The Portable Pediatrician { SECOND EDITION } Laura Walther Nathanson, M.D., FAAP To Chuck and Sara, with love Contents Preface to Second Edition Introduction to Second Edition Part One: The Well Child {1} The Pre-Baby Visit {2} Birth to Two Weeks {3} Two Weeks to Two Months {4} Two Months to Four Months {5} Four Months to Six Months {6} Six Months to Nine Months {7} Nine Months to One Year {8} One Year to Eighteen Months {9} Eighteen Months to Two Years {10} Two Years to Three Years {11} Three Years to Four Years {12} Four Years to Five Years Part Two: Illness and Injury Introduction Preface {13} Frightening Behaviors {14} First Aid: Assessing and Handling Usually Minor Injuries {15} Body Parts, Bodily Functions, and What Ails Them {16} Illnesses, Both Common and Uncommon Part Three: Pediatric Concerns and Controversies {17} Growing in All Directions {18} Chubby or Not, Here We Come! {19} Bacteria, Viruses, and Antibiotics {20} Baby Shots and Grown-Up Worries {21} Allergies, Asthma, and Eczema {22} Trouble in the Middle Ear {23} The Toddler or Preschooler Who Is “Sick All the Time” {24} Severe Behavior Concerns in Very Young Children {25} Oppositional Behavior in Two and Older {26} It’s My Potty, and I’ll Try If I Want To {27} Sibling Battles Part Four: Glossary of Medical Terms with Pronunciations Searchable Terms Acknowledgments About the Author Copyright About the Publisher This book contains advice and information relating to health care for children It is not intended to replace medical advice and should be used to supplement rather than replace regular care by your child’s pediatrician Since every child is different, you should consult your child’s pediatrician on questions specific to your child While certain sections of this book contain advice for dealing with emergencies when a doctor is not available, it is recommended that you seek your child’s pediatrician’s advice whenever possible and that you consult with him or her before embarking on any medical program or treatment Preface to Second Edition It is my fondest hope that this Second Edition of The Portable Pediatrician winds up tattered and torn, splattered with coffee stains, down on the floor beside (or under; I’m not fussy) your bed That’s where the First Edition often wound up–as many readers tell me–and I’m honored After all, if you’re a pediatrician who’s portable, that’s where you belong: where the action is, and when the action is, which is often at night Parents tend to reach for a child care book in crises, medical or emotional Crises require clear advice and a response that lets you know somebody’s really listening I hope you sense that the person on the other end of these pages has been on the other end of the phone, live, tens of thousands of times I’ve intended both editions of The Portable Pediatrician to be a source not just of medical or developmental information, but of companionship But I hope you reach for it at calmer, happier times, too Childhood is an amazing drama and it’s really fun to have the program notes at hand That way, you can be primed to cherish the moment You can also be prepared to deal with it That’s important–not just for parents, but for children Children feel safe and behave better when parents give off an aura of competence In the years since the First Edition, I’ve continued to practice pediatrics, all the while receiving feedback from readers As a result, I am very much aware that some areas need revision Hence, the Second Edition Setting Limits The first time round, I concentrated on helping parents understand the reasons for children’s obnoxious behaviors, but I was not very clear on how to prevent them, nip them in the bud, or discourage them By obnoxious behaviors, I include: * Saying No, again and again *Hitting, pinching, kicking *Digging in the heels and refusing to budge *Tearing around wildly and making annoying noises just to get your goat *Interrupting, procrastinating, whining *Mouthing off: talking back, shrieking x-rated words *Getting into things, making a mess on purpose *Refusing to use the potty despite knowing how *Sibling battles–pushing, nagging, yelling, grabbing, tattling, turning the backseat of the car into a war zone… Let’s see Have I left anything out? Oh yes: * Not listening *Refusing to stay in one’s own bedroom *Worst of all: visiting this obnoxiousness upon one’s beloved parent but behaving perfectly (perfectly!) for every other adult There are many pejorative terms for children who act this way Pediatricians, who not have to put up with them, call them Oppositional Such behaviors tend to begin around the age of a year and peak at the age of eighteen months to Two Then, if all goes well on the parenting technique front, they should begin to fade away By around the age of Three to Four, Cherub ought to have achieved a deep understanding that parents are ultimately in charge, and such oppositional behavior ought to be pretty much a thing of the past At that point–but not before then–Cherub is developmentally ripe to benefit from the techniques of Authoritative Parenting: Giving an explanation when you set a limit; presenting Cherub with the challenge of making choices, when