A Basic Review of Eczema & A New Blankie

Eczema (also known as “atopic dermatitis”) is a skin condition where allergens or other irritants make your child’s skin itchy, red, rough, and/or flakey. Doctors sometimes refer to it as “an itch that rashes” because the scratching or rubbing usually comes before any changes in the skin. In its mildest form it is often just considered “sensitive skin”, but in its most severe form it can require hospitalization and serious drugs to alter a child’s immune system.

In order to prevent an eczema flare, or to relieve mild irritation, it is important to keep the skin moisturized, as well as avoiding “triggers”which the skin responds to by becoming inflamed. Common triggers are: chemicals, harsh soaps or cleaning products, perfumes/fragrances, dyes, synthetic fabrics (e.g. polyester), wool, sweat, dry air, stress, sudden temperature changes, and anything the child is allergic to (e.g. food allergies and/or pet dander).

How do you avoid so many things? For serious eczema, an allergist can help you identify specific triggers that make your child’s eczema worse. However, everybody can take some simple steps to help their child with sensitive skin:

1. Daily bath to clean the skin. Eczematous skin gets infected easily, since open areas take away your immune system’s biggest barrier. Use warm water (not too hot or cold), and bath briefly, since long baths can make the skin worse. Use soap-free cleansers (e.g. original Dove bar or Cetaphil). As soon as the child gets out of the bath, pat the skin dry (rubbing makes things worse) and cover it in a layer of moisturizer (ointments lock in the moisture best, which is why so many people love Aquaphor for their sensitive skin).
2. Always use dye-free, fragrance-free soaps and cleansers, especially for the laundry. Many people use Dreft detergent for their baby’s clothes, but this is full of chemicals. Run all of the baby’s laundry through an extra rinse cycle to be sure to get rid of any chemical residue.
3. Re-apply your moisturizer (e.g. Aquaphor) a few times a day.
4. Keepfingernails short to avoid scratching.
5. Many older children (and adults) with eczema report their symptoms worsen at night, so make sleeping conditions as comfortable as possible. A cool mist humidifiercan help keep the air cool and moist. Use distilled water in the humidifier, do not use any menthol or scented discs in it, and clean out the reservoir with vinegar every 3 days. Children age 2 and older may be helped by taking an antihistamine before bed (discuss this with your pediatrician before giving it to your child).

Babies have a larger surface area to body mass ratio then older kids/adults, and their skin is thinner. This makes them especially susceptible to irritants, and you want to avoid using medicated creams as much as possible, since more is absorbed into their system then in older children/adults. 

A mother whose baby has severe eczema created a blanket to help relieve her child’s skin irritation, and she gave me a blanket to try out. It is the Elli & Nooli Organic Cotton Pique Blanket (http://www.amazon.com/Loopiblanket-Organic-Blanket-Pacifire-Fastner/dp/B008MBMYZ8/ref=sr_1_2?s=baby-products&ie=UTF8&qid=1346005373&sr=1-2&keywords=elli+%26+nooli). 

I brought it to work to try with a few patients, and then brought it home to my toddler son. It is designed for infants, but since it is big enough to swaddle them comfortably, it is actually big enough (30” x 40”) to cover my toddler in bed (although he will soon outgrow it). This is now my son’s favorite blanket, and since giving it to him over a month ago, he insists on using it every night to sleep. He reports that it is “comfy”. The certified organic cotton means that it is less irritating than other fabrics, as well as being chemical-free and pesticide-free. The pique weave (tight weave forming raised mini squares all over) keeps air flowing under the blanket, and even allows some air exchange through the blanket. It keeps my child warm, without over-heating, so he is not sweating at night, despite living in a house with no air conditioner during a heat wave (for the past 2 weeks only, we are moving soon). Overall, I really like this blanket, and would recommend it for babies with sensitive skin.

