Potty Training Reward Charts

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					 Caring for our Future…
Answering Parents’ Questions
       Common Questions About Children
Alysia Courtot Herzog, MD and Teresa Holt, MD
      Grant Medical Center, Columbus, OH
     Talking to Parents
-70% of parents rate their MD as
  excellent in providing health care but
  almost 80% say they could use more
  information in at least one area of
      Talking to Parents
• More important than ever
  – Early hospital discharge
  – Strains on family structures
  – Not all parents are ready or prepared
  – Missed opportunities
  – They may be getting it somewhere else
  – Parents are receptive to information from the
  – Parents rate physicians more highly
  Well Child Care Visits
• What “the boards” expect
      – An opportunity to promote learning and
        development, encourage positive parenting
        practices, help children acquire behavioral self-
        control, and enhance the well-being of children
        and their families.

• What parents expect
      – Immunizations, growth and development issues,
        opportunity to discuss behavior
  Well Child Care Visits
• What we do
  – 1997 study
    • Visit length average 20 minutes
    • Anticipatory guidance average 2.4 minutes
      (about 12%)
• Issues of time, reimbursement
      How to Get it In
– Verbal suggestions
   • brief, concrete information when parents are not stressed
       – 10% couldn’t recall diagnosis for a sick visit
       – 23% couldn’t remember medication instructions
– Standardized verbal instructions
   • improve recall
– Handouts
   • improve compliance, parent knowledge and parent
       – Mostly when personalized or discussed
– Modeling/role-playing
   • helpful for problematic parenting or child behavior
– Group visits
Parents respond best to information that
  focuses on their specific area of
      Basic Care
Common Medical Concerns
• The nurses said to put the baby on
  his back, but my mother said you
  should put the baby on his
  stomach, especially after eating,
  so he doesn’t choke.
 Infant Sleep Positioning
• Prone sleepers with 3-9 times risk of
• Decline in SIDS by 40-50% since
  recommendations for supine sleep (1992)
• Choice of sleep position most influenced by
  professional health care advice and media
 Infant Sleep Positioning
• Factors Associated with prone sleep
       –   Young maternal age
       –   Low socioeconomic status
       –   High parity
       –   Black race
       –   Tobacco exposure
       –   Male gender
       –   Low birth Weight
       –   Unmarried mothers
       –   Late initiation of prenatal care
       –   Grandmother in the home
• How much baby food should she eat
  and which ones should she eat first
  and what if she only likes the sweet
  ones and what are the things I
  shouldn’t give her?
   Introduction to Solid
• Variability in recommendations
• Typical readiness at 4 and 7 months
     • Tongue thrust gone
     • Support own head
     • Interested in food
• Solids are “extras” – amount less
     • Pleasant and relaxed
     • Look for cues that the baby is finished
      Introduction to Solid
• How To
  –   Right time of day
  –   Some appetite
  –   Something to hold in their own hands
  –   Mix with a familiar taste
       • Sweets vs. vegetables
       • Iron rich
  –   Expect a mess, expect to have to “re-feed”
  –   Wait 3-4 days before next introduction
  –   May need multiple (>10) introductions before “they like it”
  –   Don’t feed straight from the jar
  –   Lumpy is okay, especially between 6 and 9 months
   Introduction to Solid
• What to watch for      • What to avoid
  – Bloating/increased     – Egg whites
    gas                    – Cow’s milk
  – Oral/anal rash         – Citrus
  – Diarrhea               – Honey
  – Runny nose/eyes        – Cooking out the
  – Unusual crankiness       nutrients
                           – “Choking foods”
• I heard I couldn’t use a pacifier
  if I was breastfeeding.
• “Pacifier use associated with declines in
  breastfeeding duration”
     • Reason linked to mothers who chose pacifiers vs..
       nipple confusion
     • Best to avoid until breastfeeding well established
• Use associated with higher risk of
  wheezing, earache, colic, diarrhea, calls to
  the doctor
• American Academy of Pediatrics now
  recommends pacifier at nap and bed
  times for first year of life due to
  lower incidence of SIDS
  – If baby refuses pacifier, don’t force
  – Defer in breastfed infants until 4 weeks
    of life
• Well, no, he doesn’t eat any
  vegetables, but he does drink juice,
  so I think he’s okay.
     Juice Consumption
• Children are the largest consumers of
  – No benefit over whole fruit in infants/toddlers
  – Associated with malnutrition (over- or under-),
    GI complaints, tooth decay
• Food Guide Pyramid
  – Half of fruit servings can be provided in form
    of juice
  – One serving is 6oz.