that’s appropriate; and even allowing the privilege of negotiating, on occasion It’s getting to that point that’s tricky So in the Second Edition, I’ve provided stage-by-stage (which means Chapter by Chapter) guidance in discipline skills so that these parental skills build as Cherub matures There’s also a set of essays in Part III on Oppositional Behavior, Potty Refusal, and Sibling Battles About spanking Rather than go into moral diatribes against spanking, I have learned to assume that parents resort to it if their children become sufficiently oppositional, simply because they can’t think of anything else to at that point, and who can really blame them? The trick is to prevent, or nip in the bud, or squelch effectively, oppositional behavior before you get that desperate The Epidemic of Overweight Children In the First Edition, I knew very well that our culture had already come down with an overwhelming case of The Chubbies, and tried to provide guidance on the subject Today, we are faced with a true epidemic of chubbiness In fact, we have become so accustomed to seeing chubby children in real life and the media that chubby looks normal and normal looks thin Extreme chubbiness in childhood can trigger all kinds of problems, from deep distress of the soul to sleep apnea (trouble breathing at night, due to extra tissues in the upper airway), from exacerbation of asthma to the risk of early puberty–girls starting breast development in second or third grade To say nothing of disorders previously the province of overweight adults, such as high blood pressure and Type diabetes Even so, many experts feel that pediatricians should not intervene until a child has already attained a worrisome weight They fear that doing so may trigger an overreaction in parents–that they might “starve” a child or become punitive and overcontrolling They worry that restricting a child’s diet (even to the extent of eliminating sodas, french fries, and heavy desserts) may lead to eating disorders later on I don’t agree All the parents I know want the best for their children, and want the real scoop from their pediatrician They can be trusted to be caring and to use common sense So listen up! If you don’t fit this description, skip the Chubbiness sections In fact, go buy a different book The truth is, once a child is overweight, dealing with the problem is very difficult Chubbiness is best prevented Next-best is nipping it in the bud That means that parents need to know how to monitor Cherub’s weight, and need to be alert for an upward trend in the “weight for height” ratio They need the tools to figure out what’s causing the trend, and what to about it In this Second Edition, every Well-Visit chapter includes a Chubbiness Watch This section helps you figure out whether your particular Cherub is gaining weight appropriately, and flags the main lifestyle habits that may steer a child that age into Chubbiness The essay in Part III, called “Chubby or Not, Here We Come,” reviews the subject and tries to demystify and simplify those exasperating growth charts New Concerns and Developments in Medicine I’ve added a short essay on Autism/Pervasive Developmental Delay/Aspberger Syndrome, in Part III I’ve updated the section on Managed Care in Chapter One–the Pre-Baby Visit chapter: skip it at your own peril There’s an update on new controversies in the Allergy essay in Part III, and a bit on drug-resistant bacteria in the essay Trouble in the Middle Ear, in Part III And little bits and pieces of updated information (and useful websites) throughout In the Preface to the First Edition, I said that I cherish the Well-Child Visits–the basis for this book Much of my workday is filled officiating at them I still am aware that as Rites of Passage, these encounters leave something to be desired Nobody gets dressed up, there may be some screaming, and the refreshments tend to lack sophistication But think of how nearly unique these visits are They cut across religions and economic class, cultural attitudes, and degree of education At their best, these visits unite parents and pediatrician as a team, focusing on a particular child in a particular family with specific values and culture, stresses and strengths The real problem is that the Well Visits are too short to get everything done Children and parents whiz by in the whirl of time I grab them out of the current, hold them still for a second, and say: Hey, look, here we are! Here’s where we’ve come from, here’s where we are now, and here’s what you might want to pay attention to between this visit and the next time we–hey, wait, don’t leave, bye now! And out the door they go Not enough time, not enough time That’s why I write these books to years Socks Soda weight gain and Soft spot (head) Soiling (Encopresis) Soyalac Soy allergies Soy formula Spanking in daycare setting as ineffective limit-setting and oppositional behavior and Spells breath-holding jerking/twitching not-breathing See also Fits (seizures, convulsions) Spinal injuries trampolines and Spitting up See Vomiting Spleen, enlarged Spoiling birth to weeks weeks to months to months to months to months months to year daycare providers