My sister-in-law was startled when brown spots began to appear on her preschooler’s teeth. A trip to the dentist revealed that my nephew had eleven cavities, the result of constantly drinking juice as an infant and toddler. Unfortunately, time in the operating room was required to fill all the rotten spots. Today our guest blogger, Dr. Paria Hassouri, answers frequently asked questions on infant dental care. Starting care as an infant can prevent your child from ending up like my nephew with a mouthful of cavities. Dr. Hassouri is a board certified pediatrician who completed her training at the Cleveland Clinic Foundation. She has been in practice for seven years and is with Cedars Sinai Medical Group in Beverly Hills, California. She is currently writing abook about the experience of pediatrician moms across the United States. – Dr. Lai

When do I need to start brushing my baby’s teeth?

You should start brushing your baby’s teeth as soon as they come out. You can either use a clean moist washcloth or a soft baby toothbrush to do this. Before this point, many pediatricians advocate wiping your infant’s gums with a washcloth a couple times a day.

While plain water is enough to clean the teeth and gums, you can also use a small amount of fluoride-free toothpaste. Flossing should begin anytime there is tight contact between the teeth, particularly when the molars come in.

When will my baby get his/her first tooth?

While most babies will get their first tooth between 6 to 10 months, your baby may not get his/her first tooth until 15 to 18 months.

What is “baby bottle tooth decay” and how do I prevent it?

Baby bottle tooth decay is caused by frequent and long exposure of an infant’s teeth to liquids that contain sugar. The sugar penetrates the gums and affects the teeth even while they are below the surface. Sugar-containing drinks include milk and formula (even breastmilk), fruit juice, and other sweetened drinks. Putting a baby to bed for naps or at night with a bottle increases the risk. And again, remember that your baby does not need any juice.

When does my baby need to first see a dentist?

While the American Academy of Pediatric Dentistry recommends dental visits starting at age one, you can ask your pediatrician when he/she thinks that your baby should first see the dentist. If you are already following a good dental care regimen which includes brushing your baby’s teeth regularly and not letting your baby fall asleep with a bottle, your pediatrician may say that you can wait longer for the first dental visit.

What to I do if my baby dislikes or refuses to let me brush his/her teeth?

Even if your child resists brushing, it is still very important to brush the teeth twice a day. You can try brushing in front of a mirror or taking turns with your child. You can also try having your child hold a larger, thicker handled toothbrush while you use a thinner handled toothbrush to brush the teeth. In this way, the thicker toothbrush acts as a “door stop” that your child can bite on to keep his mouth open while you follow through with the thinner toothbrush. Finally, you can try blowing bubbles or singing a special song while you are brushing your child’s teeth. That way your child associates this special activity with tooth brushing; but keep in mind that this only works if you reserve the blowing bubbles or other special song for tooth brushing.

What should we do if we don’t have fluoride in our water ?

If your water does not contain fluoride, ask your pediatrician or dentist about fluoride supplements starting at six months old.

Paria Hassouri, MD

© 2010 Two Peds in a Pod

 

/* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-qformat:yes; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:11.0pt; mso-ascii- mso-ascii-theme- mso-fareast- mso-fareast-theme- mso-hansi- mso-hansi-theme- mso-bidi- mso-bidi-theme-}

Unless your child is getting the flu mist, your child may receive not only the seasonal flu vaccine as an injection this year, but also the H1N1 vaccine as an injection. Here’s how you can take away the sting of any needle:

Set the stage. Your child looks to you for clues on how to act. If mommy and daddy are trembling in the corner of the room, it will be difficult to convince your child that the immunization is “no big deal.”  Do not tell your child days in advance that she will be immunized. The more you perseverate, the more your child will perceive that something terrible is about to happen. Simply announce to your child right before you leave to get the immunization, “We are going to get an immunization to protect you from getting sick.”

 

Do not say “I’m sorry.” Say instead,”Even if this is tough, I am happy that this will protect you.”  

 

Never lie.  If your kid asks “will it hurt?”say “less than if I pinched you.”

 

Watch your word choice. Calling an immunization “a shot” or “a needle” conjures up negative images. In general, avoid negative statements about injected vaccines. I cringe when parents in the office threaten children with,” If you don’t behave, then Dr. Lai will give you a shot.”

 

Remember the mantra, if all is well in the basic areas of eat, sleep, drink, pee, and poop, then any stressor is easier to handle. 