Juice Recommendations
– No juice under 6 months
– No juice in bottles or sippy cups
– Limits
   • 4-6oz for 1-6 years
   • 8-12oz for 7-18 years
– Encourage whole fruits instead
– No unpasturized products
– Remember in your evaluation of malnutrition, GI
  complaints, dental caries
– Discuss the difference between fruit juice and fruit
  “drinks”, “cocktails” or “beverages”
• She spits up a lot. After every
          Spitting Up

• Nearly all babies spit up
• Causes of spitting up
  – Over-feeding
  – Drooling
  – Burping
          Spitting Up
• Prevention
  – Decrease feed size and increase
  – Feed upright
  – Don’t lie down after feeds
  – ?thicken feeds with 2-3 teaspoons of
    rice cereal in bottle
         Spitting Up
• When spitting up isn’t normal:
  – Growth problems
  – Wheezing/ coughing (aspiration)
  – Crying/ refusing feeds/ hematemesis
• When you ask if the new mom is “all
  ready for the baby” she reports that
  she does not have a crib or a bassinet
  yet. She just thought the baby could
  sleep with her. What do you think?
• Autonomy argument
     • By 3 months recognition and development of
• Evolutionary argument
     • Increased sensitivity to each other
     • Infants spent more time asleep when bedsharing and
       mothers spent as much or more
• Breastfeeding argument
     • Breastfeed twice as much for 3 times as long
     • Increased infant arousals (protective for SIDS)
• The SIDS argument
  – Controversial studies – “Bedsharing”
    • smoking mothers
    • infants up to 8 weeks vs. 11 weeks
    • may be higher risk with multiple bedsharers,
      alcohol, overtiredness, longer periods in bed
    • extreme risk on couches
  – Room sharing is recommended
• Safety
    •   Bedsharing without breastfeeding ?
    •   Less than 11 weeks ?
    •   Avoid if smoking, drug or alcohol use or overtired
    •   Avoid with persons other than parents (siblings)
    •   Beds -not couches – with firm mattresses, good fit
    •   No more blankets than the adult
• Weaning
    • Begin nursing outside the bed only
    • Fully satiate before bed
• You told me that the baby just had colic,
  but I am going to go crazy if he doesn’t
  stop crying? What can I give him?
• Onset about 3 weeks, resolves about 3
• Cries for more than 3 hours a day, more
  than 3 nights a week
• Often occurs late in day
• No single cause or treatment yet found
• No increase in maternal depression or
  anxiety at 6 months
            Colic Studies
• Possible Effect             • No Effect
   – dicyclomine (bentyl-       – simethicone
     now contraindicated        – methylscopolamine
     <6mo of life)              – treatment with lactase
   – low-allergen diet for        enzymes in bottle-fed
     breastfeeding mothers        infants
     or a hypoallergenic        – carrying the infant
     formula in bottle-fed        more often, using a car-
     babies                       ride simulator or
   – the use of soy-based         training parents in
     formulas                     behavioral approaches
   – the use of herbal teas
     or sucrose
•   Different formula, nipple, bottle
•   Swaddling
•   Carrier/front pack, walking, rocking chair
•   More burping
•   Positioning (across legs)
•   Infant massage
•   Infant swing
•   Car rides
•   “White noise” – radio static, machines
•   Take a break – allow grandparents or friends to stay with
    your baby
• My two year old is still sucking her
  thumb and my father says she will
  need braces if I don’t get her to
  quit. What can I do?
• Thumbsucking – 45% of two year olds
• Infants – natural reflex
• Older children – soothing, sense of
• Usually stops between 2 and 4 years
• Causes problems if permanent teeth
  are erupting and a vigorous sucker
      Breaking Habits
• Takes time to learn and takes time to
  break – often more than 3 weeks
• Involve child in planning how to stop
• Positive reinforcement works well
  while negative sometimes escalates
  the problem
• Is it okay to use the store brand
         Infant Formula
• Formula Types
  – Cow’s milk: Similac, Enfamil, Good Start
  – Soy milk: Isomil, Alsoy, ProSobee
     • Indications: lactose intolerance, cow milk allergy,
       galactosemia, vegans
  – Protein hydrolysate-
     • Alimentum, Nutramigen, Pregestimil
     • Indications: milk/ multi-protein allergy, liver DZ,
       prematurity (for initial feeding)
  – Specialty formulas- high calorie (Neosure), etc
            Infant Formula
• Recommend iron fortified for all infants
   – Several double blinded RCTs have not shown any
     increased constipation
• Formula Preparations
   –   Ready to use: $$$
   –   Concentrated liquid: $$, equal parts H2O and formula
   –   Powder: $, 1 scoop + 2oz water
   –   *cold tap water is fine after running tap for 2 mins (if
       well water or problems with local water supply, boil, then
       add after cooling)
        Infant Formula
• How much to feed?