and tantrums and Spoons fine motor skills and self-feeding Sprains Sprue Stair climbing Standing up to years to months to months to months months to year Staph infections Staring Stein, Martin Stereotypes gender Sterilization of bottles Steroids Stevens Johnson syndrome Stomach Stomachaches Stool blood in color and texture names for thyroid problems and withholding of worrisome signs See also Constipation; Diarrhea; Pooping “Stork bites” Strabismus Stranger anxiety Strangers, precautions with Strangling Strawberry marks Strep infection antibiotics for public health and scarlet fever throat vaginal inflammation and Strep pneumococcus vaccine Stress Stridor Stuffed animals Stuttering Stuttering Foundation of America Sucking breastfeeding tips breast-vs bottle-feeding lip blisters and of thumb See also Pacifiers Sudden infant death syndrome DPT vaccine concerns See also Apparent life-threatening event Sugar in baby foods for diarrhea in juices nursing-bottle mouth and nursing mothers and stomachaches and in water Sunburn Sunglasses Sunlight jaundice treatment safety concerns vitamin D and Sunscreen Supplements for 2-to 3-year-olds calcium fluoride for nursing babies for nursing mothers vitamin See also Iron Suppositories glycerine Surgery See Hospitalization Sweating Sweat test Swimmer’s ear Swimming baby classes to years to years ear infection and Sword play Synagis Systemic candidiasis Tablets Tachypnea Tacrolinus Tantrums year to 18 months 18 months to years to years to years Taste, sense of Tattling Teachers Tear ducts, blocked Tears, artificial Teasing of overweight children Teeth birth to weeks weeks to months to months to months to months months to year year to 18 months 18 months to years to years to years to years baby teeth brushing of cavities dental care coverage flossing of injuries to knocked-out nursing-bottle mouth pacifiers and permanent sealants topical fluoride treatments Teething biscuits Television watching bad dreams and year to 18 months 18 months to years to years to years to years weight gain and See also Videos Temperament birth to weeks year to 18 months shyness Temperature, body below normal crying and normal overheating rectal taking of See also Fever Temperature, outside Temperature, water See Water temperature Temper tantrums See Tantrums Testicles hydrocoele infection of twisted (torsion of) undescended Tetanus vaccine Tetracycline Thalassemia Thermometers mercury glass hazard rectal electronic use tips Thorazine Three day measles See German measles Throat herpangina injuries to scarlet fever sore strep Throat sprays Throwing skills Thrush Thumb-sucking Thyroid deficiency Thyroid hormone Thyroid problems infrequent stools and overweight and Tibial torsion Time out at daycare oppositional behavior and Tinea capitis To-do lists prenatal tasks birth to weeks weeks to months to months to months to months months to year year to 18 months 18 months to years to years to years to years Toenails Toilet skills 18 months to years to years to years to years constipation and insert seat potty refusal wiping issues See also Peeing; Pooping Tongue biting of Tonsils Toothpaste Torticollis See Neck, wry Tossing of babies Touch, sense of Toxic shock Toxic synovitis See also Limping Toys birth to weeks to months to months to months months to year year to 18 months 18 months to years to years to years to years bathtub cradle gyms mobiles safety of Trampolines Transitional objects See Security objects Travel weeks to months to months to months to months months to year year to 18 months 18 months to years to years to years to years ear infection concerns Epipen Junior kits first-aid kits sedatives Trembling Triceram Tricycles Trust development Tuberculosis Tweezers Twitching/jerkiness See also Fits (seizures, convulsions) Tylenol See Acetaminophen Tympanograms Ultimate Breastfeeding Book of Answers, The (Newman and Pitman) Umbilical cord care of infection of sleep positions and Umbilical granuloma Umbilical hernias Unconsciousness Undescended testicles Urinalysis Urinary tract infections antibiotics for delayed urination and fever and frequent urination and labial adhesions and prevention sexual abuse/molestation and smelly urine and testing for uncircumcised boys and Urine abnormal infection of See also Peeing Utensil use chopsticks feeding self forks spoons UTIs See Urinary tract infections Uvula Vaccination See Immunization Vagina bleeding from foreign bodies in inflamed irritation of labial adhesions names for yeast infections Vaginitis Varicella See Chicken pox VCUG Vegetables baby foods Vegetarian diets Video games Videos Viruses to years and antibiotics and breastfeeding transmission of common herpes See Herpes rabies rarer roseola stomachaches and toxic synovitis See also Colds; Infectious diseases Vision birth to weeks weeks to months to months to months to months months to year year to 18 months 18 months to years to years to years to years color blindness mononucleosis and nearsightedness prekindergarten testing Visitors Vitamin A Vitamin B complex Vitamin C Vitamin D hyperparathyroid and rickets and supplements Vitamin E Vitamin K Vitamin supplements Vocal cord nodules Voice Voiding