Please note that although this post mentions many brands (e.g. Dove, Cetaphil, Aquaphor, Elli & Nooli), this is NOT a sponsored post, and I have no financial stake in any of these companies.

Coughs, Colds, and Croup

Even though it's a beautiful summer here in Southern California, we are still seeing some coughs, colds, and croup, so here are my tips to help keep your family comfortable as they clear their viruses:

Helping a child with nose congestion:

-          Use a nasal saline mist (such as Little Noses nasal saline mist) to spray moisture into each nostril and help clear her out. I like the mists more than the drops because you can hold the canister right below her nose and spray it in, without touching the canister to the actual nose, and without sticking anything directly up the nose. These are also sterile, so you don't have to worry about the water source.

-          Use a humidifier. Only put distilled or sterile water into it (not tap water). Clean it at least every 3 days. Do NOT use the menthol or eucalyptus discs/drops that come with some humidifiers.

-          If she suffers from allergies and is over age 4, you can use an over the counter antihistamine to help decongest her (e.g. children’s Benadryl). Under age 4: ask your pediatrician about these. Do NOT use the over the counter medications known as “decongestants” or “medicated cough syrups”, as these have been shown to have more risks than benefits in children under age 6 years old.

-          If he is very congested you can steam up your bathroom and sit in the bathroom with your child. Make sure the air is okay and the child does not have any access to the hot water. Never leave a child alone in the steam!
-    If you want to, you can use a vapor rub on the feet or chest of a child. It has not been proven to help or hurt. However, do not let the rub get near her nose or mouth! Vapor rub placed under the nose has been reported to cause wheezing in some children, and it is dangerous to ingest. Call poison control if your child eats any of this, or gets it in their eye 1-800-222-1222 (an important number to keep in your cell phone for emergencies).

-          Children under age 2 years usually can not blow their noses, so help decongest them (e.g. get the boogies out) by using a Nose Frida (http://www.fridababy.com/) which is a device you put in the nostril and use to literally suck the snot out. Sounds gross, but there is a filter (which needs to be changed every day) which prevents you from getting any snot in your mouth. You can do this before feeds and before sleep, or just as needed to clear out the mucus in your baby’s nose. I like this better than traditional nasal aspirators because it’s much easier to clean, is difficult to put it too far into the baby’s nose, and it gets a lot more of the snot out. The key to good suction is to hold the other nostril closed, when you suck out boogers from the first nostril (should take less than 1 second).

The Snot Sucker

Helping a child with a “wet” or “phlegmy” cough:

-          Do all of the above for nasal congestion plus the following:

-          Have her sleep propped up at 30 degrees so the mucus drains easily (if over 1 year of age).

-          Give children over age 1 year a big spoonful of honey twice a day. The honey has now been shown to help relieve cough symptoms in kids & help them sleep, in 2 published randomized control trials (scientific studies). The honey they used was NOT "raw", which can have dangerous bacteria in it.
-     Warm liquids, such as chamomile (caffeine-free) tea and lemon, or chicken soup, can help people feel better. 

-          Zinc may help shorten colds and soothe sore throats, but this has not been proven conclusively. You can get this in some non-medicated cough syrups, such as Zarbees (for over age 1 since it also contains honey), or in zinc lollipops (over age 2, observing child while they eat them) at CVS (I haven’t seen them anyplace else- let us know in the comments if you find them in other places). If he is over age 7 years you can give him the zinc cough drops that are available at all pharmacies.

Helping a child with a dry, barking, or croupy cough:

-          Do all of the above for nasal congestion & wet coughs plus the following:

-          Use a cool-mist humidifier. Use distilled/sterile water in it. Clean it at least every 3 days by rinsing out the water tank with distilled vinegar and then washing that out.

-          If the child is having a coughing fit, or breathing like Darth Vader, take him for a walk outside in the cool air, or hold him in front of an open freezer for a few minutes, to reduce the swelling in his throat. If that is not helping, call your pediatrician for immediate medical advice, or call 911 if he is actually having trouble breathing.