  – Regular formula has 20 kcal/fl oz
  – Babies need 100 cal/kg (150ml/kg)
  – Begin with 3-4 oz bottle and allow infant to eat
    desired amount
  – When emptying bottle every feed, increase
    amount in bottle by 0.5-1 oz
  – Avoids over-feeding and decreases incidence
    of obesity
       Infant Formula
• Switching formula
  – Rash or emesis (not just spitting up)
    with cow’s milk formulas
  – Extreme fussiness when no other cause
    is found
  – Changes in stool habits are not an
    indication for changing formulas
• Time Out doesn’t work with this kid!
               Time Out
• Most used and most misused discipline
• Positive reinforcement is removed
  immediately following a behavior
     • Remove to a situation void of stimulation
     • Involve a sense of loss of control
     • Not end until the child is calm and agreeable to
       comply with parental requests
• Be aware that it should not be used when a
  child wants to get out of the situation
• He is a very picky eater. All he wants
  are hot dogs and macaroni and cheese.
        The Picky Eater
• Toddlers
• Appetite decreases from infancy due to
  slowed rate of growth
     • See growth charts
• Parental expectations often inappropriate
     • 1 tablespoon/serving/year of age
     • 3 small meals and 2 snacks per day is appropriate
       The Picky Eater
• Often have favorite foods, but these can
  change frequently and quickly – continue to
  offer new choices
• Be a good role model
• Leave the bad stuff in the store
• Allow them to help with meal prep
• Make foods kid friendly
• Decrease the liquids
• Do babies really get fevers when
  they are teething?
• Timing often hereditary – usually 3
  months and older
• Brush when they come
• Transfer to cup as soon as able
• Systemic symptoms ???
    • Drooling, irritability fever (less than 100 vs.
      less than 102), diarrhea (?)
• You are doing a pre-Kindergarten
  physical. The child will be five at the
  end of August. His father wants to
  know if they should “keep him back”
  this year?
 Kindergarten Readiness
• Variable “cut off dates” in school districts
• Boys held back more frequently
• Children who are the youngest in 1st grade
  may have slightly lower achievement-
  difference disappears by 3rd grade
• Social difficulties dissipate by the end of
  the year
  Kindergarten Readiness
• The basic MD assessment should identify children at social
  or developmental risk for school-related problems
• The school should be provided with a description of the
  child’s strengths, interests, areas of special need, possible
  effects of chronic illness and medication, parental concerns
  and expectations, and relevant aspects of the home
• Counseling for parents regarding development and
  temperament is appropriate at this time
• No available “readiness” test is accurate enough to screen
  children into special programs – should be standardized and
  individualized testing
• She barely eats anything on her plate
  she just picks at things. I don’t even
  know how she has gained any weight.
  How much should she eat anyway?
            Portion Sizes
• Growth slows as the leave the infant stage
• Most will not eat a “square meal” at every sitting
   – Meet nutritional requirements over several days or a
   – Each bite is important, avoid empty calories
• Don’t force eating when not hungry
• Let them choose
   – Provide healthful choices with good variety
   – Give smaller portions and allow them to ask for more
            Portion Sizes
• 1 slice of bread, 1 oz of cereal (6 daily servings)
• ½ cup of vegetables (5-7 baby carrots, 1-2
  broccoli spears) (3 daily servings)
• ½ cup canned fruit or 1 small piece of fruit (2
  daily servings)
• 2-3 oz of meat, 4 tablespoons peanut butter (2
  daily servings)
• 1 cup of milk, 2 oz cheese (2 daily servings)

• 2- 3 year olds about 2/3 of above
• My daughter has been biting in her
  daycare and at home. Do you have
  any suggestions? I am afraid they
  will keep her out of daycare. My
  mother told me I should bite her
• Infants
     • Exploration and lack of self control
     • Offer them something else
• Toddlers – most common time (1 in 10)
     • Communication (especially of emotions) and control of
       their environment
     • Poor understanding of sharing and their ability to
• Preschoolers
     • Control, attention, self-defense, extreme frustration
     • Should not be frequent after age 3
• Respond immediately (“Ouch, that hurt!)
• Remove from the situation vs.. assist in
  taking care of the victim
• Stress communication skills (“Use your
• Examine the environment
     • Overcrowding, too few toys, overstimulation, lack of
       attention, no routine
• Do I always need to wrap the baby up
  in so many blankets when we get out
  of the hospital?
• Swaddling vs. Overheating
• Important for still developing neuro
• First six months need about one more
  layer than adults
• Don’t forget to let the hands out or
  the importance of skin to skin time
• When do you need to start reading
  bedtime books to your kids?
    Reading to Children
• Infants (and children) who are read
  to are more enthusiastic about
  reading, more successful in school,
  better readers
  – Read with inflection – infants enjoy
    rhythm, sound of voice
  – Bright pictures, simple concepts, faces
  – Toddlers love repetition
• My three year old constantly has his
  hands down his pants. Is this just a
  “boy thing” and should I do anything?
