Keeping your Child Healthy

Parents usually have many questions about vaccines.  When will my child receive shots?  How many will they need?  Only your doctor can answer these questions with complete accuracy, but the following information will give you a general idea of what to expect during your child's first 18 years.

Recommended immunization schedules for children age 0-18 years

Genius!

Have you ever forgotten to give your child their antibiotic?  Or worried you might be giving it twice?  Here's a great pintrest inspired idea that we LOVE!  Excellent idea for making life easier for busy parents!

Let's Eat!

by Dr. Michelle Linkous

Parents are always excited to start their baby on solid foods!  The American Academy of Pediatrics recommends exclusive breastfeeding until 6 months and we typically recommend that parents wait until 4-6 months to introduce their baby to solids.  Here are some signs that baby may be ready to try solid food:

- Baby can sit upright with support in a highchair and control her head well
- Baby opens his mouth wide when parent brings food near
- Baby swallows food put into her mouth
- Baby has doubled his birthweight and weighs ~ 13 pounds or more

Is your baby ready?  If so, we recommend that you start with a single-grain cereal such as rice or oatmeal.  Mix with baby's regular formula or breast milk so the taste is familiar and aim for a thin, liquid consistency.  Expect the first few feedings to be messy!!  Always feed him from spoon and avoid adding solids to your baby's bottle.  Once your baby is eating cereal without difficulty and wanting more, consider adding more foods to his diet.

From this point on, introduce one new food every several days so that you can monitor for any signs of allergic reaction.  Most recommend starting with fruits or vegetables and then progressing onto meats.  I generally tell my patients to introduce all "stage 1" foods before progressing to stage 2 or 3.  The consistency of the food gets thicker in stage 2 and stage 3 foods usually contain whole pieces, which your baby may not be ready to eat until 8-9 months.

Around 6 months, you should begin offering your baby a sippy cup during her "meals".  Place a small amount of water in the cup and allow her to experiment.  Over the next few months, she can develop the skills she needs to drink from a cup and this will make it much easier to wean her from the bottle!

Finger foods can be introduced once your baby can sit well, pick up small items with his fingers and bring his hands to her mouth.  Most babies are ready for these around 9 months.  Good options for finger feeding include mashed bananas, Cheerios, well-cooked pasta and well-cooked vegetables.  Most foods are ok if you can cut them into small pieces and easily "squish" them between your fingers with slight pressure.  Avoid hot dogs, nuts, popcorn, grapes and candies as these are choking hazards for baby!

Avoid whole milk until 12 months of age.  Avoid eggs, shellfish and peanut butter until at least 12 months, but I recommend you discuss this with your pediatrician as their recommendations may change depending on your child's needs.

Help Prevent Childhood Obesity

by Dr. Michelle Linkous

Childhood obesity is a current medical epidemic that affects many of our children today.  Help us prevent this disease with the following tips:

Remember 5, 4, 3, 2, 1, 0...

5 - Eat five or more servings of fruits and vegetables every day

4 - Eat at least 4 or more meals together as a family every week

3 - Eat 3 meals a day - no skipping!

2 - Limit screen time to less than 2 hours per day (TV, computer, video games, phone)

1 - Get at least 1 hour of physical activity every day (at least 30 min continuous)

0 - Drink 0 sugary beverages each day

Tips to help you follow these recommendations:

- Eat a piece of fruit or a vegetable at every meal

- Clear the table, turn off the TV and have FUN with your family at mealtime

- Unsure if you are hungry?  Try water or a sugar-free drink first

- Put TV and computer in family room only

- Take the stairs instead of the elevator

- Turn up the music and dance!

- Do light exercise such as jumping jacks, sit-ups, push-ups or lift hand weights during TV commercials

- Choose water with lemon or lime, sugar-free flavored water, Crystal Light, unflavored tea, diet soda or skim milk when you are thirsty

As always, remember that change does not occur overnight and change is never easy.  If you or a family member are struggling with weight, start by making a small switch in your diet or lifestyle.  As you feel more comfortable and motivated, you can make more changes!  Also keep in mind that parents enable bad eating behaviors for their children, so be careful what you buy and put in your cabinets.

Visit Brenner Fit for more information regarding Brenner Children's Hospital's pediatric weight management program.  If your child is significantly overweight or has other conditions including high blood pressure and high cholesterol, talk with your physician to see if your child qualifies for this program.

Got your passport out? See us next!

by Dr. Mark Pashayan


If you are planning foreign travel, take a moment to plan an office visit for your kids.  We can provide you information on health hazards in general but also specific for your destination and travel plans.    Vaccines for your destination might take a while to become effective, or need boosters.  Typhoid vaccination and malaria preventive treatment need to start long before you enter a dangerous area.  You can be prepared with water filters, insect repellent clothing and sunscreen in a lotion or a fabric!


At your destination we might find that:

• Accidents in motor vehicles are a huge risk in many countries (at a minimum check for seatbelts!)
• Fresh Fruits should be peeled to avoid surface bacterial contamination
• Tap water might be contaminated- 
• don't use fountain drinks with ice cubes
• brush your teeth using bottled water, from a sealed bottle that you opened yourself
• consider buying a small UV water sterilizer 
• Walking barefoot and swimming in freshwater streams, and ponds might expose you to parasites
• Entry from a third country might require vaccinations you didn't anticipate when you traveled from the US

Please schedule a visit as soon as you begin your travel plans but at least a couple of months before your trip.  Bring an itinerary with your specific departure and return dates, each city you will visit and any unusual plans such as wilderness treks, visits to farms, high adventure activities.  We will be able to tell you exactly what you need for each leg of your journey, alert you to health risks currently active and plan what treatments you need before you leave and after you return.

Bon voyage!