Check out other mom pediatrician blogs on the topic, such as this one from Dr. Stuppy:
http://pediatricpartners.blogspot.com/2013/12/but-snot-is-green-or-how-can-we-treat.html

Other Important Stuff:

-          If your child is wheezing, noisy breathing, breathing hard, breathing quickly, breathing with flared nostrils, or other signs/symptoms not mentioned, please call your pediatrician or 911, or take them to the ER immediately. This information is not intended to act as a substitution for speaking to your physician or using common sense!

-          If your child is breathing so hard that they have trouble walking or talking, or if their lips or fingernails turn blue, please call 911 for immediate medical assistance.

-          Some of the products listed above can be found on my pinterest health board: http://pinterest.com/motek42/kids-health/. I have not been paid to review any of these products and I do not get money from their sales- I am just letting you know what has worked in my experience.

Traveling with Children

Fortunately for us modern moms and dads, anywhere we want to go is just a plane, train, or automobile ride away. Despite the conveniences of modern transit, traveling with children remains a difficult endeavor. Here are a few tips to make your journey a little smoother:

1) Know your rights.
This sounds funny, but a lot has recently changed in U.S.A. airport security rules. For example children under 12 do not need to remove their shoes during screening. According to the TSA's website, you may carry as much juice and milk for toddlers as you "need until you reach your destination". The precise definition of how much you need varies by who is screening you at security.  During one trip with my then 1 year old, the security agent at LAX insisted that 3 small juice boxes was too much for a 5 hour flight, and threw all of our drinks away. I did not know enough to argue and instead I spent $$$ buying some non-organic, non-dilute juice for my child at the airport :( This also brings up the point to remember to be flexible, and give your self extra time for the unexpected.
For the latest information, check out the government's website:
http://www.tsa.gov/travelers/airtravel/children/index.shtm

2) Know your company.
Certain airlines and hotel chains are better at hosting children than others. Conversely, some airlines have recently banned children from first class on their flights, so don't expect an upgrade (or even friendly service) on those airlines. Malaysia Airlines is going to institute a "child free zone" even in their economy cabin on some flights. In general, European and Asian companies have been known to be friendlier to children on flights than USA airlines, often providing coloring books, special snacks, small toys, and other treats for families. Some airlines offer pre-boarding for families with infants and toddlers, while others have none. This may be more annoying than you think. When traveling with our then 2 year old, we had to wait until first class, business class, and everyone with a silver/gold card from the airline boarded (more than half of the passengers) before we were allowed to get on with a toddler, car seat, and hand luggage. Trying to get past the tiny aisle with people everywhere and a large car seat was not fun, and I think it disturbed the other passengers as well. Allowing us to board early, install the car seat and settle in would have prevented a lot of hassle for everyone. However, when we got to our destination we stayed at a hotel that provided us with squeaky bath toys and other amenities in the room that made us feel like family.
Here is a recent article from yahoo on the most family friendly airlines:
http://travel.yahoo.com/ideas/best-airlines-for-families.html

3) More tips just for flying with children:
- Try and book a flight with as few stops as possible, as take-off, landing, and boarding are the toughest times.

- Make sure you have assigned seats together in advance. Many companies have been separating families on flights, and then you rely on your fellow passengers to switch seats so you can sit together.

- I take our car seat when flying with my son, to make sure he is strapped in securely during our flight. This also ensures that he has a safe car seat for automobile travel when we arrive at our destination. It is also easier for him to fall asleep during the flight in his car seat, and more difficult for him to annoy other passengers by kicking them or climbing on the chairs. We use a GoGo Kidz Travelmate to turn the car seat into a stroller at the airport.