• Preschoolers
  – Discovering and fascinated by their
    body – especially when out of diapers
  – Eager to share all they are learning
  – Becoming aware of gender differences
  – Sensual creatures
• Impossible to eliminate
• Avoid excessive attention or ignoring
• Direct to socially appropriate places
  and times
• My mom said he wasn’t walking yet
  because I didn’t buy him shoes.
• Not needed in infants and actually may
  interfere with learning to walk
       • Use toes to balance
•   Flexible sole is important
•   Used shoes are OK
•   No benefit to expensive shoes
•   Check the size frequently
       • 2-9 year olds may change every 4 months
       • 10 and older every 6 months
• When you ask your patient what he
  likes to do after school he says,
  “Watch TV or play Nintendo.”
• More TV correlated with lower
  academic performance
• Increased attention problems
• Diet differences
• Obesity
• Maximum 2 hours per day for older
  children, 1 or less for preschoolers
• Choose programs, don’t use TV as
  background noise
• Recommend greatly limiting with
  signs of ADHD
• Suggest no TVs in the bedroom
• What do you mean about setting the
  water temperature? What should it
  be set at? I don’t even know how to
  do that?
   Water Temperature
• Hot water tanks should have
  temperature set at 120 degrees
  – Adult skin burn times
    • 2 sec – 150 degrees
    • 6 sec – 140 degrees
    • 2 min – 120 degrees
• You asked the patient to draw a
  picture of a person. Now what do you
  do with it?
• Evaluation of Visual-Motor and Problem Solving
• Points for each detail (max 51)
• Scoring to allow comparison to norms for age
        3   4   5   6   7   8   9   10 11 12 13
        2   6   10 14 18 22 26 30 34 38 42
• My 16 year old sleeps ALL day.
  Shouldn’t you test her thyroid?
   Teenagers and Sleep
• Teens need increasing amounts of
  sleep – at least 9 hours
• Circadian rhythm –
  – Feel awake later into evening (often
    through midnight)
  – Report being most alert at 3PM
  – 20% fall asleep in school
• My new baby cries a lot? Does he
  have colic?
• Average infant cries three hours per
• Peak crying is between 6 and 8
  weeks, decreasing to about an hour a
  day by week 12
• The well child stickers have
  “Discipline” in the Anticipatory
  Guidance check boxes. What do you
  do about this one?
• “A matter of communication – telling a
  child the way it is and the way it is going
  to be”
• Everyone makes judgments about child
• Sometimes helpful to explain the ABCs
     • Antecedent (what happens before the behavior/why
       is the child acting that way)
     • Behavior
     • Consequences (what happens after the behavior)
     Discipline Techniques
•   Redirection
•   Preteaching
•   Bribes and threats
•   Positive Feedback
•   Reward Charts
•   Time Out from Positive Reinforcement
•   Loss of Privileges
•   Behavior Contracts
•   Ignoring
•   Spanking
      Discipline Pitfalls
• Consistency
• Immediacy
• Reasonable expectations
  – Developmental appropriateness is key
  – Language – don’t give a choice
  – Moral – children less than seven are unable to
    distinguish lies and untruths from reality
• While picking the chart up from
  outside the door you hear the mom
  say, “I told you I was going to spank
  you if you do that one more time.”
• 90% American families use spanking
  for toddlers and more than 50% use
  for teens
• Boys more than girls
• Low income and increased stressors
  predict harsher discipline
    Corporal Punishment
• Less effective than extinction techniques
• Less effective over time
• Less effective if characterized by rage or
  rejection of child following
• Inappropriate in children less than 18 months –
  unable to connect behavior with punishment
• In older children associated with more aggressive
  behavior, depression, lower educational
Controlled circumstances and methods
• At no time is it acceptable to strike a child
  with an object, use enough force to leave
  marks, pull hair, jerk arms, or shake a
• Physical punishment delivered in anger
  with the intent to cause pain is never
• My daughter has been trying to lose
  weight and now she wants to be a
  vegetarian. I think she has an eating
      Eating Disorders
• Eating patterns and satisfaction with body
  appearance should be asked of all preteens
  and adolescents
• Most adolescent females express concerns
  about being overweight and many diet
• Referral based on concerns of parents,
  friends or school personnel should be
  taken very seriously
         Eating Disorders
•   Most weighed, when, how tall
•   Least weighed, when, how tall
•   What do you think you should weigh
•   Exercise and how stressed if missed
•   Dietary practices – specific, restrictions
•   Diuretics, vomiting, etc
•   Menses
• I want you to do an exam on her to
  tell me if she is having sex.
       Teens and Sex
• More than half of all high school
  seniors in America are sexually active
    • One quarter have had more than 4 partners
• Highest teen pregnancy rates in the
    • One half occur in the first 6 months of
      sexual activity (20% in 1st month)
        Teens and Sex
• Communication
  – Most parents are uncomfortable
  – Best time may be in pre-teen years
    (when they still may think it’s gross)
  – Clear messages about when parent
    thinks it is appropriate and the
    importance of protection if they do
    decide to have sex
• She needs a note to get back in
  school. I let her stay home the last
  week because she said her head and
  stomach hurt each morning and she
  really didn’t want to go.