Safe Sleep for Baby

by Dr. Michelle Linkous

Sudden infant death syndrome is currently the leading cause of death for babies 1 month through 12 months.  Infants are at greatest risk from 1-4 months of age.

Parents can reduce the risk of SIDS and sleep-related suffocation by following these recommendations:

- Always place your baby to sleep on his back for naps and at night.  This does not increase his risk of choking/aspiration, even if he spits up frequently, because he has inborn protective airway mechanisms to prevent this.  Once your baby can roll both ways (front to back and back to front), you may allow him to sleep in the position of his choosing.

- Always place baby on a firm surface to sleep.

- Keep soft objects and loose bedding articles out of her crib.  This includes pillows, quilts, blankets, stuffed animals and bumper pads.  You may use sleep sacks or other clothing designed to keep her warm without being "loose" if you desire.

- Avoid co-sleeping with your baby.

- Breastfeed until at least 6 months if possible.

- Immunize your baby as recommended by your physician and the CDC.

- Don't smoke

- Avoid alcohol and drugs

- Avoid overheating him.  Most infants need one more layer than what parents are comfortable in.  If you are hot/cold, your baby probably is too.

- Allow her to have a pacifier at nap/bedtime.

- Do not use apnea or breathing/heart rate monitors unless otherwise recommended by your doctor.

- Remember "Tummy Time" while your baby is awake.  While we recommend that you always put her to sleep on her back, your baby needs play time on her tummy while she is awake to help her develop and avoid excessive flattening of the back of her head, also known as positional plagiocephaly.

For more in depth information, you may reference the AAP's most recent article regarding SIDS prevention via the Journal of Pediatrics, October 2011: http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-2284.full.pdf+html

Baby Book for New Parents

Brenner Children’s Hospital Pediatrics-Clemmons

Abby Haas MD

Michelle Linkous DO

Mary Evelyn O’Neil MD

Mark Pashayan MD

Brenner Pediatrics - Clemmons

2311 Lewisville – Clemmons Rd

Clemmons, NC 27012

Phone 336-713-0582

                                                                           Fax 336-713-0581       

336-716-WAKE (9253)

·         If your telephone call is an EMERGENCY, please say so and state what the emergency is.

·         Please give the receptionist your child’s first, middle and last name and date of birth, so we can be sure to have the correct medical record.

·         If you are calling to make an appointment, inform the receptionist first that this is all you need.

·         Your questions about mild illnesses, normal child care, and vaccinations can be answered by our skilled clinical assistants.  They are familiar with our treatment plans.

·         A parent or authorized adult must accompany the child to our office.  Adolescents may be seen alone with parent’s consent .

·          When you are waiting for someone from our office to return your call, please stay off the line to allow us to call you back as quickly as possible.

·          Have the name, address, and phone number of your pharmacy available when you call.

OUR ADVICE, DRUG DOSES, AND SCHEDULES OF EXAMINATIONS, VACCINATIONS AND LABORATORY TESTS ARE UP TO DATE AS OF MAY 2012.  WE MAY UPDATE AS NEW INFORMATION BECOMES AVAILABLE.

GENERAL OFFICE INFORMATION

YOUR PEDIATRICIAN   Your Doctors are fully trained Pediatricians, Board Certified by the American Board of Pediatrics.  We are in a group practice to ensure that whatever time of day or night an illness or accident arises, help is available. Your children can generally see their regular doctor, but if your doctor is unavailable, one of our other doctors would be happy to see your child.

APPOINTMENTS     

Regular office hours are 8:00 AM to 5:00 PM. 

Evening and weekend office hours will vary with seasonal needs. If you feel your child needs to be seen, please call as early in the day as possible, to allow you the earliest possible appointment. Please arrive at the office 15 minutes before your appointment time to register and update records.  If you arrive late for your appointment you might have to reschedule or wait for others who were on time to be seen first.

If you have an emergency, call us immediately and describe the problem.  If you suspect a contagious disease such as chicken pox, or influenza, inform the receptionist when you arrive so that we can separate your child from others.  Emergencies are given priority at all times of day or night so please be patient if we are called away.

CONFIDENTIALITY   A physician and a physician’s staff have an ethical obligation to keep any information about patient care strictly confidential.  Federal HIPAA legislation (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996) became active in the spring of 2003.  At your first visit to our office, you will be asked to review the practice HIPAA  policies.  We are allowed to discuss a child’s care with parents and guardians authorized by parents.  You have the right to request that your child’s health information NOT be shared with others.  Please inform our staff of any special restrictions on information or visitation such as might occur after a divorce or custody disagreement.

Adolescent-age patients need to know that our legal and ethical obligation to confidentiality extends to them as well.  We will keep our conversations and physical exam findings in confidence.  We encourage family members to share this information among each other.  We MUST inform parents or guardians if we learn that a patient plans to harm themself or someone else.

TELEPHONE CALLS   Our clinical staff is very familiar with our recommendations for treating common conditions.  They will consult us immediately for emergencies and unusual problems.  If you feel that additional information is needed, ask the nurse to have one of the doctors return your call (which may be possible between patient exams or after office hours.)

On weekends or holidays when the office is closed, please call early in the day to allow time to plan for emergency visits, X-ray or laboratory tests. Of course you should call at any time if an emergency exists.

EMERGENCIES AFTER OFFICE HOURS      We have a physician and nurse on call for the practice twenty four hours a day.   After hours all calls to the office number will be directed to our answering service  which will contact the nurse on call.  (You may call the answering service directly at 716-1166.)  Clemmons Pediatrics, Westgate Pediatrics and Mocksville Pediatrics share after-hours call at night and on weekends.

Health On Call provides a nurse on call who will return your call promptly.  Emergencies are given first priority.  Our nurses are experienced and can advise you on your child’s problem.  They will call the physician on call if necessary. 

