1. Most drownings occur WITH adults around.  In preschoolers, 70% of all drowning incidents occur when children are in the care or one or both parents.
2. Infants can drown in very shallow water (bathtubs, buckets), the #1 type of drowning for children under one year of age.
3. There is no substitute for a parent being IN the water within an arm’s length distance from a child who cannot swim.  “Floaties” and other assistance devices may increase enjoyment, but don’t necessarily increase safety.   Such toys or devices are not a life jacket, can slip off, and can also entrap a small child under the water or in a dangerous position.
4. Don’t assume that other adults are “supervising” your child – unless they are specifically tagged to do so and are “on” all the time.
5. Childhood drowning can happen quickly – it only takes a slightly open door or turn of the head because of distraction.
6. Provide swimming lessons for your children – but understand that they also need to be physically and developmentally able to understand water safety.  This milestone may not be reached until a child is age 4. 
7. Infant/Toddler “swimming lessons” are not a complete safeguard against drowning, however, new evidence shows that children ages 1 to 4 may be less likely to drown if they have had formal swimming instruction.  Nevertheless, parents should not have a false sense of security regarding drowning risks and these younger children.  Swimming skills are from different than water-safety skills.  
8. For teens, the dangerous combination is alcohol and water, head trauma and water, or alcohol and head trauma and water. Parents should have a specific discussion with their adolescent children about this concern.
9. Safety measures at your home or homes that you visit (friends and family) are not complicated, and it is not presumptuous to inquire about what types of safety measures (gates, alarms, lockable covers) exist at a home where your child is staying.
10. Don’t drink alcohol while you are swimming or are supervising children who are in the water.
11. Hot tubs and spas have the same inherent risks.

We want children to enjoy the water and water activities and for parents to feel as though their children are safe when they are participating in all of the fabulous water recreation and activities that we have available in the San Diego area. The AAP (American Academy of Pediatrics) does have a policy statement and recommendations regarding water safety.  You can search the AAP website (www.aap.org or www.healthychildren.org) or combine the search terms “AAP” and “water safety.”  Good websites to access information are also www.poolsafely.gov, which is produced by the Consumer Product Safety Commission, as well as www.cdph.ca.gov  (search under “pool” or “drowning”).

My childhood was peppered with events that surrounded the needs of the children in the orphanage.  Holidays were spent distributing gifts, serving meals and supervising during outdoor events.  Yet I always felt that my mother was the center of it all.  She had the ability of letting everyone know how special they each were, and that included me.  I look to her image as a guiding compass of my own life.

As a pediatrician, I have had the privilege of sharing with many mothers during the innumerable sick and well visit that have become my daily routine.  I have learned, that as mothers, we all want what is best for our children – health, opportunity and a sense of purpose for their lives.  I have seen mothers, who in spite of all the hardships of life, still put their child’s needs above everything else.  I salute each and every one of your mothers for sharing your children’s health and dreams with all of us at CPMG.

May your children remember you as the kind, generous and confident mother that you are and always look to you for the abundance of strength and love that you provide. 

With appreciation,

Chrystal de Freitas

Pediatrician

Healthy eating. What comes to your mind when you hear that phrase? Several years ago that phrase had a very different meaning to me than it does now. I used to associate healthy eating only with a certain amount of calories or fat in a meal or snack. I had no clue how to read the ingredients list on a food label or understand what was really important on the Nutrition Facts list. Essentially, I was primarily focused on what I shouldn’t eat. After coming to a crossroads with my own personal health, I realized that focusing on the good, whole foods that I should eat allowed me to develop an optimal diet for good health, without feeling deprived. As Hippocrates said it thousands of years ago, ‘Let food be thy medicine and medicine be thy food.’

Now, certainly food is to be enjoyed and not only utilized for achieving good health. Thankfully, however, I have learned that enjoying good food and achieving good health and prevention through our diets can be one and the same! No matter where you are in your personal health journey or where you are in your dietary habits, there are always ways to improve, delicious new foods in which to partake, and health benefits to reap as a result. Start one step at a time, one recipe at a time, one choice at a time. We often think we have to delve into a drastic diet or cleanse in order to lose weight or get healthy, and although there is a time and place for those things, sustainable changes that become a lifestyle most often are developed over time. In other words, the culmination of many small decisions can create a large, more permanent result, as opposed to a temporary health binge that eventually wears off and leads us back to old habits.

As you evaluate your personal health goals and how improving your diet can help achieve those goals, perhaps it would also help to consider the following:

• Partner with a friend. Having a friend or spouse walk through changes with you can provide helpful accountability and make the process more fun and enjoyable! Try new recipes together, swap recipes, and create fun challenges for each other.
• Focus on what you should put in your body, as opposed to what you shouldn’t. We often fall short of our goals because we are focusing on the things we feel deprived of, rather than focusing on finding ways to enjoy what we should be consuming. This also helps keep the hope for success in reach, as you focus on the positive variable. Your thoughts and feelings strongly impact your ability to improve your health and lifestyle.
• Eat more fruits and vegetables. This is a given. Hardly anyone eats the recommended 7-13 servings a day…more matters!
• Ask for input. Do you have people in your life that seek to follow a healthy lifestyle that could be of encouragement or help provide some yummy, healthy recipes with which to get started? If so, ask for help! If not, feel free to contact me for recipes and ideas. We can all use a little help!