           School Refusal
•   1-5% children – ages 5,6,10,11
•   Gradual onset – after holiday, illness
•   Stressful events at home, with peers
•   Fear, panic, tantrums, somatic symptoms
•   Worsens as allowed to stay home
•   Long term sequelae
       • 45% did not complete high school
       • 43% in psychiatric care
       School Refusal
• Evaluate as a psychiatric diagnosis
• School Refusal Assessment Scale
• Avoid writing notes, treat comorbid
  psych or family dysfunction
• Exposure/Desensitization therapies,
  Relaxation therapy, Social Skills
• I don’t want to lay her on her back all
  the time because their heads get all
  flat then.
           Tummy Time
• Increased “positional skull deformities”
  with Back to Sleep campaign
• Important to allow awake, supervised time
  on stomach which also helps in
  development of upper body strength
  – Also
     • Alternate side you turn head
     • Move crib around room
     • Limit time in car seat
• Deformity usually improves in 2-3 months
• Tell the doctor about that stuff
  you’ve been taking. His coach told
  him about this stuff and he’s been
  using it. I told him he should check
  with you. Some sort of creatine
  powder stuff…
  Teens and Supplements
• 1 million 12-17 year olds have used
   – 70% could not identify any negative side effects
   – Most use for sports – to enhance performance
   – Supplements used much more than steroids or ephedra
      • Creatine > Gatorade
• Considerable amount of research in past 20 years
  – none in athletes under age 18
• Non-regulated
• De-value principles of balanced diet, sound
  physical training, fair play
• Many can be tested for in higher level competition
• Look at this bug bite. I think he
  must be allergic. What should I give
      Insect Repellents
• Maximum concentration of DEET for
  infants and children is 30%
  – Concentration relates to duration of protection
    (10% = 2 hrs, 30%=5hrs)
• Alternatives (citronella, skin-so-soft) last
  about 20 min, new botanicals may last up to
  90 but not recommended for <3years
         Insect Repellents
  –   not recommended in infants less than two months of age
  –   apply sparingly
  –   apply only to exposed areas of skin (not under clothes)
  –   do not apply on hands of young children, to cuts, wounds or
      irritated skin or mucous membranes
  –   do not spray directly onto face; spray on hands and rub on face
  –   wash off after coming indoors
  –   avoid spraying in enclosed areas
  –   do not use near food
  –   do not use combo sunscreen products (sunscreen needs more
      frequent application)
• He took a toddler “Learn to Swim”
  class last year and does a great job in
  the water now, so I feel much better
  about him being around the water.
       Water Safety
• Infants never unattended in
• Toilet seats down
• Children under 4 or 5 do not have
  neuromuscular capacity to learn
  proper swimming skills
• I think her hearing should be tested
  because I worked in a very loud
  factory when I was pregnant.
       Noise Exposure
• Exposure to excessive noise during
  pregnancy may result in high-frequency
  hearing loss in newborns
  – Possible relation to prematurity, IUGR
• Exposure to noise in the NICU may result
  in cochlear damage and disrupt the normal
  growth and development of premature
• My three year old won’t sleep without
  the light on, but I heard that will
  ruin her vision. What should I do?
        Sleeping Issues
• 1999 report that sleeping with night lights
  hurt young children’s vision
     • Strongly disputed
     • No other evidence of this nature
• Allow period to calm anxiety and then
  reintroduce falling asleep without the light
• 3-6 year olds have active imaginations and
  frequent “bad dreams”
• My baby boy has breasts, is that
   Breast Development
• Gynecomastia
  – Any palpable breast tissue in males
  – Types
    • Infancy (breast buds)
    • Pubertal gynecomastia
    • Adult gynecomastia
   Breast Development
• Pubertal gynecomastia
    • 50-65% of males
    • Bilateral 55%
    • 90% resolve by 18 months
    • If normal testes and phallus size, and <2cm
      of breast enlargement, then reassure
    • If abnormal exam endocrine referral
    • If > 2cm in size consider surgery referral
   Breast Development
• Breast Abscess
  – Unilateral mass with fever, warmth, and
  – Most often < 5 weeks old
  – Male: female ratio 1:2
   Breast Development
• Neonatal breast buds
  – Bilateral but up to 50% asymmetry is
  – Male = female incidence
  – Due to exposure to maternal estrogen
  – Small galactorrhea is also normal
    Breast Development
• Benign premature thelarche- Age < 6 y/o
  – Increased breast profile with no/minimal
    growth of nipple or areola
  – No growth of labia minora
  – No accelerated growth
  – No pubic hair
  – Shiny/ reddish vaginal mucosa (no/minimal
• What do you think about putting the
  twins in the same class at school?