 

Kids talk. Be aware that kids, especially those in kindergarten, like to scare each other with tall tales. Ask your child what they have heard about vaccines. Let children know that Johnny’s experience will not be their experience.

 

The moment is here.

 

You may have heard about a topical cream which numbs up an area of skin. Unfortunately, because the creams anesthetize the surface of the skin and most vaccines go into muscle, I do not find the creams very effective at taking the pain away. 

 

Instead, practice blowing the worries away. Have your child practice breathing slowly in through her nose and blowing out worries through her mouth. For the younger children, bring bubbles or a pin wheel for your child to blow during the immunization. In a pinch, take a piece of the exam paper in the room and have your child blow the paper.

 

The cold pack: holding something very cold can distract your child’s brain from feeling the pain of an injection.

 

“Transfer” the immunization to mommy or daddy.  Have your child squeeze your hand and “take the immunization” for him.

 

Tell your child to count backwards from 10 and it will be over. In reality, it will be over before your child says the number seven.

 

Have as much direct contact with your child as possible. The more surfaces of his body you touch, the less your child’s brain will focus on the injection. Again, this is the distraction principle at work. By touching your child, you are also sending reassuring signals to him. For the younger child, if he is on the table, stay close to his head and hug his arms, or have him on your lap. For the older child and teen, hold their hand. I sometimes see parents of older teens and college students leave the room. Even the big kids may need someone to keep them company.

 

Help hold your child firmly. Holding him will make him feel safe and will  prevent him from  moving during the injection. Movement causes more pain or even injury.

 

After the drama is over. 

Have your older child sit quietly for a moment. As the anxiety and tension suddenly falls away, the body sometimes relaxes too suddenly and a child will start to faint.  This phenomenon seems to happen most often with the six foot tall stoic teenage boys.  We have a saying in my office- The bigger they are, the more likely they are to fall.

 

Compliment your child. Remind them that you will never let anyone really hurt them.

Now a story:

When my middle daughter was two years old, my family trouped into my office for the flu vaccine injection. We all sat calmly in a circle and smiled. 

First, the nurse gave me my immunization. I smiled. My middle daughter smiled.

Second, the nurse gave my husband his immunization. He smiled. My middle daughter smiled.

Then the nurse gave my oldest daughter her immunization. She smiled. My middle daughter smiled.

Then the nurse gave my middle daughter her immunization. She did not smile. She did not cry. Instead, she slugged the nurse with her little fist.  I think the nurse felt more pain than my child.

Someday all immunizations will be beamed painlessly into children via telepathy. Until then, I have no advice on how to take the sting away from the punch of a two year old. 

Naline Lai, MD

© 2009 Two Peds In a Pod

Why the recent American media hub-bub over “the flu” and “the swine flu”?  Both are forms of the same virus called influenza.  Usually known as “the flu,” this year, “the flu” is called the seasonal flu in order to distinguish it from “the swine flu,” properly known as the 2009 H1N1 flu.  Getting hit by any form of influenza can feel like being hit by a ton of bricks.  Just ask my husband.  Last winter, the same man who ran his first Marathon in the fall, couldn’t run 500 feet for nearly a month after his bout with the seasonal flu.   Complications from either form of influenza include sinus infections, pneumonia and even death.  Influenza   infections in the States occur mainly from October to April each year.  Usually, only the  seasonal strain is of concern, but this season there is the added concern that the 2009 H1N1 strain, which first leaped into the spotlight this past spring, will also add to the total number of people affected by influenza.

Both influenza forms are viral illnesses which predominantly cause airway symptoms.  Classic flu symptoms are sudden onset of nasal discharge, cough, high fever, headache and achiness.  A virus is a category of germs which are named for the way they reproduce.  Examples of viruses vary wildly.  Chicken pox, the common cold, and Human Immunodeficiency Virus (HIV) are all caused by viruses.  Whether an illness is caused by either a virus or a bacterial germ does not necessarily reflect the severity of an illness.  To add to the confusion, people sometimes call any viral illness which causes stomach upset “the stomach flu.”  “The Stomach flu” is not caused by an influenza virus.  If your child has diarrhea and vomiting alone with no stuffy nose or cough, they are not likely to have a form of influenza.

How do I protect my kids against either the Seasonal Flu or H1N1?

Wash, wash, wash. 