- To avoid pain from the changes in pressure in the ear during flights, teenagers and adults can chew gum or drink water to encourage swallowing, and thereby open up the eustachian tubes in their ears to relieve the pressure. For babies the best way to do this is breast (or formula) feeding. Breast (or formula) feeding has the added bonus of providing sugar to the infant, which is a natural pain reliever. For toddlers, diluted juice in a straw cup works well. Older children can suck on lollipops to get them swallowing (and happy and distracted by candy). Nasal sprays can also help relieve congestion and prevent pain during the flight, but speak to your pediatrician about this (salt water sprays can help babies with stuffy noses, while kids with ear infections or sinus problems may need a prescription nasal spray). If all this ear tube talk is confusing, check out the ear anatomy pics here:
http://pinterest.com/motek42/ear-infections/

- I recommend waiting as long as possible before flying with infants. The younger an infant is, the less developed their immune system, and the more likely they are to get sick. The air on airplanes is re-circulated so it is very easy to pick up germs from other travelers, even ones who are seated far away from you. Infants younger than 2 months old who catch an illness with fever may have to undergo extensive testing, including blood, urine, and spinal fluid exams if they get sick. I know this is not possible for all families, but waiting until your infant is 9 months or older can save you a lot of hassle and illness later on. In addition, the USA is currently experiencing a surge in measles cases, most of which can be traced to foreign travel- see these links for more information:
http://www.reuters.com/article/2012/04/19/usa-health-measles-idUSL2E8FJDSD20120419
http://wwwnc.cdc.gov/travel/page/measles-for-air-travelers.htm
And don't forget to check the CDC website, and make an appointment with your pediatrician at least 2 months prior to any foreign travel, so you can get medications and vaccinations for your trip.

4) Have your bags packed with items that will keep your child calm, quiet and comfortable. 
I prefer small, light items. If you are used to distracting your child with your phone or other electronic items, keep in mind that you will not be able to use them on take-off or landing, and they might run out of batteries on long car trips, so make sure to pack low-tech items as well. I recommend packing a carry-on or car bag with:

• baby wipes (good for cleaning up messes for kids of all ages)
• snacks
• your own sippy cups or bottles
• four more diapers than you think you need
• several different sizes of ziplock bags (for messes, soiled clothes, soiled diapers, and they are just generally handy to have)
• a medical bag (children's acetaminophen, children's ibuprofen, children's benadryl, bandaids)
• sunscreen (the sun through a car's windows can burn a child, and then sun through a plane's window has more radiation than down on the ground, so slather yourself and your child with sunscreen to avoid sunburns and -much later- skin cancer)
• lollipops for age 4 and above
• extra clothes (even for older children, as it's easy to get spilled-on during a flight or car trip, and you never know if, when, or where you'll get stuck)
• books
• re-usable stickers
• dry-erase crayons and board
• a soft blanket
• your child's lovey (favorite blankey, stuffed animal, or other comfort item). 

I've linked to a few of these items, as well as book suggestions, on pinterest:
http://pinterest.com/motek42/traveling-with-children/

This blog has many more great travel tips, and this link is for a funny story illustration why you shouldn't feel bad about that huge carry on with all of the extra supplies:
http://eatpackgo.com/pack/pack-diaper-ninja/

Traveling with children is a lot more stressful then traveling alone, but with patience, planning, and a large bag it can be a fabulous adventure.

Have any good tips or links of your own? Please tell us in the comments!

(photo of my son in his car seat, looking out of the airplane window, photo taken by me 2009 (c) )

Interviewing a Pediatrician

Recently, one of my friends asked me what questions she should ask when interviewing a prospective pediatrician, so I thought I'd share my answer with everyone:

1) What insurance do you take?
Of course, this is only important if you're using insurance. I know several families now that have health insurance for emergencies, but pay for general health maintenance out of their own pockets. This reduces their overall medical expenses (because they have a cheap insurance plan, only for emergencies), and allows them to see whatever doctor they like. These families usually use free clinics for vaccinations, or pay out of pocket. This only works if your family is healthy. If you choose the latter option, ask about visit prices instead.