         Twin Placement
• Separation                  • Same Classroom
  – Frequent comparisons        – Already dealing with
  – Behavioral disruptions        separations (first year
    (one mothering or             of school)
    distracting)                – Emotional trauma at
  – Togetherness hindering        home
    development of one or       – Parental or twin
    both (should make             request
    other friends after age
  – Twins or parental
• My nine month old still wakes up to
  eat at night and my friend says to let
  her “cry it out.” Is this what I
  should do?
     Sleep Requirements
Newborn – feeding         6 weeks – may skip one
  dictates sleep (q 2-4     night feed – normal to
  hours)- 18/24 hours       wake several times
  asleep                  3 months – able to
1-2 months – increased      establish routine – put
  day alertness – still     to bed sleepy
  need about 2 naps       4 months (12-13 lbs) –
   (1-2 hours)              can and do sleep
                            through the night
        Sleep Training
• Routines are important
• Put into bed before they fall asleep so
  they can learn to fall asleep/back to sleep
  on their own
• Works best if started before they can pull
  themselves up in crib (6mos)
• Check in frequently
• Takes about a week ?
• Do I still need to use a car seat?
• State laws vs.. NHTSA
• Rules do not apply to taxis/public
  vehicles or emergency situations
• First offense $100, Second up to
  $250 and 30 days
• Up to 95% installed incorrectly
  – New LATCH system
• Preemies – eval and special side type
• Birth to one (and at least 20 lbs.) – rear
• 1 to 4 years – may be forward facing
• 4 to 8 years (and over 40 lbs.) – belt
  positioning booster seat (unless over 4’9”)
• Under 13 years – back seat
• You just finished a circumcision and
  the parents want to go home. Can
  they go home now? What do you tell
  them about the circ?
      Circumcision Care
• Watch babies for 1 hour after circ to
  assess bleeding
• Routine care:
  – Change Vaseline gauze or add Vaseline with
    each diaper change
  – Gently cleanse area with water daily and after
    each BM
  – A clear crust is normal for 7-10 days
      Circumcision Care
• When to call the doctor:
  – No wet diapers for 6-8 hours after
  – Blood stain > quarter size in diaper
     • 1:10,000 need transfusion, nearly all have hemophilia
  – Infection- 1:1,000
     • swelling >3-5 days, yellow D/C > 7 days
  – Plastibell (if used) not off in 10-12 days
• The two year old in your office isn’t
  saying much and you can’t really
  understand what she does say. How
  can you tell if her speech
  development is normal?
• Rule of 4s for intelligibility
   – 2/4 intelligible to stranger at 2yrs
   – 3/4 at 3yrs
   – 4/4 at 4yrs
• By 2 years
   – 25-50 words
   – 2 word sentences
   – 2 step commands
• I don’t think she will ever stop
        Weaning from
• Decision between mom and baby
• Goal is ≥ 1 year, then straight to
  whole milk in a cup
             Weaning from
• Weaning process:
   –   Wean least favorite feed first
   –   Have another person give bottle or cup
   –   Decrease by one feed very few days or weeks if possible
   –   Pump/ express to relieve pressure only
   –   Night-time feed is usually the last to wean; make
       another routine that doesn’t involve breastfeeding
• If sudden wean is required:
   – Wean by expressing or pumping and follow same pattern
     as above
• My five year old still wets the bed
  every night and my three year old is
  dry. I don’t let him drink at night
  and I try to make him get up to go.
  Is this normal?
• Diagnose after age     • Rule out secondary
  of 5                     causes
  – 2 or more episodes     – History
    per month              – Physical
• 15-25% 5 year olds       – Urinanalysis
  – Declines 15% per
  – 1-3% adolescents
        Enuresis- Causes
• Maturational
• Sleep disorder
       • OSA
•   Behavioral or Psychological
•   Anatomy
•   Antidiuretic Hormone Levels
•   Genetic
       • 77% if both/43% if one/15% if neither
        Enuresis - Therapy
• Alarm
            – Good effect, lower relapse
            – Long time to effect, disruptive
•   Positive Reinforcement
•   Responsibility Training
•   Other “Behavioral” Techniques
•   Drugs
        • DDAVP
            – Rapid effect, few side effects
            – High relapse
        • Imipramine
            – Rapid effect, inexpensive
            – High relapse, side effects
• Which brand of sunscreen do you
         Sun Protection
• Avoid sun between 10am and 4pm
  (especially 11am-1pm)
• Appropriate clothing, hats, sunglasses
• Sunscreen with SPF >15
     • Even under six months okay for a minimal amount to
       exposed skin if other measures impractical
• Avoid tanning beds
• SPF rating only for UVB
         – Greater than SPF30 increases chemicals with only small
           increase in protection (time to burning)
• Only some provide complete UVA protection
         – Avobenzone, zinc oxide, titanium dioxide
• Reapply about every 2 hours
• Should apply under clothing
         – Cotton T shirt is an SPF 5
• Typical adult body needs an ounce per application
  (one handful) and child needs half an ounce
• What about Vitamin D?
