Archive for February 2012

Monthly Archive

Toddler Sleep: Early Morning Awakenings

Every week in clinic families ask me about strategies to help with children who awake before the sun is up. We all thrive with improved, uninterupted, prolonged periods of sleep at night. Particularly on those Saturdays where an extra hour or two of sleep can be life-sustaining for exhausted parents to toddlers and preschoolers. Because of our boys’ early schedules, late last year Santa conveniently dropped off an incredible tool: a toddler teaching clock. The clock has helped our 3 year old know when 7 o’clock rolls around. And we’ve made a deal with boys for 2012: no leaving their bedroom until 7 appears on the screen. And so far, it’s working–we’re batting about .900. Learning to play quietly on their own in the early morning has been a great benefit, too.

Toddlers and preschoolers between 1 and 3 years of age need about 11 to 13 hours of total sleep within 24 hours (night time and nap combined). Sometimes no matter what time bedtime starts, early morning awakenings continue to happen. As many parents learn, moving bedtime later doesn’t always shift the time a child awakens in the morning. But with time, shifts in schedules sometimes improve that Saturday morning sleep…

Dr Craig Canapari, a pediatric pulmonologist and sleep expert in Boston helps explain some reasons for these uber-early wake-ups and what we can do about it:

Why does my toddler get up so early in the morning?

Read full post »

Toddler Sleep: 4 Reasons Toddlers Wake Up At Night

There is a lot of writing online about how to get your baby to sleep through the night during infancy but not as much expertise to help those of us with toddlers and preschoolers who wake a number of times. Between age 2 and 3 when O was released from crib jail and moved to a big bed, he’d come to find me a couple of times a night. I’d often awake (and startle) to find him standing next to my bed! I tried many things to improve his opportunity for a full night’s sleep yet for those kids who never quite figure out that sleeping through the night starts around 7 or 8pm and ends with the sun coming up around 7am, we want to help. Recent data shows that 1 in 5 infants who have trouble sleeping may continue to have challenges during the toddler years. Clearly challenges with sleep that span multiple years affect many of us.

I turned to a pediatric sleep expert for help. Dr Craig Canapari is a doctor I met on Twitter (of all places) who answered questions surrounding sleep challenges for toddlers. Dr Canapari is a father to 2, a pediatric pulmonologist & sleep expert, and is thinking of starting a blog! He told me that when he was a kid he, “definitely did have problems falling asleep sometimes,” so not only is he an expert, he’s experienced! Check out his responses here and leave comments and questions — I’ll get him back on the blog to respond as needed.

Why does my toddler wake up at night?

Every parents has experienced the dreaded 2 AM call. You hear your little one stirring on the monitor. Either you wait, fingers crossed, to see if they go back to sleep and they don’t, or you run in there as fast as you can to stuff the pacifier in their mouth before they really wake up. Most babies are capable of sustained sleep (6-8 hours in a row) at night by age six months. If you are nursing your child, it may take them a bit longer to achieve this. I think that it is reasonable that every child should sleep through the night most nights by 9-12 months of age. Now, every child wakes up sometimes at night. I view the awakenings as a problem if they are more than a few minutes in duration, occurring multiple times at night, or resulting in significant daytime irritability for either the child or the parents.

If your child is having problematic nocturnal awakenings, there are a few possible causes: Read full post »

Mommy Daddy Days

For the last month or so O has woken up every single morning with the same question:

“Is today a Mommy Daddy Day?”

What he means is, “Is this a weekend where I get the day with both of you?”

The answer, less than 2/7 of the time, is unfortunately “No.” And on some level it kills me. I don’t usually only say, “No” when he asks, I usually end up marketing the day. It goes something like, “No, but the great thing is today you get to go to school and you have swimming lessons. Or, “Today you get to go to the zoo with the nanny and make thank you cards. Or, “Today is a Daddy Day!”

It weighs on me. O is extremely attached and has been since day (before) one. I often think about how he’s as attached as I am. F on the other hand adores his independence.

I traveled all week and fortunately mid-week from Florida I face-timed with the boys. It was delicious really, and settled my aching heart in spite of the fact that the first thing O said when he saw my face was, “Come home, Mommy!”

Being a working parent tugs on us in bizarre ways. But it also elevates us. And as I spent the week crossing the country giving lectures, I was reminded of my strong sense of purpose. My need to speak up and improve the world for my children. The need to scream from the roof tops about revolutionizing health communication. I mean what I say and I believe in what I do. And while the boys thrive, this equation of clinical responsibility and working to change health care, works. The only problem is that this week O might have missed me as much as I did him. I would suggest this new reality is not entirely ideal.

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Reading A Growth Chart: Mama Doc 101

Parents, pediatricians, and nurses have been using growth charts since the late 1970′s to track growth in their infants and children. The charts were revised back in the year 2000 as the data for the first charts (from a small study in Ohio) that didn’t accurately reflect the cultural and ethnic diversity of our communities.