2) What hours is the office open for well visits? For sick visits? When is your chosen primary pediatrician actually in the office during the week?
Keep in mind that the smaller the office, the less hours they are usually open. So if you want to do well visits at night or on weekends, you will probably have to go with a very large practice, and may be seeing a different doctor (or nurse practitioner) each time.

3) Who covers for your physician when they are not in the office, not on call at night, or they are on vacation?
For night call, is the person on the phone a physician from your practice, a physician from another practice, or a physician extender (NP or PA) or nurse?

4) Do you use electronic medical records?
These can reduce errors, and allow the physician on call (if they are a doctor from the same practice) to access your chart at night and on weekends, if needed.

5) Can I always get a same day sick visit appointment?

6) Who answers regular questions by phone during the day? What I mean by this one is, does your pediatrician call you back if it is not urgent? Does a nurse handle most questions about illnesses on the phone? Does another physician answer the phone when your physician is not available?

7) Are there any physician extenders (nurse practitioners or physician assistants)? Are they the ones to see you for same-day sick visits or phone calls, or will your physician or their partner see you?

8) Are there separate sick and well waiting rooms? Are there separate sick and well exam rooms?
This reduces the chance of your baby being exposed to a virus

9) What is your vaccine policy?
If the physician allows un-vaccinated children in their practice, consider that your baby (who is too young to be vaccinated for certain diseases) may be exposed to somebody in the waiting room with measles, chicken pox, etc...

10) How often do you see the baby for child for regular check-ups?
This can actually vary quite a bit between pediatricians for the first 3 years of a child's life. After that, your child is seen for an annual well check every year.

11) Do you have a website? Do you use email to communicate with patients?

12) What hospitals do you cover? Will your chosen primary physician be the one to see your baby everyday in the hospital (when they are born and if they are admitted later) or will one of the covering physicians see them?

13) What kind of parenting resources can you offer?

14) Where is the best place to park or closest public transportation stop?
I have found (at least in big cities, such as LA and NY), that the best place to park for my doctor appointments is often somewhere other than the valet parking in the medical building. The website or administrative assistants at your pediatrician office should be able to tell you the best (free) place to work, as well as help you get there by public transportation, if that's your preferred mode of transport.

That's all I can think of for now, but please leave your tips in the comments section!

[My son is too young to be your pediatrician right now, but isn't he cute? ;) (c) ]

A Spoon-full of Sugar Helps the Medicine Go Down

Lots of parents have trouble getting their children to take medicine, so here are some tips to help:

Some techniques to help medicine go down easier:

Marry Poppins was right- a spoon-full of sugar helps the medicine go down! More accurately, a spoon-full of chocolate syrup will cover up the taste of most yucky medications. Apple sauce and yogurt are other common foods used to mask bad tastes. Many medications can be made to taste like your child's favorite flavor by the pharmacist before you even pick it up, so ask about this when you submit your prescription. Some medications come in "orally dissolving tablets" which kids (age 3 and older) can put in their mouth and they will dissolve without having to chew or swallow.

Liquid meds are often easiest to give to babies with a syringe (a tube that looks like shot, but does NOT have a needle on it), which you can get at any pharmacy, baby store, or from your physician. Squirt small amounts of medication into your baby's cheek and they'll usually swallow it. Don't squirt it directly onto their tongue or into the back of their throat, as this can lead to gagging. Follow-up with breast milk or formula (whatever they normally drink), before giving the next part of the dose. Alternatively, you can put the liquid medication in a bottle nipple along with a little breast milk/formula, and have them suck directly from the nipple, without the bottle attached. I do not recommend mixing the medication in a whole bottle, unless you know the baby will take the whole thing regardless of taste.

Most baby stores also sell special devices to help kids swallow medications,such as something that looks like a bottle, but keeps the medication separate, so you know exactly how much the child takes. I do not recommend giving children medications with droppers, because it's difficult to measure the amount you're giving, difficult to get all of the medication out of the dropper, and difficult to clean and dry the dropper fully between each use.