    • Older child – 16 ounces of milk
    • Infant
       – 500 mL formula/ day = adequate supply of vit D
       – Exclusively breastfed should get supplements
         since adequate sunlight exposure is hard to
         determine for each individual
           » 200 IU/ day, as OTC drops or tablets or as
             part of a multivitamin
• The chief complaint on the chart
  reads “Behavior Problems at School”
  – what do you go and get?
       ADHD Evaluation
• Symptoms occur in more than one setting, such as
  home, school, and social arenas
• Occur to a greater degree than in other children
  the same age
• Onset before the child reaches 7 years of age
  and continues on a regular basis for more than 6
• Significantly impairs the child’s academic and
  social functioning
• Not better accounted for by another disorder
      ADHD Evaluation
• Initiate evaluation in a child 6-12 years
  presenting with inattention, hyperactivity,
  impulsivity, academic underachievement or
  behavior problems
• Must meet DSM-IV Criteria
• Requires evidence obtained directly from
  caregiver/parent and teacher
  – Vanderbilt forms
• Assess for comorbidities
• How many times a day do I need to put
  alcohol on that cord thing?
    Umbilical Cord Care
• No treatment is needed!
  – Alcohol: led to skin dryness and
    irritation with no decreased infections
  – Triple dye: decreases staph. aureus
    colonization but no decreased omphalitis
• No bath tub until cord is off- usually
 by 7-10 days
• My two year old doesn’t eat very well.
  What type of vitamin should I give
Vitamin Supplementation
• More than half of all 3 year olds are given a
• AAP does not advise supplement use for the
  general pediatric population
   – RDAs met through normal diet vs.. supplementation
• Risks
   – >10,000 reports to poison control of overdoses in
     children <6 years
   – Asthma and food allergies studies
   – Over-reliance on a pill/ Establishing healthy patterns
Vitamin Supplementation
• Special Circumstances
  –   “Nutritional risk”
  –   Vitamin D
  –   Iron
  –   Vegetarian diets
       • Infants
          – No extra supplementation
       • Toddlers
          – Strict vegan diets – Vit D, Vit B12, Fe, Ca, Zn
          – Excess bulk and fiber content in foods may limit ability
            to take in enough nutrients and calories
• When you ask a father what he does
  when his daughter has a temper
  tantrum, he says, “Whatever I can to
  make her stop.” What do you say?
     Temper Tantrums
• Nearly universal between the ages of
  12 and 36 months
    • Independence
    • Attempting more complex tasks
• More than 2 per day suggests need
  to look at “medical causes” – most
  often inadequate sleep or food
     Temper Tantrums
• Consistency
• Immediacy
• Positive Reinforcement/Labeled Praise-
  during times without tantrums
• Planned Ignoring – verbal and visual
     • Children thrive on attention
     • Must warn that will often increase the behavior
       before it stops
• I don’t know how old our house is, but
  there aren’t any paint chips or
        Lead Prevention
• Dust more common problem than
  “eating paint chips”
  –   Wet cleaning to remove dust
  –   Frequent handwashing
  –   High iron and calcium diets
  –   Vacuum rentals
  –   State health department assessments
        Lead Prevention
• Symptoms
     • Headaches, abdominal pain, decreased appetite,
       constipation, decreased activity
• Late Effects
     • Cognitive development and IQ, ADHD symptoms,
       reading disabilities, absenteeism
• Testing
     • “if possible all children at age 1 and again at age 2”
     • Mandatory for “Medicaid eligible”
• Can you do some tests on her for
  learning. Her teacher thinks we
  should hold her back this year but I
  don’t want to…
      School Retention
• Most children do not “catch up” when held
• Often fall behind again in later grades
• Increased tendency to get in trouble,
  dislike school, feel badly about themselves
• Many students who “drop out” were held
      School Retention
• Less harmful if…
  – Positive self esteem and good social
  – Difficulty due to lack of opportunity vs..
    lack of ability
  – ? Different environment
• My six year old has such a hard time
  having bowel movements. What
  should I do?
• 3% of general outpatient pediatric visits
Normal Frequency of Bowel Movements
  0 – 3 months             (mean)
      breast milk          2.9 daily
      formula              2.0 daily
  6-12 months              1.8 daily
  1-3 years                1.4 daily
  over 3 years             1.0 daily
• After neonatal period, most common cause is functional
   – Painful bowel movements with resultant voluntary withholding
     of feces
• Management
   – Education
       • Pathogenesis
       • Explanation of overflow incontinence (i.e. soiling not willful)
   – Disimpaction (oral or rectal)
   – Maintenance Therapy
       • Dietary interventions – fluids, carbohydrates (sorbitol)
       • Behavioral modification – regular toileting (unhurried, after meals)
         and diaries (reward system)
       • Laxatives (earlier remission) – lubricant or osmotic vs. stimulant;
         wean only after regular bowel movements without difficulty (may
         take months)
• My baby won’t be 2 years old for a
  few months and she still needs a
  bottle of milk in bed to fall asleep.