Here’s to happy, healthy eating on your journey to better health!

Leah Schitter is a Certified Health Educator and she is also host of our “Kids Yummy Eats” classes here at Pediatrics in Paradise. Make sure you join us for a class and see how you can help your children with healthy eating habits. Check our website for class dates and times, www.pediatricsotayranch.com.

Summer is just around the corner, which means lots of outdoor activities for families in sunny Southern California.  Although outdoor activities are fun and healthy, sun exposure can cause permanent damage to the skin.  Did you know that your risk of skin cancer doubles if you have had five or more sunburns?  That is why it is so important to protect your child’s skin from the start!  Here are some tips to help keep your whole family protected.

The best protection is to avoid the sun.

• Try to keep everyone covered in light, comfortable clothing.
• Keep babies less than 6-months old in the shade whenever possible with a stroller canopy or a tree’s shelter.
• Use hats to keep sun off of the face and use sunglasses to protect the eyes (and look how cute they look in shades)!
• Limit outdoor activities between 10 am and 4 pm – time when the sun is at its strongest.
• If you will be swimming, look for bathing suits that have SPF 50 built in.  Target^TM sells rash guards for the boys and cute shirts and bottoms for girls.  My kids only wear these and they never get sun under their bathing suits!

The second best protection is sunscreen.

There seems to be a lot of controversy about sunscreen these days.  Since it’s well known that sun damage increases the risk of cancer, sunscreen is still very much recommended.  The American Academy of Pediatrics recommends using sunscreens that create a barrier on the surface of the skin.  Look for the ingredients zinc oxide or titanium dioxide.  These ingredients are not absorbed by the skin and therefore do not have affect on a child’s growing body.  For babies less than 6 months of age, these are the best products to use on exposed areas.

• Always look for products that have broad spectrum UV protection.  Ideally, you want UVA and UVB protection.
• Look for SPF (Sun Protection Factor) of at least 30 or more.  This means that it will take the skin 30 times as long to burn from UVB exposure.  SPF does not indicate UVA protection, so be sure the coverage is clearly stated with your product .
• Besides zinc oxide or titanium dioxide, other ingredients that are safe and effective are avobenzone or Meroxyl^TM.
• Creams, lotions, and sticks are the best types of sunscreen.  Be careful with sprays as they can be inhaled and cause lung damage, and always use a spray in a well-ventilated area.

 Ingredients to avoid:

• Oxybenzone is very effective against UVA and UVB and is approved by the FDA for anyone over 6 months.  However, there continues to be concerns that once absorbed by the skin, oxybenzone can act as a hormone disrupter, which can have negative effects on growing children.  More research needs to be conducted on this ingredient.
• PABA was initially a very popular ingredient in sunscreen due to its ability to block UVB rays.  However, PABA was found to cause allergic reactions, increase risk of sunburn and cell damage, and discolor clothing.  It also came off easily in water.

My recommendations:

• My favorite type of sunscreen to use is the stick.  These are convenient to carry, the product does not run into the eyes, and my kids can now apply it themselves!
• I have used Aveeno Baby Natural^TM and MD Solar Science^TM.  I also love California Baby^TM products and will probably try their sunscreen this summer.
• Other popular organic brands that I love, like Seventh Generation and Earth’s Best, make sunscreen. 
• Check out the Environmental Working Group website for more suggestions at www.ewg.org.

Always put sunscreen on before putting on clothes or bathing suits and always apply at least 15 minutes before going in the sun.

Constipation, characterized by stools that are hard, painful, and difficult to pass, is a very common and trying problem in children.  The frequency of stooling varies from infant to infant and child to child, and is not as important as how easily stools pass.  Diet, hydration, behavior, and environment are all issues that influence stooling and can lead to constipation.

 Changing from breast milk to formula, too much cow’s milk, not enough water, or the typical high-carb toddler diet can all lead to harder stools.

 Another big culprit is stool holding.  Brought on by fear, stool holding can occur after passing large, hard painful stools, or being uncomfortable using a toilet away from home.  Unfortunately, both situations create a vicious cycle; fear causes holding and the eventual passage causes pain, producing more holding.

 Here’s how I recommend you treat constipation:

 In infants, give 2-4 oz. of diluted prune or pear juice.

In older infants, incorporate higher fiber foods like apricots, plums, and prunes.

 In toddlers and children, increase fluid intake, make sure they’re eating high-fiber foods, like raw vegetables, fruits, and whole grains, and, finally, cut back on the high-dairy, high-carb diet.