Learning how to swallow pills:

Once your child is ready to swallow pills (often by age 5!), it's a great help to teach them how, since many medications are easier to take in pill form, the older they get, the bigger the dose, and some medications are not available in liquid/ chewable form. Starting young can also be beneficial in preventing anxiety associated with swallowing pills. Adolescents and adults often have trouble swallowing pills because they fear that the pill will get stuck in their throats. Relaxation techniques and deep breathing can help. Looking in a mirror, sticking your tongue out, and saying "aaah" out loud (this lifts the palate so you can see your throat), can help people see that their throat is much bigger then the pill, and ease some of the anxiety.

The first step in learning how to swallow a pill is to practice with something that is NOT medication. I recommend starting with small, smooth, round candies (such as mini m&m's), and progressing to slightly larger candies (such as regular m&m's). People with anxiety may want to start with tiny candies, such as sprinkles. Other people prefer to start with tiny bread balls (made from mooshing a tiny piece of bread between your fingers), and go progressively bigger, since the bread dissolves easily in the throat. You will also need a big glass of water, juice, or carbonated beverage (such as sparkling juice, which the pill can float on).

Younger kids can be told to just try swallowing the candy without chewing, because they are often successful without thinking about it. Older children, or those without a natural tendency to swallowing whole pieces, can start by visualizing the item floating down their throat on water, like a little boat. They should start by making sure the mouth is moist, by salivating or taking a sip of their drink. Nest place the candy as far back on the tongue as possible, using the teeth to scrape the candy to the back of the tongue (a mirror helps some people see how far back it is). Then take a big gulp of the liquid, which should float the candy and allow it to be swallowed, just as you would usually swallow any regular drink. Some children will swallow the candy (and later pills) more easily by drinking the liquid through a straw.

When it comes to taking real medicine, some people hide their pills in mini-marshmallows, which are slippery when wet, and therefore easier to swallow. I recommend trying this without medication first, since these are bigger then most pills. You can also try covering the pills in chocolate syrup, applesauce, yogurt, or jam (but see the warnings below before trying that).

I suggest experimenting with these techniques in a relaxed environment until you find something that works for you.

Warnings:

These techniques are for generally healthy children, with normal anatomy and mentation! They should not be used for children with any anatomical abnormalities, dysphagia (trouble swallowing regular foods or drinks), or any medical conditions that effect swallowing, the head/face, the GI system, or the neurological system.

All children should be supervised when practicing swallowing candies, and when taking ANY medication. NEVER tell your child that the medication is candy, as this can cause them to sneak some more when you're not looking (many medications these days actually do taste like candy). Always keep medications (over the counter and prescription) and vitamins/ supplements out of reach AND in a LOCKED container. Kids are good at climbing and getting into high cabinets, purses, closets, and other hiding places.

Please speak to your pharmacist (who is usually in the back of the store, who has spent at least 5 years in post-graduate university studies, getting a doctorate degree in pharmacy), about what you can take your medication with, and whether you can cut, crush, chew, or open the medication. Many medications should NOT be taken with grapefruit juice. Some medications should NOT be taken with anything dairy. Some pills can be crushed and mixed with foods, where as others can not. Your pharmacist and/ or physician are the best people to speak to before taking your medication with anything but water.

Good luck & feel free to leave your own tips & experiences below :)

My son loves taking medicines! (c) 2009

Tips for Stopping Bad Habits (giving up the bottle, paci, and thumb)

When should you quit?

The bottle should be the first thing to give up, between 12 and 18 months. Continuing to give a bottle at bedtime increases the child’s risk for ear infections and dental problems. Your toddler should be drinking 16oz-24oz (2-3 cups) of milk per day. Less than 16oz does not give them enough calcium and vitamin D, but too much milk can cause iron deficiency anemia and fill up your child, preventing them from eating other nutritious things.