The hallmark of a well child check is the review of a child’s growth. Growth can be a reflection of a child’s overall health, nutrition, and/or tolerance of possible underlying medical conditions. So understanding what your doctor or nurse practitioner says about your child’s growth should be a priority.

Watch the video to learn more about interpreting growth charts.

If your doc doesn’t have a computer in the room, ask to see the chart (on paper) or on a computer in their office. It will not only inform you, I suspect it will delight you to see what your child has done since the last time they have been seen.

The human body really is a fine-tuned machine and growth is simply astounding if you really stop to think of it.

If you have a challenge understanding how your child is growing or how the growth chart is presented, demand clarification. It’s okay if you don’t understand the presentation of facts on these grids; have confidence to speak up and ask for the doctor or nurse practitioner to explain it.

Revisions to the growth charts in 2000

Understanding growth charts

Half & Half

I had a great trip to the grocery store today with the boys. Life has been so hectic these past few weeks, we haven’t had weekend time for a leisurely trip to the aisles of fruit and fondue. Today, we had the luxury of time, a list, and a proper plan. They weren’t hungry (and neither was I) so our stomachs didn’t drive the cart and the boys were uniquely engaged. We perused the produce area. We made peanut butter in the machine that crushes raw peanuts. We talked about some of the beginnings of the food we bought (the avocado came from Mexico, the mini-oranges from California). But I thought most about how pleased I am when I end up at checkout with more fresh food in the cart than food stuffed into packages. Today I think I came close.

And that’s the lesson. One thing I say over and over again in clinic is, “If at all possible, for every single meal you offer your child at home, make sure 1/2 the plate is covered in fresh fruit and veggies.”

So if that’s the goal, the cart should always look the very same way.

Pacifiers: A Love Affair Worth Having?

Pacifiers, a love affair worth having? It’s up to you, of course. Pacifiers are hotly debated among some parents, some pediatricians, some lactation consultants, and some dentists. I say some, as I believe not all clinicians have strong impressions/judgments. That’s because pacifiers don’t cause excessive harm. Yet most parents agree on one thing: they all have an opinion about what to do with one. Some hate them, others adore them. Just like babies. Silicon pacifiers can be all the rage, or none of it…

At our house, we had a love affair with a pacifier. Twice. Without even trying. And it all happened by accident.

Although the American Academy of Pediatrics and National Institute of Child Health and Human Development recommend using a pacifier at night to decrease the risk of SIDS, if your infant doesn’t like one, you certainly DON’T need to force it upon your content baby. Don’t over-think or over-value the pacifier, either.

With F (our first born), I waited, held off, and withheld the pacifier hoping to improve my changes of successful breastfeeding. We had a few sleepless weeks (with the fussing and crying normal for a newborn) until a couple weeks of age when we realize it really was the “plug” he was looking for. F’s crankiness improved, and we had another tool to help support him when holding, rocking, feeding, changing diapers, or swaddling didn’t soothe him entirely. The pacifier was just something he loved.

With O (our second), I didn’t get the choice. While in the NICU, the nurses used the pacifier to “quiet” him down. I asked that they didn’t, but when I returned to feed him, there it was again, in his mouth. And he was in love. So we continued to use it and I didn’t take it from him. As I’ve written before, I loved to see him enjoy and indulge with that pacifier. I mean, he really craved and adored the time he got with it (mostly during sleep or in the car). Weaning him from it was harder on me, it turns out. And I faltered a couple of weeks after the wean during a moment of weakness…

We used pacifiers in our homes until both the boys were just under 2 years of age. And like I said, it really was a love a affair.

The reason is simple, babies soothe by sucking and pacifiers are a perfect tool. My advice on pacifiers: follow your instincts. You’ll be able to find studies both that support use and studies that dissuade use to back up either decision. So don’t over-think this. And stop beating yourself up for using one if you are…

Mama Doc’s Cliff Notes On Pacifiers:

  1. These are things you already know: Wash the pacifier regularly (dishwasher safe are easiest) in warm soapy water, get rid of old pacifiers that show cracking or damage, and use a one-piece silicone design if possible. Don’t dip the pacifier in anything (ie sugar water, honey, etc) ever. And never tie the pacifier around your baby/toddler’s neck.
  2. As your child grows, the pacifier should, too. Don’t let toddlers have infant sized pacifiers due to choking risk. Smaller pacifiers may rest more on their front teeth as well and cause more malocclusion or “bucking” of teeth. Get the correct size pacifier if your older toddler or preschooler still uses one.
  3. When your child approaches 6 months of age, consider weaning. If neither of you are interested in breaking up with pacifier, try again at 2 years of age. By 3 years, get it out of the house or the love affair will cause a most terrible break-up.

Additional Safety Tips on Using Pacifiers:

Mayo Clinic’s Do’s & Don’ts on Pacifiers

Review article about dental problems caused by pacifiers after age 3.