Please call if you feel your child has a medical emergency. We may be able to determine from your description of the situation whether your child needs to be seen at the Pediatric Emergency Department or needs referral to a particular facility or specialist.  In a serious emergency it may be necessary to call 911 for transport to the appropriate Emergency Department.  Whether you are home or traveling, a Pediatric Emergency Department (such as at Brenner Children’s Hospital) is most appropriate for your young children.

To minimize delays for these urgent calls please remember the following rules:

·         After hours call only if you have an urgent problem which cannot wait until the morning.  This may be an injury or severe illness, or if you need to determine if a trip to the Emergency Department is required.

·         Call during regular office hours Monday through Friday for scheduling appointments, refilling routine medicines, and asking questions regarding minor illnesses, over the counter med doses and behavioral problems.

INSURANCE  At the time of your visit or after a hospitalization, you will be provided with an itemized statement that will include all of the information needed by your insurance company.  The contract for coverage is between you and your insurance company and obligations such as co-payments are not optional.  You may be required to pre-certify procedures or hospitalizations.  Occasionally their payments will not cover our usual charges.  Please read your policy information carefully.  Our practice manager would be glad to help you understand your coverage.

PAYMENT AND PROFESSIONAL FEES      We must ask that payment or co-payment be made at the time of your child’s appointment.  If you are experiencing financial difficulties, please speak with our practice manager or our billing office. An “Office Visit” fee will apply to most of your child’s “sick” visits.  If anyespecially brief visit is required, (for example to check the resolution of an ear infection after finishing an antibiotic) there may be a “Brief Office Visit” fee.  If your child’s problem is complicated, there may be an “Extended Office Visit” fee. If your child needs a booster shot and sees only the nurse, there may be a “Nurse Visit” fee.  Minor surgical procedures and laboratory tests done in our office will incur separate charges. “Well Child Care” and Immunizations may be covered by your insurance or by the N.C. Vaccination Program.  Check with our staff if you have any questions about your insurance coverage.

OFFICE RECORDS     Your child’s medical chart is a medical and legal document which we must retain long after treating your child.  When you move from the area and need records sent to the next treating physician we would be happy to prepare a summary of immunizations, allergies, significant illnesses, hospitalizations, surgery, and special evaluations. You must provide written consent for the release of our office information, or that of any outside laboratory test, x-ray, specialist consultant, or report.  Special requirements exist for records of some medical conditions and tests.

THE INTERNET       Be careful when doing a general search for medical information.  There is a great deal of misinformation and opinion which might be confusing.  Reputable organizations such as The American Academy of Pediatrics, and commercial sites such as The Physician’s Desk Reference are a good starting point.  Many special interest sites are devoted to specific diseases and can be quite useful.  Start with

http://www.wakehealth.edu/Health-Central/

http://www.healthychildren.org

http://www.eatsmartmovemorenc.com

http://cdc.gov/

  At the present time, we cannot communicate by email with specific medical questions concerning your children.  HIPAA requirements dictate a secure server in a “Data Repository” to which you have access with a user ID and password.  This keeps your Protected Health Information (“PHI”) totally confidential, which can’t be guaranteed with standard email.  Our new Electronic Medical Record system will have an option for web access to records, and email communications.

THE NEWBORN CHILD

BASIC SUPPLIES

·      Acetaminophen infant drops (such as Tylenol®)

·      Acetaminophen suppositories (such as Feverall®

        80mg or 120 mg size)

·      2 rectal thermometers (you’ll probably break one the first midnight illness you need it)

·      1 “ear syringe” to suction nostrils and mouth (usually given to you at the hospital)

·      1 bottle Isopropyl Rubbing Alcohol (for sterilizing thermometer and umbilical cord-not for sponge bathing!!!)

·      1 tube diaper ointment

·      3 dozen cloth or 6 dozen disposable diapers

·      waterproof sheets

·      3 waterproof lap pads

·      Approved Car Seat

·      Cotton balls

·      Infant carrier

Note:  Set your water heater thermostat at 1200 to 1250 F.  Water at this temperature is much less likely to cause a third degree burn in the event of an accidental scalding at bath time.  Smoke detectors and carbon monoxide detectors are a great idea.

THE HOSPITAL EXPERIENCE   When you deliver your baby, the nursery will notify our office.  We have Neonatology Specialists available if you have a Cesarean Section, a premature infant or if your Obstetrician feels there may be some other problems. After a routine delivery the doctors and nurses in attendance do a rapid assessment. 

You may feel like spending some time together in the delivery room if you are both doing well. Babies are often alert and want to breast feed. In the Nursery they are weighed, measured, and monitored for “vital signs” temperature, pulse and respiratory rate.  They are given eye ointment to prevent infection, and a vitamin K injection to aid blood clotting, and a Hepatitis B vaccine.  There is a transitional period during which the babies are left undressed under a warmer.   The nurses can easily notice any breathing difficulty or color change. 

The babies are checked by a Pediatrician or a Neonatologist daily while in Forsyth Medical Center.  Before discharge a blood sample will be sent to the NC State Lab to test for several diseases, such as PKU and low thyroid, as well as hemoglobin disorders such as Sickle Cell Trait and Disease, and Thalassemia.  If you are discharged before feedings have been well established (usually 24 hours) you will have to have a second specimen drawn after going home.

JAUNDICE    Before birth, babies have an excess of red blood cells in order to get oxygen from the mother’s blood since the lungs are not full of air yet.  Since the baby receives plenty of oxygen when the lungs expand after birth, the extra blood cells can break down and be recycled. If they break down faster than waste products can be excreted, the baby’s skin may become yellow or “jaundiced.”  If this occurs after you leave the hospital, let us know.  The treatment can be quite simple, but may require blood tests.