The pacifier is usually the next thing to give up, between 1 and 3 years old. It is important to stop in order to prevent ear infections and poor teeth/ jaw alignment. The pacifier has also been blamed in some for lisps, and delayed language development (the child may use it as an excuse to not speak properly).

Thumb sucking is the hardest to stop, and most pediatricians recommend no intervention until age 4, since most kids will stop sucking their thumb on their own before then.

Sleeping solely in the child’s own bed is a very personal decision, as there is nothing medically wrong with sharing the bed with a toddler (unlike in infancy, when you must be careful of how you co-sleep to prevent SIDS). However, teaching them to sleep on their own is a way to help children learn to self-comfort, as well as providing the whole family with better sleep.

How Do We Stop?

Some tip for breaking any habit:

  (1) Decide if you want to stop the behavior completely all at once (“cold turkey”), or wean it off gradually (usually by limiting the activity to bed time).

 (2) Do not turn it into a confrontation with the child. Let them know you are here to help them stop the habit, and why you want them to stop.

(3)     Have them come up with alternative methods of self-soothing with you. Ask them, “What can you do instead?” Guide them to choosing something that is reasonable.

(4)  Point out that their older siblings, friends, even characters that they like, do not use a pacifier/ suck their thumb/etc… and let them know “big kids” don’t do it. Example while watching Dora The Explorer, “Wow, look what a big girl Dora is! She and Boots have all these adventures and she doesn’t suck her thumb, even when Swiper comes.” Point out how much your child has changed/ grown in other ways, and let them know how proud you are of them.

(5)  Do not prohibit them from self-soothing in high anxiety situations, or when there is a big change (such as a new sibling being born or a parent going on a business trip).

(6)  Make sure they are aware they are doing it (by pointing it out in a helpful, positive way), and distract them with something else to do.

(7) Give them an acceptable substitute, such as a blanky/lovey, small stuffed animal, special new cup, or small cloth square to keep in their pocket (this last item can be rubbed by the child with fingers in pocket, especially when substituting for thumb-sucking or nail biting). Make sure the child is involved in choosing the new item, and knows why. If you decide on a lovey that your child gets attached to, make sure you have 3 identical ones in rotation, so one can always be in the wash, one in use, and one back-up.

(8) Reward charts can be helpful for children who are age 3 and above (the older, the better). This is a sheet with calendar spaces for 2 to 4 weeks, with the last space with a pre-determined prize, such as a trip to a special place (e.g. Disneyland), or special new toy. The child puts a sticker or X in the space every day that they don’t do the habit, in some cases only consecutive days of not doing the habit are allowed to be charted.

The bottle is the most important thing to give up, for your child’s health. At 12-18 months transition to a sippy cup, then around 21 months transition to a regular cup for meals and snacks (sippy and straw cups are fine to use when going out). Start by holding the cup for the child, and teaching them to hold it themselves with very small amounts of water in it (to reduce spills/ clean up). You can also give gradually less milk in the bottle until there is none (e.g. decrease the amount of milk in it by 2oz each day).

The pacifier is usually a difficult transition because of age, and the new toddler’s desire for independence. In addition to the general tips above, you can also try the following: (1) Give it away to a baby (not the child’s new sibling, since that can lead to jealousy), or a favorite character (such as on a trip to Disneyland). Make sure the child participates in the giving away ceremony. (2) Have the pacifier sewn into a stuffed animal (like at one of the Build a Bear workshops), then the child can sleep with the stuffed animal. (3) Cut a hole in the pacifier, so the sucking action stops working. (4)  Make a necklace out of the pacifiers, and hang it on their crib. Let the child know if they don’t use the pacifiers for a certain amount of time they get a pre-determined reward. This works well with older children, with a reward chart.