Hand washing with soap and water for 15 seconds has been proven to decrease germs.  For young (or impatient) children , have them sing the Happy Birthday Song until they are done.  One note- alcohol containing hand sanitizers do kill germs; however, most brands contain a greater percentage of ethylene alcohol than distilled drinks. Hand sanitizers contain over 60 percent alcohol versus 30-40 percent alcohol in liquor. According to my sister, Melisa Lai, MD, a Boston area toxicologist, toddlers have ended up in comas from alcohol poisoning after drinking hand sanitizer.

No nose-to-nose. 

 

Both forms of influenza are spread through air via coughing and sneezing. Tell your kids that they don’t want boogies from other kid’s noses to go into their nose.  If their noses can touch the noses of other children, then they are too close.  Cough away from other kid’s faces.  If we use national standards for spacing between sleeping cots in daycares (Caring For Our Children Health and Safety Standards, 2nd edition), children are ideally kept two feet apart.

Keep ‘em away from crowded places.

Any parent knows, keeping playing children two feet apart from each other is near impossible.  If your child is sick, keep them away from crowded places such as birthday parties, school and daycare.  If your child is already ill, you do not want them to catch a secondary illness on top of their current illness.  For the protection of your child and others, keep your child at home until  he/she is 24 hours fever free.  This school and daycare exclusion criteria is already recommended not only for influenza by the American Academy of Pediatrics, but for all illnesses (www.AAP.org).  A few days ago, the Centers for Disease Control http://www.cdc.gov/h1n1flu/schools/  published the same guidelines for influenza.

Immunize.

There are two types of immunizations against the seasonal flu.  Because the seasonal influenza strains change from year to year, the vaccine changes and need to be given yearly.  One is a nasal spray for children two years old and up.  The other type is injected into muscle and is approved for those six months and above.  Because the vaccines are made up in eggs, children with egg allergies cannot receive the vaccine.   Under nine years of age, the first year a child receives the seasonal flu vaccine, two doses are required.  If only one immunization was given the first year, the child will require two the second year.  If your child is ill or had a reaction to the seasonal vaccine in the past, ask your doctor about administration of the vaccine.

 As of this writing, vaccines for the H1N1 flu are still not available.  Vaccines are expected to be available in the late fall.  Uncertainties about the H1N1 formulations, side effects and distribution still persist.

 The priority groups for the seasonal flu immunization and the 2009 H1N1 flu immunization are slightly different.  The main difference between the set of recommendations is that those over 65 years of age are not a target groups for the 2009 HINI vaccine but a target for the seasonal flu vaccine.  Also, college aged (19-24 years) adults are part of the 2009 H1N1 target group but not of the seasonal flu vaccine target group.

 According to the Advisory Committee on Immunization Practices, a working group of the Centers for Disease Control which meets to review infectious disease  data and recommends national guidelines for immunizations, the following groups are the priority groups for influenza vaccination:

Priority groups for the seasonal influenza vaccine:

1.       Children aged 6 months up to their 19th birthday

2.       People 50 years of age and older

3.       People of any age with certain chronic medical conditions

4.       People who live in nursing homes and other long-term care facilities

5.       People who live with or care for those at high risk for complications from flu, – includes Health care workers, Household contacts of persons at high risk for complications from the flu, Household contacts and out of home caregivers of children less than 6 months of age (children too young to be vaccinated)

6.       Pregnant women

Priority groups for the 2009 H1N1 influenza vaccine:

1. All people from 6 months through 24 years of age
2. Household contacts and caregivers for children younger than 6 months of age
3. People aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza.
4. Healthcare and emergency medical services personnel
5. Pregnant women

Is there treatment?

Treatment is generally supportive.  Have your child drink plenty of fluids and get as much rest as possible.  Fever reducers such as ibuprofen (i.e. Morin, Advil) and acetaminophen (i.e. Tylenol) may help keep children comfortable enough to do the things such as drink and sleep that will make them better.  Outpatient antiviral does exist but the strains of flu can morph, thus rendering them sometimes ineffective.   Antiviral medications are for children whose illness is moderate or severe or if they are at high risk of complications.  Generally antivirals work best within the first 48 hours after onset of symptoms.  Antibiotics such as Amoxicillin and a “Z-pack “will not kill influenza viruses.  Antibiotics are prescribed if there is bacterial infection overlying the influenza infection.

This winter, although your family may escape both strains of influenza, remember, there are plenty of “flu-like” illnesses out there which can also wreck havoc on your child’s health.  Hopefully, if the threat of the seasonal and 2009 H1N1 flu forces us to pay attention to good hygiene habits, we may overall end up with a healthier winter.