cysto-urethrogram Volvulus Vomiting birth to weeks color of dehydration and headaches and head bonks and infections and intestinal upset and Ipecac syrup and names for persistent/projectile pyloric stenosis and solid foods and stomachaches and treatment of Vulva Walkers Walking Wasp stings See Insect stings Water bacterial diarrhea and bottled in breast milk diarrhea treatment and fluoride in formula-fed babies and giardia and for nursing mothers weight control and from wells See also Drowning dangers Water intoxication Water temperature Weaning Weight birth to weeks weeks to months to months to months to months months to year year to 18 months 18 months to years to years to years to years concerns and controversies See also Obesity Weight for age chart Weight for height chart Well-child visits birth to weeks months months months months year 15 and 18 months years years years years insurance coverage Wet nurses Wheezing asthma and bronchiolitis and Whining Whiplash “Whipperdills” White, Burton L Whooping cough WIC program Willett, Melinda Wipes, premoistened “Witch’s milk” Worms See Pinworms Wry neck Xyphoid process Yeast infection thrush vaginal Yeast rash Yellow jacket stings See Insect stings Yersinia Yogurt Zinc Zovirax See Acyclovir Acknowledgments In the First Edition, I said “Thank You” to the gigantic village that raised this particular pediatrician This time, I’d like to recognize some of the people who made working on this revision a pleasure I have been extremely lucky to be a part of a practice that has always put patients’ best interest above the contingencies of Managed Care My special thanks to our Managing Partner, Fred Frumin, M.D., who has made this his guiding principle: I could not write about Pediatrics with a clear conscience and a happy heart without that assurance And to my other partners, Rosalind Dockweiler, M.D., Gary Gross, M.D., Nick Levy, M.D., Christine Ito Wood, M.D., Sangita Bhasin, M.D., Julie Snyder-Blok, M.D., Ron Park, M.D., and Melissa Reinhardt, M.D.: What good doctors! Along the same lines, I want to thank our office staff You can’t write (or practice medicine) wholeheartedly if you’re not part of a team you trust I particularly want to thank our office manager, Rita Adams, for her steady hand on the wheel; Referral Office director Diane Molina for protecting us from so many Managed Care snafus; and Medical Assistant Lourdes Carr, for her ability to solve problems before they happen My friends and extended family have been more than supportive In particular, thank you, Sam Popkin, for your unqualified enthusiasm: Folks, if you were given a copy of the First Edition as a present, there’s a good chance it came from Sam Thank you to my always on-target agent, Sandra Dijkstra, and to Joe Sweeney, fitness trainer extraordinaire, for endowing both Sandra and me with all this energy and musclepower Writing a monthly column for Parents magazine has made this revision easier Thanks especially to Kate Lawler, Betty Wong, Catherine Winter, and Janet Gold My editors at HarperCollins, Matthew Benjamin and Megan Newman, have been exceptionally efficient and helpful, and my hat is off to the copyeditor! I want to thank Kay Life, whose drawings capture so well the fun of being a parent and/or pediatrician Most of all, I salute my husband, Chuck Nathanson Despite his own demanding schedule, he finds the time to untangle my prose, demystify my software, bring me coffee, and in general stand in for The Muse Finally, a big thanks to our daughter Sara, who has made parenthood so much fun–even now that she’s grown up–that I just had to go and write about it About the Author LAURA WALTHER NATHANSON, M.D., FAAP , in her third decade of full-time pediatric practice, has handled more than 270,000 office visits and more than twice that many phone calls and she says she still hears something new every day She earned her B.A magna cum laude from Harvard and her M.D from Tufts Medical School She is a partner of El Camino Pediatrics in Encinitas, California She and husband, Chuck, have a daughter, Sara Visit www.AuthorTracker.com for exclusive information on your favorite HarperCollins author Copyright THE PORTABLE PEDIATRICIAN Copyright © 2002 by Laura Walther Nathanson, M.D., FAAP All rights reserved under International and Pan-American Copyright Conventions By payment of the required fees, you have been granted the non-exclusive, non-transferable right to access and read the text of this e-book on-screen No part of this text may be reproduced, transmitted, down-loaded, decompiled, reverse engineered, or stored in or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical, now known or hereinafter invented, without the express written permission of HarperCollins e-books EPub © Edition MAY 2007 ISBN: 9780061983634 10 About the Publisher Australia HarperCollins Publishers (Australia) Pty Ltd 25 Ryde Road (PO Box 321) Pymble, NSW 2073, Australia http://www.harpercollinsebooks.com.au Canada HarperCollins Publishers Ltd Bloor Street East - 20th Floor Toronto, ON, M4W 1A8, Canada http://www.harpercollinsebooks.ca New Zealand HarperCollinsPublishers (New Zealand) Limited P.O Box Auckland, New Zealand