Pools

With the summer already into its later phases, let me remind everyone about pool safety from 2 perspectives.

First is infection.  So many diarrheal illnesses originate in swimming pools.  Make sure that chemical balance–especially pH and chlorine–are scrupulously maintained.  Even chlorine sensitive infections are only killed by prolonged exposure.  Recall that sunlight consumes and rainwater dilutes chlorine so close supervision is crucial.  This is particularly true for hot tubs and public “kiddie” pools which are shallower and warmer allowing for more chemical dissipation and better bacterial growth environment.  Also, make sure that everyone bathes before entering the pool and no one with diarrhea should enter the pool.   Note that 75% of diarrheal illnesses contracted from the pool are caused by chlorine resistant cryptosporidium.  Therefore experts recommend that we should wait one week after resolution of diarrhea symptoms prior to re-entering the pool.  I will agree that that seems somewhat impractical but I do think that a thorough soap shower, concentrating on the anal area and the buttocks particularly in younger children and  those in diapers is necessary.  It’s estimated that these kids have up to 10 gm of feces on those body areas.  So do the math–if 10 little kids are splashing around in there, that’s 100 gm–over 3 oz–of poop in the pool.  Sounds like that scene from “Caddyshack!”

Younger children should take bathroom breaks every hour and parents who change diapers should do so in the bathroom and wash hands thoroughly prior to returning to the pool area.  Finally, try and remind children to not swallow pool water.

The other safety issue, of course, is submersion injury.  Drowning is the second leading cause in death ages 1-4.  In other words, children without congenital defects (the #1 cause) are more likely to die from drowning than any other cause.  I have touched on the subject previously so let me add just a few reminders.  All back yard pools should have a self closing and self locking gait(that’s building code mandate) and be separated from living quarters on all 4 sides.  Get kids swimming lessons–in most instances this can be initiated as young as 3 years of age (although never consider a toddler a”water safe” swimmer).  Most important, we should note that most drownings do not begin with a lot of splashing and flailing but are actually much quieter events.  So its essential that all children be supervised by an adult or trained teen lifeguard who is maintaining full attention to the pool–no grilling food, mowing lawn, or playing cards or aps then.  WATCH.  ONLY.

One final point about drowning–many toddlers actually drown in toilets or large buckets after falling in head first and then lacking strength to extricate themselves, so be vigilant about these objects in your home.

Send along questions or comments, and thanks for following

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Product recall; constipation

Please note that on July 16 the FDA sent out an alert that Pharma Tech LLC has recalled liquid docusate (brand name Diocto  Liquid) after it was found to have bacterial contamination in 5 states.  This product is also sold under the name “Colace”(among others) and is frequently used to treat constipation in children.  The recall does not specifically apply to that brand but I do think caution should be exercised when using this stool softener at this time.

Please allow me to segue from this to some remarks about the unpleasant topic of constipation.  Firstly, normal stool texture varies from child to child and according to diet and hydration status.  As my erudite and beloved residency mentor, Dr. Walter Bundy (Gd rest his soul) taught me–“anything from mustard to putty” is ok.  Secondly, not everyone stools daily.  Additionally, grunting and turning red is not necessarily abnormal–as I often suggest(“LOL”): take a video selfie some time while one answers nature’s call; most of us grunt and turn red a bit.

If a child does appear to experience pain while stooling (infants or toddlers screaming and turning red, older kids with complaints of abdominal pain) there are a number of more natural things that we can do:

 

  1. Increase fluid in the diet (water is fine)
  2. Increase fiber with vegetables (strained or cooked and soft for toddlers) and fresh or dried fruit (strained for littler kids).  Careful about calories in dried fruits with chubbier kids.
  3. Gentle rectal temperatures stimulates defecation (better for littler kids)
  4. There are a number of fiber supplements available.  I like maltsupex (liquid or powder) with its less gritty texture, but metamucil, citrucil, naturacil, and others are good too.  Generally,  1 TBL/day for toddlers.  “Gummy fibers” are gummy bear candies with added fiber–  1-2/day for younger kids, but for both above,  please call for specific dosing.
  5. There are a number of relatively milder medications that may help “from above”(by mouth): Simethicone (“mylicon”) drops or liquid, magnesium hydrates (“mylanta,” others) are usually well tolerated.  Again, call me to discuss dosing.
  6. Mostly, I try and avoid more aggressive interventions–laxatives or enemas and suppositories– where possible.  While they can be stronger and more effective, they carry greater risk of side effects like pain, vomiting, bleeding, or even electrolyte abnormalities.  Moreover, no child is a fan of having objects stuck in their rectums.  Take a child uncomfortable with/about stooling, shove stuff up there and you may cause more problems than you solve.

Be sure to call me if your child is vomiting, has bloody or black stools, poor weight gain or weight loss, more disruptive behaviors associated, or combined urine and stool issues. Remember, parents: your mission in life need not be to get a poop out of that kid every day.  Call me to discuss or with questions or comments, and thanks for following.

