there is culpability there. But as for fraud, that is very tricky because science is based on trust," she added.

"None of us go back and ask for the case records of patients involved. But we need to become aware that any article that comes in could be fraudulent. And we have to be absolutely vigilant and investigate properly when concerns are raised. It's a constant cycle of oversight that needs to be done."

Medscape Medical News contacted The Lancet for its reaction to the BMJ series of articles, but officials there had "no comment on this."

Dr. Godlee said that she would also hope that coauthors would serve as backup for honesty in reporting and that all of this study's investigators "failed in their duties as authors" — especially since there were only 12 patients involved.

Adding a name to a paper carries a responsibility to ensure that no fraud has been committed. This should serve as a wake-up call for other researchers in the future. It's their reputation that can be damaged if they are found to be associated with someone else's failures of integrity.
"Adding a name to a paper carries a responsibility to ensure that no fraud has been committed. This should serve as a wake-up call for other researchers in the future. It's their reputation that can be damaged if they are found to be associated with someone else's failures of integrity."

Diversion of Research Funds

The editors write that although a breach of trust this large is "almost certainly rare," it raises questions about what could have been done earlier, what further inquiry is needed, and what can be done to keep it from happening again.

Future BMJ articles in the series, to be published during the next 2 weeks, will deal with these questions and The Lancet's actions from study publication through retraction.

"We wanted to also look at what motivated Andrew Wakefield, looking at the commercial schemes he established to exploit the MMR scare, and then we examine what happened when the issues of concern were first raised back in 2004 and why it was not taken more seriously at that time," explained Dr. Godlee.

"To people who might ask why we're interested in all of this now, the answer is that what Brian Deer has unearthed is much more substantial than what most of us knew or what came out in the GMC hearing. This study was not only bad research but fraudulent as well. And it's taken an enormous amount of time and effort and money away from legitimate lines of inquiry," she concluded.

Mr. Deer's original investigation was funded by the Sunday Times of London and the Channel 4 television network. The current articles were funded by the BMJ. He reported receiving no other funding except for legal costs from the Medical Protection Society on behalf of Mr. Wakefield. The editorial authors have disclosed no relevant financial relationships.

BMJ. Published online January 6, 2011.