FEEDING      Breast feeding is a very satisfying and healthy experience for you and your baby.  The advantages run the gamut from nutritional, and immunological, through psychological, to economic and practical. We encourage you to breast feed, but recognize that there are times when bottle feeding works better.  A commercially prepared infant formula can provide a diet similar to breast milk.  Your loving attentive bottle feeding can certainly engender close family

BREAST FEEDING    We encourage breast feeding because breast milk has definite advantages over formula.  There are antibodies to help fight infection, maternal bacteria to populate the skin, nose, and GI tract, and nutrients that are balanced, digestible and absorbable.  When nursing, find a quiet comfortable area where you and your baby can relax. Initially you’ll gain the benefits of colostrum, and after a few days, adequate amounts of milk will be produced.

Careful positioning of your baby on your breast will make it comfortable for you. The mouth should open fairly wide to take a breast feeding.  Rather than just sucking, the tongue puts pressure deep in the milk collection system, and moves the pressure forward in a rhythmic manner.  The milk will be ejected and “kneaded” and then sucked and swallowed in a similar manner.  If you find the positioning and feeding  awkward, slow or painful, please call.  We can help solve many of these problems, and will refer you to the Lactation Consultants at the Hospital if necessary.

Babies do not need anything added to the diet for a number of months.  We occasionally need to add fluids by bottle for special conditions, and you may choose to add formula or expressed milk feedings for your own reasons.  (Although there are physical and psychological benefits to breast feeding, you can do fine with bottle feeding or some combination of breast and bottle feeding.  Babies and parents are adaptable and can respond to many different situations.)

Ultimately you will nurse for approximately 20-40 minutes total, 10-20 minutes per side, every 2-4 hours.  Alternate which breast is used first.  These times are approximations.  You will learn to follow your baby’s cues as to how long to nurse at each feeding.  Babies will usually have a bowel movement with every one or two feedings at first.  They will urinate several times a day.  In the first few days of life there will be some weight loss, but we expect that adequate milk supply and successful feeding techniques will avoid dehydration.  Breast feeding mothers should eat a nutritious diet and drink plenty of fluids.  Most foods are well tolerated.  Please check before using medicines- both OTC and prescription.

During the first month or so your nipples may become tender. It is common to experience pain for the first few minutes of a feeding. To avoid cracking of your nipples it may be a good idea to rub the tissue with expressed breast milk.  The use of a blow dryer (WARM not HOT) or air drying after nursing may be helpful.  Never use harsh soaps on the nipples as this may cause drying or cracking.  You do not need lanolin or other moisturizers. This may actually make things worse by clogging up the delicate lubricating glands present in the nipple.  You should not try to “toughen” up the breast tissue by vigorous towel rubbing, as this will be irritating rather than helpful.

ENGORGEMENT   Some mothers experience very painful breast swelling if their milk is produced in very large quantities.  Their babies may not be able to suck when the breast is so hard and large.  If this occurs, you must reduce the size of the breast by expressing milk just prior to nursing.  The decrease in swelling will then allow the baby to get a better grasp on the nipple.  A warm shower or heating pad might also help.  A brassiere that supports the breasts firmly but does not fit too tightly will make you more comfortable.  Don’t be discouraged if breast feeding is not as easy as you thought.  If often takes a few weeks for you and your baby to get used to each other before you find it to become “natural.”  Call us for help if you feel frustrated and are ready to give up.  Breast feeding should be an enjoyable experience. Relax!  Be patient!

MASTITIS    If you have a painful, red, warm, swollen area on the breast associated with chills, and/or fevers, notify your doctor for treatment.  This may be an infection which requires antibiotics. If so, the baby should continue to nurse.  The breast infection will heal faster without any harm to a nursing infant.

WEANING    If you return to work you can easily substitute two or three bottles of formula or pumped breast milk during the day and continue to nurse in the morning, evening and night.  Weaning depends on the needs of you and your child; therefore, when you decide to totally wean, gradually substitute a bottle or cup until accomplished.

BOTTLE FEEDING     If you are not breast feeding, we feel that it is better to use a commercially prepared formula than to make up one yourself.  We do not recommend “low iron” formula for any reason.  Occasionally we will prescribe a milk-free formula made with soy protein such as Isomil® or Prosobee®.  Be certain to carefully follow the instructions on the package when you mix a powder or liquid concentrate with water.  All the necessary nutrients, vitamins and iron will be in the formula. Most city water contains fluoride which is necessary to protect growing teeth. If you have a well, it will be necessary to test the water for fluoride to see if supplements are needed.

FORMULA STERILIZATION   If you prepare more than 1 bottle at a time, boil the water for 10 minutes.  Keep all articles scrupulously clean.  Bottles, nipples and caps should be rinsed with hot water after use.  Later you should scrub them with hot soapy water and rinse them well.  A dishwasher is acceptable. 

FORMULA FEEDING  You may wish to warm formula before feeding but it is not necessary.   DO NOT HEAT THE BOTTLE IN A MICROWAVE OVEN OR ON THE STOVE.  Instead, put the bottle in a bowl of warm tap water until the chill is taken off. The nipple should drip milk slowly when tipped over.  Test the formula after warming by dripping a few drops on your wrist before feeding your baby.  His head should be held up slightly.  Never prop a bottle for feeding and never place a bottle in his bed. (If you are holding your baby and bottle you will decrease the chance of choking on vomit.  After your baby begins to teethe, falling asleep with a bottle in the mouth often leads to severe destructive cavities across the front surfaces of all the teeth.)

BURPING   Even if fed properly, your baby will usually swallow some air.  For most babies, burping every 5-10 minutes and again after feeding is sufficient. This can be done by gently patting with the baby across your lap or on your shoulder.