Satisfying your baby’s needs: Pacifiers

Measles At The Super Bowl

Like the makings of a Hollywood movie, I learned this week that there were an estimated 200,000 people in Super Bowl Village this past weekend in Indiana. Amongst them on February 4th, was one (or maybe two) child with infectious measles. Fortunately, the child didn’t attend the game. Yet, measles is highly contagious. The period of infectivity starts before symptoms in some cases and usually 4-5 days before the typical rash, when many think they have just a bad cold. Measles is spread by the respiratory droplets infected people share when breathing, coughing, or sneezing. And the virus can survive for about 2 hours on surfaces or in the air after a person leaves the room. Measles has a wild history and although most children/adults do well after recovering from the illness, measles can result in severe complications like pneumonia or encephalitis. Fortunately, the majority of those in attendance last weekend who may have walked by or been near the infected person were protected by the measles vaccine.

The incubation period (the time it takes to get sick after being exposed) is about 10 days with measles. So if unprotected people contracted measles last weekend, they may get sick this weekend or early next week. Hopefully, we’ll hear of no one.

Measles spreads easily. There are reports of measles infecting every single unvaccinated person at a picnic. The public health department, even here in Seattle, sent an advisory email last night with instructions for what we doctors should do if we suspect measles in someone who was in Indiana last weekend.

But this is a global thing not just a US national sport thing. Starting in 2009, the number of cases of measles rose sharply in Europe. In 2010 for example, there were over 30,000 cases of confirmed, reported measles and in 2011 (through October), there were over 25,000 cases, with over 14,000 cases in France alone. Fifty percent of those with reported measles were children, less than 14 years of age. Immunization rates for measles have declined in Europe and public health officials point to waning vaccination as one reason for the surge. Read full post »

An App For That?

Stop what you’re doing to read this The New England Journal of Medicine perspective by Dr Doug Diekema. It’s about vaccines, opportunities for health, and physician obligation. Written for physicians, it also speaks loudly to parents and includes a few very essential points. The whole time I read the article, my thoughts kept leaping to our imminent opportunities. Today, in 2012, we can harness the tools of social media and technology to solve many of these problems. It’s time. HPV vaccine? Varicella vaccine? Remember your yearly flu shot?  I really think there could an app for that.

Let me explain.

Dr Diekema opens describing a scene very typical in Seattle.

Recently, the mother of a young child confessed to me that she didn’t know any parents who were following the recommended immunization schedule for their children. She said that when she told her pediatrician she’d like to follow an alternative schedule, the physician had simply acquiesced, leading her to assume that the recommended schedule had no advantage over the one she suggested.

Yes, the physician obliged her desired schedule for many reasons, I suspect: time restraints/desiring a partnership/a hope for future opportunities to provide education and update immunizations for the child. In a state (Washington) that leads the nation in vaccine exemptions, we encounter patients daily who prefer a delayed or personal schedule. I’ve written about parents and alternative schedules and physicians’ conditional comfort with alternative vaccine schedules. But when Dr Diekema mentions this family, he highlights what many pediatricians and family physicians realize: families may be clustered together in vaccine-hesitancy. Friends of friends instruct each about vaccine schedules and share beliefs about safety. We know that 40% of parents who use an alternative schedule create it themselves.

Family members persuade my patients not to get immunized. Even in the midst of a pertussis outbreak in the county in which I practice, grandparents and relatives of newborns refuse the Tdap vaccine. My patients are bombarded with advice and naysayers. Who we love (friends and family) and who we trust (friends and family) certainly affect what we do. My patients get confused. And most of health (care) conversations happen outside the exam room. Therefore, hesitancy clusters in neighborhoods naturally and poses regional risk. What if we had real time information about our schools? About our neighborhood? What if Google mapped our rates of protection from vaccinations? What if we had a smart phone app that provided us yearly data on school immunization/exemption rates when we selected a kindergarten? Why not an app for that? Read full post »

What About Chores? Seattle Mama Doc 101

So what about kids and chores? My take is that it’s personal. But also I’ll hint that I think chores are a great opportunity to build community and citizenship. Research has found great lifelong reward from doing childhood chores (think: less drug use, higher self-esteem, more sound relationships, beginning a career path, less anxiety, etc). I mean with those findings, sign me up! But it’s possible not everyone agrees and research may not be what sways you. It may be a need to get things done around the house. A popular poll (done way back in 2001) found that 75% of people feel children do fewer chores today than 10 or 15 years ago. I don’t know if that’s just recall bias or pessimism or favorable historians talking. But…

A smattering of opinions about chores:

What do you think; is there controversy here at all? Do you think chores help transition our children into responsible adults?

Carpooling Reduces Booster Seat Use

Survey results published this week found that the majority of parents report carpooling with their 4 to 8 year-old children. About three-quarters (76%) of those carpooling parents reported that their child used a booster seat when riding in the family car. But when carpooling–the seats were used far less often. For example, the survey found 1 out of 5 parents do not always ask other drivers to use a booster seat for their child. And only half of parents always have their child use a booster seat when riding with friends who do not have boosters. So what your friends do really may change what you do.

This makes sense. I guess. It’s clear people get tired of recommendations. Today, for example, when I sent out a link to the Washington State Booster Seat Law, someone replied on Twitter, “Oh come ON!” Read full post »