http://www.harpercollinsebooks.co.nz United Kingdom HarperCollins Publishers Ltd 77-85 Fulham Palace Road London, W6 8JB, UK http://www.harpercollinsebooks.co.uk United States HarperCollins Publishers Inc 10 East 53rd Street New York, NY 10022 http://www.harpercollinsebooks.com * I sat next to the Duchess at tea It was just as I thought it would be Her rumblings abdominal Were simply Phenomenal And everyone thought it was me * In both these blood group situations, the mechanism is the same If a little of the baby’s blood gets into the mother’s circulation, and her body recognizes it as foreign, she’ll make antibodies to those red cells These antibodies return through the placenta to the fetus, and tear down the red blood cells Hence: hemolysis If your baby has a heart murmur, or sweats while feeding, or has prolonged jaundice (more than two weeks), or frequently assumes an arching position, or has green or watery or painful stools, or has any other deviation from normal, I would insist on a full work-up, or a second opinion, before assuming that fierce incessant crying is due to colic M arshall H Klaus, M D., and Avroy A Fanaroff, M B., Care of the High Risk Neonate W B Saunders, 1991 It is rare for boys of this age and older to get urinary tract infections because Nature has made the stool relatively inaccessible to the urethral opening, which is pointing in the opposite direction M oreover, most little boys this age prefer grabbing their penises to finger painting with their stool Urinary infections are rare in uncircumcised baby boys, and are ten times more rare in circumcised ones The worry about breaking a child’s spirit becomes more intense as the child enters into social activities later This worry tends to focus on whether or not to limit physical aggression and to encourage courtesy M any parents worry about raising a “wimp.” This may make parents unwilling to set any limits In this situation, the baby can’t become comfortable with the idea of emotional separation from parents He’ll be preoccupied with it, and will still be dealing with this basic issue when he should be learning other things He may even turn out to be a wimp after all, because the idea of challenging limits is so fraught with anxiety Or he may simply seem spoiled and obnoxious, which is not the same thing as having an unbroken spirit Sand can get into eyes, noses, mouths, vaginas, rectums, and under intact foreskins, and cause pain Sand can be contaminated with animal feces and even asbestos Sand at the beach is worth it, usually; sand in a sandbox should be asbestos-free and covered at night Container toys like M atty’s kettle are very successful, as are nesting and stacking toys Shape toys are frustrating for adults, because children this age don’t match the shapes but play with them and force them into the “wrong” openings * The American Academy of Pediatrics recommends whole milk up until the age of Two, when fats ought to be somewhat restricted The chapter on Two Years discusses this fat issue Still very dangerous and chokable for Twos * (Fraley, M C et al.: J Dev Behav Pediatr 1991 12:301) From the months of “October through April, a preschooler is likely to be starting, having, or getting over a cold about half the time” (Report on Pediatric Infectious Diseases, Oct 1992 21111 [9]: 35.) * (Labbe, J Pediat Nov 1990 86:703–706.) * Freidrich et al., “Normative Sexual Behavior,” Pediatrics Sept 1991 88 [3] I always think of the humorist James Thurber, who lost the sight in one, then eventually both, eyes after a penetrating injury from a crust of bread hurled by his brother Such eardrops can cause pain if the eardrum perforates under pressure and the drops leak through into the middle ear Too much moisture encourages dust mites, to which many children are allergic There are breathing problems, like hyperventilation, that originate in the soul; and others, like the sighing of diabetes, that originate in the acid balance of the blood See gastroesophageal reflux, under the Reflux entry in the Glossary See the well-child visit of the appropriate chapter Lack of sense of smell Sometimes the harness needs to be used only for a few weeks, sometimes for months and months It does not inhibit a baby from doing anything—and I mean anything Rheumatic fever, a late complication of strep that can cause heart damage, is almost unheard of in children under the age of Five But very young children with strep can pass on the bacteria to older ones who are at risk, and so are treated anyway This was written prior to the bioterrorism concerns of September 11, 2001 ... and copper are automatically present in correct amounts, not vulnerable to the rare manufacturing error Vitamins and iron are built-in and present in absorbable form Extra water is automatically... start out with a baby-safe home and a medicine chest appropriate for a newborn’s welfare, and then we add on as the child grows Health and Illness: What pattern to expect for this age range, and... back and forth between the two All commercial formulas–milk-based, meat-based, or soy, brand-name or generic–must conform to the FDA’s standards for adequate safety and nutrition Milk formulas