CHOKING   Small, hard foods may cause choking.  Foods such as popcorn, nuts, unpeeled grapes, raw carrots and uncut hot dogs should not be fed until three years of age and the molars are in, because of the choking danger.  Teach your child to eat while sitting, not running or walking.  Don’t give your young toddler chewing gum!

GENERAL CARE

CAR SEATS   It is of utmost importance to use an approved car seat for every trip in an automobile INCLUDING THE FIRST TRIP HOME.  It may save a life or prevent serious injury in an accident or even a quick stop. Buckle up all passengers too!  Many injuries occur when an unbuckled occupant collides with other people in the car.  NC law requires that all children must be secured in an approved safety seat under the age of 8 years and up to the weight of 80 lbs.  After that time a seat belt or booster restraint may be used.  It is not possible to safely hold a child in your arms.  Parents should also wear seat belts not only for their safety but also as a role model for the children.

SLEEPING     If you are using an old bassinet or crib make sure that it is safe.  Here are the 2011 U.S. Consumer Product Safety Commission standards:

http://www.cpsc.gov/onsafety/2011/06/the-new-crib-standard-questions-and-answers/

Choking can occur if there are large gaps between the mattress and sides, or a gap between the slats or if the side drops unexpectedly.  A “bean bag” type pillow may cause suffocation and should never be used.   You should use a firm mattress without suffocation hazards such as pillows, stuffed animals, wedges, or heavy blankets. 

Sleep patterns vary widely, but you might find your newborn sleeps 20 hours a day.  Each feeding will be followed by a short alert, wakeful period.  After 2 or 3 months old, babies will stay awake longer and bunch together longer sleep times.  Encourage more activity and wake time during the day and evening when you want to be awake, and less activity in the night when you want to be asleep.  If your baby always falls asleep in your arms they may require you in the middle of the night to get back to sleep.  If they are put into the crib drowsy, they learn to comfort themselves and make the transition to sleep on their own.  You might find less middle-of-the-night awakenings for rocking and/or feeding.

In the early 1990s we learned that babies sleeping on their stomachs have a greater incidence of Sudden Infant Death Syndrome.  From the first nap in the newborn nursery your baby will become used to sleeping on his/her back.  Remind grandparents and babysitters how important it is to change their old habits!

HOMECOMING   Your baby must leave the hospital in an approved auto safety seat. Premature infants might be too small for the seat, and use an approved “bed” style device.  Your older children might be upset by the new arrival and become jealous or regress a bit in their developmental skills.  They might need extra T.L.C.- give some!  They might want to try breast feeding- let them. Toilet training might disappear as they ask for diapers, extra cleaning up and attention!  They might feel better by having chores, contributing to the baby’s care.  Have some wrapped gifts (“from the new baby to you”) as treats.  Let them carry, feed and diaper stuffed animals.  Be patient and supportive; try to ignore as much negative behavior as possible and things will soon return to a more normal state of affairs.  Friends and relatives will wish to visit.  Try to arrange for a helper, such as a grandparent or friend, to be around for the first one or two weeks.  Visitation should be when it is convenient and comfortable for the mother.  Physical contact with the baby should be limited to parents, siblings, and helpers; others should view rather than hold or touch the newborn in order to minimize the chance of spreading infections.  It is important to keep the baby away from anyone who is sick.

Visitors and family members should be reminded not to smoke around your baby, or around children in general.  Respiratory infections, allergies, middle ear infections and asthma are all worsened by exposure to smoke.

NAVEL CARE  Keep the area clean and dry.  If the skin around the stump of the cord becomes red, the baby needs to be seen as soon as possible. It is normal to notice a small amount of blood coming from the base as the cord begins to separate.  Until the cord falls off, which is usually between one and two weeks of age, give your baby a sponge bath with soap and water.  Do not place him in a tub or basin until after the cord has fallen off and the base has dried up.  No dressing is required for the healing cord.   Belly bands, taped down coins, etc. do not in any way help prevent or cure a navel hernia.  They are simply old-timey home remedies which actually often cause irritated skin or allergic reactions.

SKIN CARE    Many babies are born with dry skin.  Don’t worry!  This will flake off after birth leaving no scars or sores.  Do not use baby oil, lotions, powders, or other types of ointment or salve on your baby’s head or scalp.  Using such preparations will often trap bacteria and small dirt particles, thus causing or intensifying “cradle cap.”  Use zinc oxide or other protective diaper ointments such as Desitin® or Balmex® in the diaper area or around the anus when the skin begins to appear red or inflamed.  Do not use Q-Tips® in the ears- you will push ear wax deeper inside and may actually make a hole in the ear drum.  The ears, navel, and vagina should be cleaned sufficiently by using a wash cloth or cotton balls and warm water.

“FUSSY TIME”   Most newborn children have a “fussy” period during some portion of the day.  At this time he will appear restless, will cry and “fuss” for no apparent reason, will usually not be interested in eating and most often will not be totally comforted by rocking or cuddling.  Be assured that this activity is NORMAL and realize that this will require patience and understanding on your part.  Most often this activity occurs during the late afternoon or early evening.  The combination of a screaming, apparently unhappy child and tired parents can often make the situation unbearable.  Try your best to relax and to know that things WILL get better if you just make it through the first three months. Some infants prefer snug blanket wrapping, others prefer to be loose and wiggling around.   You might just need a break occasionally to get some rest, so don’t hesitate to trade off with your spouse, or get a baby sitter if you’re frazzled and exhausted.