  That’s okay, right?
      Weaning from Bottle
• Bottle to bed
  –   Not okay at any age
  –   Increases risk of otitis media
  –   Increases risk of dental caries
  –   If parents insist, then insist on water if
      baby > 6 months old
      Weaning from Bottle
• Goal is to wean by 12 months, but
  definitely by 18 months
• Wean process
  –   Cup with lid and 2 large handles
  –   Consider water first to teach skill
  –   When ready, rid of bottle and only offer cup
  –   Consider warmed whole milk or combo of whole
      milk with breast milk (or formula)
• What do you say about potty
  training? And when do you say it?
      Toilet Teaching
• Between 18 and 24 months is typical,
  some children may not be ready until
  30 months or after
• Avoid stressful times
• Do not rush the child
• Introducing the concept earlier than
  you expect to train is helpful
           Toilet Teaching
• Your child stays dry at least 2 hours at a time during the
  day or is dry after naps.
• Bowel movements become regular and predictable.
• Facial expressions, posture, or words reveal that your child
  is about to urinate or have a bowel movement.
• Your child can follow simple instructions.
• Your child can walk to and from the bathroom and help
• Your child seems uncomfortable with soiled diapers and
  wants to be changed.
• Your child asks to use the toilet or potty chair.
• Your child asks to wear grown-up underwear.
• Don’t give them a bottle to sleep
  with. What else do they need to
  know about cavities?
         Oral Hygiene
• Most prevalent infectious disease
    • 40% of children with caries by Kindergarten
• Well documented mother to infant
  transmission of cariogenic flora
    • Generally acquire by age of 2
    • Sharing utensils, washing off pacifiers in
            Oral Hygiene
• Risk Factors for Dental Caries
  –   Bottle to bed or breastfeeds at night
  –   Low income
  –   Older sibs (2nd or 3rd children)
  –   Mother with poor dentition
• If high risk, should refer to dentist 6
  months after first tooth or by 12 months
          Oral Hygiene
• Risk Reduction
  – Delay/Avoid Colonization
        – No shared spit
  – Enforce good habits in parent
        – Exam, brush/floss, xylitol gum, no soda
  – Examine at 6 months and refer as needed
  – Brush when teeth, floss when touching
  – Fruit juice only with a meal, no soda
• I think she must have pink eye. Her
  one eye isn’t red, but is always full of
 Newborn Eye Discharge
• Conjunctivitis or Not?
  – Day 1-3 – allergic due to antigonorrheal
  – Day 2-5 –gonorrhea
  – Day 5-14 – chlamydia
  – Day 2-5 – other bacteria (staph, strep,
  – Day 3-15 – viral (HSV 1 or 2)
• Gram stain and culture preferred
• Congenital Nasolacrimal Duct Obstruction
  – Occurs in 6% of newborns Typically unilateral
  – Watery discharge, tear overflow, reflux of
    mucoid material (matting/crusting)
  – Worsened with URIs, exposure to wind/cold
  – Treatment
     • Nasolacrimal massage 2-3 times daily and cleansing
       of lids
     • Spontaneous resolution in 96% by 1 year
• I don’t think I am going to
  breastfeed because last time I didn’t
  have enough milk. You say…
     Breast milk supply
• Inadequate breast milk supply is very
  – Thyroid disease
  – Peri-areolar breast surgery
  – Sheehan’s syndrome (post-partum
    hemorrhage that leads to pituitary
     Breast milk supply
• Signs that baby is getting enough
  – By end of first week: 6 wet/d, 2-5
  – Audible swallow (must have a good latch)
  – 8-12 feeds/ 24 hour period (supply and
    demand system)
  – Baby gains 4-7 oz./ wk after day 4
     Breast milk supply
• Growth spurts
  – more frequent feeds to increase supply
    for accelerated growth
  – 2-3 weeks
  – 6 weeks
  – 3 months
    Breast milk supply
• Reglan
  – 10 mg TID for 14 days ATC, then wean
    to lowest effective dose or off
  – Can increase risk of depression
• Is it normal for my daughter to have
  an imaginary friend? My husband
  thinks there may be something wrong
  at school.
• Imaginary friends are thought to give
  children a feeling of control in their lives
• Not an indication of personality flaws
  –   Support, but don’t overdo it
  –   Don’t let the friend take the rap for mistakes
  –   Make the friend an ally
  –   Treat unreasonable requests with common

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