A few words about ADHD

Almost everyone knows some child with ADHD–its virtually ubiquitous.  And we all know of the many medicines used to help these children focus.  I wish to emphasize that drugs are not the beginning and certainly aren’t the end of ADHD management.  Rather, behavioral interventions are basic to helping ADHD children succeed.  Now, as I often say, kids with ADHD are the same as everybody else only more so.  What I mean is that behavior principles that one employs for ADHD are useful for any child and virtually all situations.

The American Academy of Pediatrics stresses 3 basic points to keep in mind:

  1. Positive communication: give your child your full attention and try to use the same words he uses.  This demonstrates that you are listening to him.
  2. Positive reinforcement.  Most important to teach good behavior is to pay attention to and reward behaviors you like and ignore those that you don’t. (Notice no mention of “punishment”–absolutely last resort).  Make sure rewards are timed closely to the good behavior.  Praise and positive attention (play with your kid!) are usually best.
  3. Structure.  ADHD children don’t like change and don’t do random well.  Try to keep to daily routines as much as possible.  When deviations are necessary it’s best to try and discuss with your children beforehand to prepare them.

There are a few other suggestions I can offer:

  • Adequate rest–everyone is more emotional and distractible when fatigued
  • Choices, but not too many.  This limits confusion and anxiety.  For example, at a restaurant, ask your child “do you want (a) or (b)?” instead of “what do you want?”
  • Homework.  Avoid multi-tasking.  ADHD kids should do homework in a quiet room at a desk/table without TV/videos/music/social media distractions.  Frequent short breaks are helpful.  If possible, offer assistance (but the kid does his own work, right?)
  • Prepare for good behavior–review expectations calmly before the event rather than during when discipline may be deteriorating.  Before is the time to say “this is what I want(don’t want).” Identify the positive reinforcement for cooperation (“if you help Dad we can ride bikes together afterwards”).  I always encourage parents to add “I know you want to be a good boy.”(I think that simple phrase is often very helpful).
  • Reasonable expectations.  In academics, no one excels at all subjects.  If your child isn’t as good/dislikes math then make sure he is in the right track class, encourage best effort, and accept the results.  Life will go on without A’s in every class.  Outside of the classroom, avoid placing your child in situations that have historically troubled him. For example, don’t take your kid on a 2 hour food shop with you on a sunny weekend day when he wanted to play with his friends.  That’s surely trouble.

I wish to be helpful while keeping things general here.  Please come on in when you need and we can discuss specifics.  And thanks for following.

Talking to your kids about weight

Here are 2 recent scientific studies about the dangers of overemphasizing weight, body image, and dieting to our children and in particular our daughters.

archpedi.jamanetwork.com/article.aspx?articleid=1863907

http://www.ncbi.nlm.nih.gov/pubmed/27270419

Now, that is not to say that parents cannot have positive influence on a child’s diet.  But we must be thoughtful and a bit clever about it.  Here are some suggestions:

  1. What’s in the house?  Well into adolescence, still, most children’s caloric intake and food choices are dictated by the family fridge and pantry.  Have healthy snacks and don’t have soda and sport drinks.  Even fruit juice should be limited (breakfast only, I think): the whole fruit containing the fiber is much healthier.
  2. Meal time.  Eat dinner together when possible.  You can strongly influence what your child eats by meal choices (more whole foods prepared by parents and less processed foods heated from the freezer or poured out of a box).  Smaller portions.  Engage in conversation during meals and encourage your child to stop eating while talking.  Your child can help out at mealtime by serving you a bit (put used dishes in the sink, retrieve condiments from the refrigerator, etc.).  I say that if the emphasis is on etiquette and not weight you are safer (better for her to think herself ill mannered rather than unattractive!).  So it’s not polite to eat too much and leave nothing for others, not polite to talk with a full mouth, and is polite for him to tend to Mom and Dad, who otherwise work so hard for him, at the dinner table.
  3. To the extent that every household will have some “fun food” snacks, keep to modest amounts and stress that the child “pace themselves.”  Again, etiquette-“don’t be selfish and finish everything yourself leaving nothing for others.” As to complaints that there’s nothing left?  My suggested answer–” I don’t have all the time and money to go to the supermarket over and over.  I will shop again later in the week.  Meanwhile you can make do and next week pace yourself a bit better.”
  4. It’s not that difficult to get a child to be physically active.  Throw the kid outside with other kids (no tablets!) his age and invariably, they will exercise. Another great way is to play with your child yourself:bike rides, walks, even jogging or playing sports if you are physically up to it.  You are making you, your child and your emotional bond stronger simultaneously
  5. Along those lines–always try and be a role model.  Be active yourself as above, and endeavor to make healthy food choices for your health’s sake as well as your child’s.

Perfection is unnecessary with these things.  Busy parents sometimes have to offer a quick, frozen meal so do what you have to do.  Soda at a birthday party is fine, as are modest amounts of cookies, ice cream, or chips at home.  An occasional family pizza night is terrific.

As I often summarize: moderation in all things.  Send along questions and comments, and thanks for following.