NASAL CONGESTION  Remember that, for the first few months, babies are nose breathers; they cannot adequately breathe through their mouths.  If your baby’s nose is congested it may be necessary to help clear this mucus from her nostrils.  Use the rubber suction bulb syringe to remove visible mucus.  If it is thick and does not suction or drain easily, make salt water drops by putting 1/4 teaspoon salt in 1 cup water.  Put drops in each nostril before suctioning with the rubber bulb.  You may use this as often as needed.

DRESSING BABY  Many people overdress their children.  Use your own comfort as a guide when you take your baby outside for walks.  Remember that a padded stroller or car seat is another layer of insulation. 

We do recommend keeping children below eight weeks of age out of large crowds, workplaces, and nurseries and definitely away from sick people!

BREAST SWELLING  Babies may develop swollen breasts as a result of a female hormones which pass from mother to child.  This is normal and will disappear in several weeks.  A milky secretion from the breasts may also be normal.  Do not massage these swollen tissues.  If redness or sudden increase in swelling appears on the breast, call the office.

VAGINAL DISCHARGE   Your new baby girl may have some mucus secretions in her vagina, caused by temporary increased levels of hormones which came from the mother’s bloodstream.  Occasionally, this discharge may be bloody.  To clean this area, gently wipe with moist cotton balls.  If the bleeding seems excessive or continues for longer than 24 hours, call the office.

BOWEL MOVEMENTS   Infants vary greatly in the number and consistency of bowel movements.  Newborn stools, especially breast-fed newborn stools, will usually be loose, will vary in color from yellow to green and may occur as frequently as one or two times with every feeding.  Some children, however, may go several days between bowel movements.  If the stools are not hard, the baby is not constipated, even if you hear grunting and straining. 

CIRCUMCISION   If you choose to have your baby boy circumcised, it will generally be done in the hospital using one of the two common techniques.  Usually there is a gauze bandage on the tip of the penis where the foreskin was removed.  When the gauze falls off apply some Vaseline® to the head of the penis with each diaper change for 3 or 4 days.   There may be a small plastic ring on the end of the penis.  It will fall off as the foreskin dries up. 

URINE    A newborn baby will urinate frequently.  A boy baby should be able to forcefully void high into the air.  Call us if the urine just trickles out; it may be a sign of a blockage in the urine tract.

HICCUPS   Hiccups are common and of no danger to your child.  If hiccups are prolonged it may help to give the child a few swallows of milk or water in order to stop them.

VISION AND HEARING   Babies are able to see your face, lights, and other objects.  They are able to hear well and eventually to differentiate their mother’s or father’s voice from other voices.  Observe your baby to assure yourself that he responds to your voice as well as most other sounds.

PACIFIERS AND THUMB SUCKING    If your baby has a strong sucking desire, you may want to use a pacifier.  This is simply a sucking reflex and does not mean hunger. Thumb sucking is also very common in infants.  It does not harm the jaw or teeth in young children.  There  are no effective methods to stop a child intent on sucking a thumb.

TOOTH CARE   Teething does not cause fever, diarrhea, colds, or other illnesses.  Twenty teeth appear in about a year and a half.  So a tooth seems to be coming in around the time of many minor illnesses which also occur during your toddler’s first few years.  The discomfort of teething may be relieved by chewing on something hard or cold.  Liquid teething medicines are usually of no value.  You may try acetaminophen.  Teeth usually begin to erupt at 6 to 8 months of age.  As soon as you see them start to clean them.  Toothpaste is not recommended until your child is old enough to spit it out.  Fluoride in swallowed toothpaste can exceed the daily fluoride needs, and cause white enamel stains on the teeth.  Infant toothpaste without fluoride, may be used at first.  Older children should always use fluoridated toothpaste.  City water generally has fluoride.  If you have a well, we recommend testing for naturally occurring fluoride (at the Health Department).  If you have no fluoride, we need to prescribe it.  If you have fluoride, you definitely don’t want to overdose it and stain the teeth. 

WELL CHILD EXAMINATIONS

CHECKUPS     When your baby goes home from the hospital, we will arrange a weight check about two days later, and a two week check up.  If your baby is born at another hospital, you will need to call us to arrange the first check up.  If your baby is delivered outside a hospital, you must also call for an appointment so that your baby can be examined on the second day of life.

SCHEDULE FOR ROUTINE CARE

First month of life- Check up at least one time

2 Month-  Check up and immunizations- Diphtheria, Tetanus, Pertussis, Injectable Polio Vaccine,Hepatitis       B (Pediarix)/ Haemophilus Influenzae B (Pedvax)/ Strep pneumoniae (Prevnar)/ Rotavirus (Rotateq)

4 Month -  Check up and immunization – Pediarix/ Prevnar/ Pedvax Hib/ Rotateq

6 Month-  Check up and immunization - Pediarix/ Prevnar/ Rotateq

9 Month -  Check up

12 Month- Check up and Prevnar/ HIB / Hepatitis A (HepA) and MMR & Chicken Pox (Varicella) . Hemoglobin, lead test

15 Month- Check up

18 Month- Check up and immunization- DTaP / HepA

24 Month- Check up and blood lead test

3 Year-     Check up and vision / hearing test

4 Year-     Check up and vision / hearing test

5 Year-     Check up and DTaP / IPV / MMR, Chicken Pox; vision /hearing

6-10year- Check up every one to two years

11-21year-Check up and TdaP.  Varicella, MMR & Hepatitis if not done previously. HPV vaccine for girls and boys.  Meningococcal Vaccine.  Urinalysis one time.  Hemoglobin for menstruating girls.

(Schedule updated May 2012)

We will change our check up and immunization schedules as we receive recommendations from governing agencies.  Occasionally a vaccine shortage alters the schedule.  These are general guidelines so your doctor may recommend a different schedule based on your child’s needs.  Your infant will be given the first Hepatitis B vaccine prior to discharge from the newborn nursery.  There is a great deal of publicity in the media for alternate vaccine schedules.  These schedules are not safe because your child is unprotected from very dangerous infections.  We would be happy to share scientific reasoning behind the standard vaccine schedule.