For the most up to date information on influenza: www.CDC.gov

Naline Lai, MD and Julie Kardos, MD

©2009 Two Peds in a Pod®

 

Ouch! Stung on the scalp.

Ouch! Stung on the hand.

Ouch! Stung on the leg.

Ouch! Ouch! Stung TWICE on the lips.

Those nasty, nasty hornets.  During the hot days of August, they become more and more territorial and attack anything near their nests.  Today, in my yard, hornets mercilessly chased and attacked a fourth grader named Dan.  As everyone knows, you’d rather have something happen to yourself than have something negative happen to a child who is under “your watch.” As I rolled out the Slip and Slide, I was relieved not to see any wasps hovering above nests buried in the lawn.  I was also falsely reassured by the fact that our lawn had been recently mowed.  I reasoned that anything lurking would have already attacked a lawn mower.  Unfortunately, I failed to see the basketball sized grey wasp nest dangling insidiously above our heads in a tree.  So, when a wayward ball shook the tree, the hornets found Dan.

What will you do in the same  situation?

Assess the airway- signs of impending airway compromise include hoarseness, wheezing (whistle like sounds on inhalation or expiration), difficulty swallowing, and inability to talk.  Ask if the child feels swelling, itchiness or burning (like hot peppers) in his or her mouth/throat.  Watch for labored breathing.  If you see the child’s ribs jut out with each breath, the child is struggling to pull air into his/her body.    If you have Epinephrine (Epi-Pen or Twin Jet)  inject  immediately- if you have to, you can inject  through clothing.  Call 911 immediately. 

Calm the panic- being chased by a hornet is frightening and the child is more agitated  over the disruption to his/her sense of security than over the pain of the sting.  Use pain control /self calming techniques such as having the child breath slowly in through the nose and out through the mouth.  Distract the child by having them “squeeze out” the pain out by squeezing your hand.

If the child was stung by a honey bee, if seen, scrape the stinger out with your fingernail or a credit card.  Do not squeeze or pull with tweezers to avoid injecting any remaining venom into the site.   Hornets, and other kinds of wasps, do not leave their stingers behind.  Hence the reason they can sting multiple times.

Relieve pain by administering Ibuprofen (Motrin,Advil) or Acetaminophen (Tylenol).

As  you would with any break in the skin, to prevent infection, wash the affected areas with mild soap and water.

Decrease the swelling.  Histamine produces redness, swelling and itch.  Counter any histamine release with an antihistamine such as Diphenhydramine (Benadryl).  Any antihistamine will be helpful, but generally the older ones like Diphenhydramine, tend to work the best in these instances.  Unfortunately, sleepiness is common side effect.

To decrease overall swelling elevate the affected area.

A topical steroid like hydrocortisone 1% will also help the itch and counter some of the swelling. 

And don’t forget, ice, ice and more ice.  Fifteen minutes of indirect ice on and fifteen minutes off.

Even if the child’s airway is okay, if the child is particularly swollen, or has numerous bites, a pediatrician may elect to add oral steroids to the child’s treatment.

It is almost midnight as I write this blog post.  Now that I know all of my kids are safely tucked in their beds, and I know that Dan is fine, I turn my mind to one final matter:  Hornets beware – I know that at night you return to your nest.  My husband is going outside now with a can of insecticide.   Never, never mess with the mother bear…at least on my watch.

Naline Lai, MD and Julie Kardos, MD

©2009 Two Peds in a Pod®

Recently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, poison ivy is NOT contagious. You can catch poison ivy ONLY from the plant, not from another person.

Also, contrary to popular belief, you can not spread poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch :

• Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.
• Hydrocortisone 1%.  This is a mild topical steroid which decreases inflammation.  I suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day
• Calamine lotion – a.k.a. the pink stuff. this is an active ingredient in many of the combination creams.  Apply as many times as you like.
• Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti itch properties.
• Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub.
• Do not use alcohol or bleach- these items will irritate the rash more than help

The biggest worry with poison ivy rashes is not the itch, but the chance of super-infection.  With each scratch, your child is possibly introducing  infection into an open wound.  Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.  However, a hallmark of infection is tenderness- if there is pain associated with a poison ivy rash, think infection.  A hallmark of an allergic reaction is itchiness- if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure.  Infection usually occurs on the 2nd or 3rd days.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

Naline Lai, MD and Julie Kardos, MD

2012 Two Peds in a Pod®