[Photo of my son while still happily sucking his pacifier at 9 months old (c) ]

Thumb sucking is the hardest habit to break, since you can’t take away their fingers. For this reason, and since most toddlers stop thumb sucking on their own, it is recommended to wait until the child is 4 years old before intervening. Peer pressure at that age also helps them try to stop (at least in public), and they respond better to reasoning. First try all of the above tips in the general section, especially pointing out when they do it, distracting them, giving them a substitute, and reward charts. In addition, you can provide a barrier by tying socks or mittens on their hands (there is no need to spend money on the fancy devices that do the same thing). Some girls respond to having a manicure. Other children are better reminded to stop by placing bandaids on the thumbs. I think bitter nail polish should only be used as a last resort, since this seems like a punishment to me, and I try to keep the experience positive, letting the child know that their parent is there to help them. The key at this age is that they need to want to stop, which means a lot of discussion in the house about why it is important to stop.

Bedtime is usually a big struggle with toddlers, so each family needs to decide for themselves how they want to handle it (pick and choose your battles). If the parents want the bed to themselves, or simply want the toddler to sleep on his own, the younger you start with sleep training, the easier it is. If your toddler is getting up in the middle of the night and coming to your bed, you can firmly, but simply, bring them back to bed each time. A music box or sleep sheep (white-noise maker) that they associate with going to sleep can really help (be sure to use this at regular bedtime and naptime as well). Another option is allowing them to sleep in your room, but not in your bed, so they feel close to the parent, but not comfortable. You can put a simple mattress down on the floor, or even just a blanket. This minimizes the parents waking up, which can be a big help to everyone. Another option which some people recommend, but which I never use, because it just seems cruel and unsafe, is to put a baby gate or lock on the child’s bedroom door, so that they cannot open it and leave their room at night. Whatever method you choose, or even if you choose to let the child sleep in your bed, just try to provide minimal attention when they wake up, since you do not want to reward them for getting up in the middle of the night, and everyone needs a good night sleep.

About myself & the blogosphere

Hello everyone, I am excited to be joining the blogosphere. I have decided to start a blog in order to provide general pediatrics advice in a longer format than I usually have in clinic, as well as share my experiences as a mother. This information does not substitute speaking to your physician, and all opinions are my own and do not necessarily express the opinions of my employers. The following is my bio:

I  grew up in Los Angeles, California, graduating from the Hamilton High School Academy of Music. My mother is a pediatric rheumatologist, giving me some extra insight into how medicine has changed over the past 30 years.

The University of California at Berkeley is where I spent my under-grad, receiving my B.A. with honors, majoring in Inter-Disciplinary Studies, Environmental Science. I went on to get a Master’s degree in Regulatory Science from the University of Southern California School of Pharmacy, which led to a position in clinical research at Childrens Hospital Los Angeles. While working there  I realized research was not enough for me, and I wanted to be a doctor too. I love medicine because it allows me to be a scientist, teacher, and detective every day, as well as help the next generation of children grow up healthy.

I obtained my M.D. from the Ben-Gurion University Medical School for International Health in Collaboration with Columbia University Medical Center. I received the Dean’s Award for Outstanding Contribution to the Medical School for International Health.  The school not only has an outstanding emphasis on clinical skills, but also allowed me to work with diverse populations, including a very short time in Ethiopia, and a senior project with the Bedouin community.

My internship and residency in pediatrics was completed at Maria Fareri Children’s Hospital, Westchester Medical Center,  New York Medical College, where I was their American Academy of Pediatrics Delegate.  I am honored to have received the Pediatric Residency Leadership Award. I am a member of the American Academy of Pediatrics and the Los Angeles Pediatric Society. I am certified by the American Board of Pediatrics.

I am happy to have recently moved back to Los Angeles with my family. I am lucky to have a wonderful, supportive husband, and a beautiful toddler son, who teaches us something new each day.

I am now seeing patients at Roxbury Pediatrics in Beverly Hills, CA. You can check us out at http://www.roxburypediatrics.com/

Thank you for taking the time to read my thoughts!