WELL CHILD VISITS    The “Well Child Visits” are valuable checks of growth and development.  Problems in intellectual development, emotional maturity and behavior are not always obvious to parents.  Examining a child who is healthy will provide valuable clues to us.  Sick visits to the doctor are often stressful for parents and children and these other, very important factors are often ignored or missed.  The Well Child Exams are also the times for some laboratory tests such as a hemoglobin, to detect anemia; a urinalysis, to uncover kidney disease; and hearing and vision testing.  We also use the Well Child Exam for Anticipatory Guidance where we teach you about development, typical behavioral and emotional changes, home safety, feeding and common illnesses.

IMMUNIZATIONS   After an immunization your baby’s leg might become sore and develop a lump under the skin.  There may be generalized crankiness and even some fever.  We recommend a dose of acetaminophen, (such asTylenol®) after the injection is given.  Use the medicine every four hours if needed.  Call us if your baby has fever over 104°F, cries non-stop for several hours or if the injection reaction lasts more than 24 hours.  Something else might be going on.

FEVER

·      The normal oral temperature is approximately 98.6°F

·      The normal rectal temperature is approximately 99.6°F

·      A fever is considered to be rectal temp 100.4°F for infants less than 4 months old, 101°F if older.

A “fever strip” on the forehead is not accurate.  Thermometers which measure the temperature in the ear are only accurate if the sensor is aiming directly at the ear drum.  This will not be possible if there is wax, pus draining, or if the ear canal is narrow and twisted, or if your child is not cooperating.  A rectal temperature is the most accurate.  Fever generally means the body is fighting an infection by a bacterium or virus.  Fever in a child less than three (3) months old may be a sign of a serious problem even without other symptoms.  Call us at once if your child is under three months of age and has a rectal temperature over 100.4°.

A child older than four months who has a temperature above 101° Fahrenheit and is still alert and active probably has a mild illness that will resolve spontaneously in a day or so.  You may try to lower the temperature with acetaminophen.  If a child is acting very sick or if the fever lasts more than a day or two we may need to examine the child.  Do not bundle up a feverish child to “sweat out a fever.”  This will only keep the temperature high and may be dangerous.  If the temperature is 101° F or higher try acetaminophen (such as Tylenol® or Tempra® every four hours. 

Don’t panic!  Having a “high fever” is not harmful.  We are much more concerned about what is causing the fever- a mild, self-limited illness or a serious bacterial infection which might need antibiotics.  Many children are quite unaffected by fever.  Some children get very sluggish when the temperature is high and lowering the fever should perk them up.  Check the label on your medicine because the amount of drug (mg.) will be different depending upon which form you have.  The “elixir”, “drops”, tablets and rectal suppositories are all different concentrations of active medication.  If a high fever (above 104°F) does not decrease thirty minutes after a dose of acetaminophen, sponge bathe with lukewarm water to provide some additional relief.

We generally do not recommend ASPIRIN for anyone under the age of twenty one.  Reye Syndrome is an illness that seems to occur more often in young aspirin users.  You may safely use ACETAMINOPHEN during these illnesses.  We may recommend Ibuprofen for some children.

GUIDELINES FOR PARENTS OF CHILD WITH FEVER

Call immediately if:

·      Your child is less than 3 months of age

·      Fever is more than 105° Fahrenheit

·      Your child is crying inconsolably

·      Your child is difficult to awaken

·      Your child is confused or delirious

·      Your child has had a seizure

·      Your child has a stiff neck

·      Your child has purple spots on the skin

·      Breathing is difficult and your child does not feel better after the nose is cleared

·      Your child is acting very sick 

·      Your child has an underlying risk factor for serious infection (e.g. sickle cell disease)

Call during office hours if:

·      Your child is 3-4 months old (unless due to a vaccine)

·      Fever is over 104° Fahrenheit

·      Your child is less than 2 years old

·      Burning or pain occurs with urination

·      Fever has been present for more than 72 hours

·      Fever has been present for more than 24 hours without an obvious cause

·      Fever went away for more than 24 hours and then returned

·      Your child has a history of febrile seizures

·      You have other questions

Acetaminophen

(such as Tylenol®)

Dosage of 10 - 15 mg / kg of body weight / 4 hours

Age	4 – 11 month	12 – 23 month	2 - 3 year	4 – 5 year	6 – 8 year	9 – 10 year	11–12 year
Weight (lb.)	12-  17 lb.	18 - 23 lb.	24 - 35 lb.	37- 46 lb.	47- 59 lb.	60- 71 lb.	72- 95 lb
Dose (mg med)	80 mg	120 mg	160 mg	240 mg	320 mg	400 mg	480 mg
Oral Drops 80mg / 0.8ml	0.8 ml	1.20 ml	1.6 ml	-----	-----	-----	-----
Suspension 160 mg / tsp	½ tsp	¾ tsp	1 tsp	1 ½ tsp	2 tsp	2 ½ tsp	3 tsp
Chew Tabs 80mg	-----	1½ tab	2 tab	3 tab	4 tab	5 tab	6 tab
Suppository 120 mg	2/3	1	1 ½	-----	-----	-----	-----

For accurate medicine dosing please become familiar with measurements in ml or cc.

1 teaspoon = 5 ml = 5 cc

1 Tablespoon = 15 ml = 15 cc

Silverware is not the same as measuring spoons.

Measuring droppers should only be used with the medicine they come with

COMMON ILLNESSES

COLDS An “upper respiratory infection” (URI) is “the common cold”. Children average 5 a year ( 10 if in daycare). It is due to a viral infection and there is no cure.  Cold medicine may decrease runny noses and acetaminophen or ibuprofen may help aches and fevers. Antibiotics may treat a bacterial infection (such as an ear infection) which might develop during the course of a viral cold.

A child under a year old may simply need the nostrils clear of mucus.  Try putting 2 or 3 drops of saline solution (1/4 teaspoon salt in one cup of boiled water) into each nostril followed by suctioning with an ear syringe.  You should repeat this procedure 5 to 10 minutes prior to feeding your child.  For the older child you may want to use over-the-counter decongestants and / or antihistamines.  These preparations used along with cough suppressant at bedtime, and the occasional use of nose drops may relieve some cold symptoms.  Over the counter cough/cold medicines are not recommended for children less than 8 years old, unless specifically directed by your physician.

SORE THROAT This could indicate a streptococcal infection, which, if untreated, could lead to Rheumatic Fever.  Call for an appointment so we can test for strep and look for viral-triggered bacterial infection. If we find infection in the sinuses, middle ears, or lungs we can treat appropriately.

MIDDLE EAR INFECTIONS  Children are quite susceptible to “otitis media” (middle ear infection), because their Eustachian tubes may not let air into the middle ear.  Swimming, cold wind, and bath water do not cause otitis media.  A “swimmer’s ear” is an infected outer ear usually from moisture and bacteria collecting inside the ear canal.  A middle ear infection is in or behind the ear drum.  We need to look in there before treatment.  Occasionally, pain felt in the side of the head will prove to be a headache, throat pain, neck gland pain or jaw pain from teething.  So, your child’s “earache” may be any of these other things.  If your child develops intense ear pain during the night use acetaminophen or ibuprofen until we can see him in the morning.  A heating pad may also help, but never let anyone sleep on the heating pad for it may cause a bad burn.  Don’t put oil in the ear.

VOMITING    The cause of vomiting may be as simple as a 24 hour flu or as severe as appendicitis.  Infants often vomit or “spit up.”  This is usually due to the fact that they swallowed too much air, did not burp well, or ate too quickly.  Be certain that no extra holes were added to the nipple or that the one hole was not made larger, for this will allow him to get too much air.  If he continues to spit up regardless of better burping, call the office.  If vomiting occurs with severe abdominal pain, high fever, extreme lethargy or any other severe symptoms, call for advice.  Treat vomiting with very small amounts of a “clear liquid” diet.

1.  Clear liquids — such as Pedialyte®

2.  Wait 2 hours after vomiting before offering liquids.

3.  Start with 1/2 to 1 oz., every 15 - 30 minutes.

4.  If there is no vomiting for 4 hours, use 1 or 2 oz. at a time.

5.  If your child has fever, use acetaminophen, not aspirin.

6.  Call if there is worsening of the vomiting, increasing lethargy, hard abdomen, unusual behavior or decreased urine.

DIARRHEA  Diarrhea should be defined as frequent, loose stools, not just an occasional runny bowel movement. The extra loss of body water must be replaced by drinking more fluids.  A balanced solution of salts, sugar, and water such as Pedialyte ® may provide the best replacement.    Continue to feed your child a fairly normal diet, but increase the starchy foods such as rice and bread.  Avoid excessive fruits/juices, fats or dairy products We no longer recommend a pure Banana Rice Applesauce Toast (BRAT) because nutrients are essential for the bowel to heal.  If the symptoms persist or get worse, be certain to call the office.  We are more concerned when diarrhea has blood, black specks (digested blood), and leads to decreased urination and decreased activity.

DIAPER RASH  Often caused by yeast that grows in moist areas.  When you see redness, change diapers as soon as they are wet, and wash and dry the skin gently.  Use a “barrier” ointment containing zinc oxide.  If it begins to blister or spread, call for an appointment.

EMERGENCIES

POISONING   Poisoning accidents are very common.  Household cleaners, etc should be kept locked away from children.  All medicines should be kept in a medicine cabinet that can be secured or locked if possible.  Bathrooms, kitchens, garages and utility rooms are full of dangerous items.  Toilet seats need to be kept down to prevent drowning and if possible bathroom doors should be fitted with spring door closures to help keep children from entering.

ALSO: ask your pharmacist to use safety tops on all medications; never tell a child that medicine is candy; flush outdated medicine down the toilet; do not carry medicine in purses.  Remind your house guests who don’t have small children at home about the dangers of their medicines being in reach of your children.  If your child eats or drinks something that you feel is harmful, call the office immediately. 

We no longer recommend Syrup of Ipecac to make a child vomit a poison. We may consult with the regional poison center for information on a specific substance.  In the Winston-Salem area, our poison center is 

1-800-222-1222  or

1-800-84-TOXIN.

ANIMAL BITES    Scrub all animal bites vigorously with soap and water as soon as possible.  Your child may need a tetanus injection.  Animal bites, may become infected with bacteria.  Call us for instructions.  Rabies is a rare but dangerous disease.  Dog bites must be reported to the Sheriff’s or Animal Control Department in the county where it occurred.  A dog must be kept tied up for ten day after biting a human.  This allows enough time for a dog with rabies to show the outward signs, and let us know that the bite could have transferred rabies to your child.  If the dog disappears or becomes very ill, your child may need rabies shots.

WHAT IS AN EMERGENCY?    Convulsions, accidents and lacerations, head injuries, stiff neck with lethargy and/or irritability, poisonings, eye injuries, difficulty breathing, prolonged or severe diarrhea or vomiting and abdominal pain are all emergencies.  However, such things as colic, teething, simple fever, rashes, swollen glands and minor accidents are not usually emergencies and can wait until you have tried symptomatic measures. Your health insurance may require approval by your primary care doctor to use an emergency facility.