 For stool holders, you will most likely need a stool softener (you can discuss this with your pediatrician) and some retraining.  Have your child sit on the toilet 10-15 minutes after each meal for at least 10 minutes and use a reward system when they are successful.

 You should see your pediatrician if your child has been experiencing constipation for a long time, pain or blood with bowel movements, or generalized abdominal pain.

 I know it’s tough mom, but be patient.  Constipation is a chronic problem that will take some time to work its way out!

 Ear infections are the most common condition for which antibiotics are prescribed for infants and children.  Do all ear infections need to be treated, and do bacteria cause all ear infections?  The answer to both is no, not all ear infections need to be treated and both viruses and bacteria cause ear infections.  Now the tricky part…how can you tell the difference?  We (pediatricians) know what a normal eardrum looks like, and we know what an abnormal eardrum looks like.  With that being said, it’s a combination of how the eardrum looks and the associated symptoms and complaints of the child.  Older children can verbally express their pain, but in younger preverbal children, rubbing or pulling on the ears, not feeding or sleeping well, crying, fussiness, and/or fever suggest pain. 

 How do the new guidelines differ from the past?  The take-home message is accurate diagnosis.  The new guidelines have a more stringent definition of acute otitis media (how we characterize the ear drum); they address pain management, and offer the option of observation vs. antibiotic treatment.  Age and severity of associated symptoms help guide the decision making for treatment. 

 In a nutshell, antibiotics should be prescribed for acute ear infections in children 6 months and older with severe signs or symptoms (i.e., moderate or severe ear pain for at least 48 hours or temperature of 102.2°F or higher).  In younger children, 6-23 months of age, the associated severe signs or symptoms are not necessary and antibiotics should be prescribed.  Now the option of observation: in healthy children 6 months and older, without severe signs or symptoms (i.e., mild pain for less than 48 hours and temperature less than 102.2°F), there is the option of antibiotics or observation with close follow-up. This can also be an option for younger children, 6-23 months of age, with a single ear infection and without severe signs or symptoms.  In both cases, antibiotics should be started if the child worsens or fails to improve within 48-72 hours. 

 The choices of antibiotics, along with the discussion of tubes, are also in the new guidelines.  Both of these topics are better suited for you to discuss with your pediatrician.  Finally, there is a strong reminder of the benefits of vaccination, something every pediatrician, including myself, finds extremely important. 

 The primary message…these guidelines are recommendations meant to help you and your pediatrician decide the best course of action for your child. 

It’s surprising to me how many cases of iron deficiency I diagnose.  Surprising enough that it compelled me to write about it!  The good news…. it’s pretty easy to fix.  I recommend starting with a vitamin with iron and dietary changes.   Gummy vitamins do not contain iron, so make sure you pick out a liquid or chewable vitamin.  The vitamins are the easy half of the fix; the diet can be a little trickier.  There are lots of foods fortified with iron, which are helpful, but the body actually absorbs and utilizes iron best from the natural source.  Red meat, eggs, green leafy vegetables, dried fruit (like prunes and raisins), soy products and beans are the best sources.  In addition, foods rich in vitamin C, like citrus, help the body absorb iron.  Dairy and other foods high in calcium can actually bind iron, so make sure not to overdo it.

A typical case of iron-deficiency anemia is a toddler who fills up on milk and dairy, with an otherwise very limited diet.  Remember, milk does the body good, but only in moderation.  On the bright side, once you limit your child’s dairy intake, they actually eat better!  Not filling up their stomachs with milk leaves lots of room to be hungry.

Why is iron deficiency so important to fix?  Because iron is very important for growth and cognitive functions.  Symptoms of anemia come on gradually, so initially you may not even notice.  However, it can eventually lead to generalized weakness, irritability, easy fatigability, headaches, poor feeding, anorexia, poor weight gain, and pica (which is a craving to eat non-food things).

If your child is picky, as many are, you may need to be a bit creative and sneaky.  It may be difficult at first, but remember that persistence pays off.   Once corrected you will find that your child is happier, more energetic, and can even fight off infections better.

Some food for thought…. Iron-deficiency anemia does not discriminate.  It is seen most commonly in toddlers because of their picky and limited diet; however, any picky eater at any age is at risk for anemia.  Finally, adolescent girls are also at risk for anemia and can definitely benefit from a multi-vitamin with iron.

Birth:

Newborns sleep an average of 18-20 hours per day.  Add in feedings every  2-3 hours, and you can see why “sleeping like a baby” is not really good sleep.  This is a good age to use the “feeding on demand” schedule.

2 Months:

By this age feeding schedules start to get more consistent and so do naps.  Try a routine of sleep, eat, awake time, and sleep again.  This gives you and baby a routine and some predictability.  It will also help you “sleep train” by preventing a habit of falling asleep during feeding.  Sleep training is the process of teaching babies to self-soothe and fall asleep by themselves.

4 Months:

This is the age at which most babies let you know they are ready to fall asleep by themselves because they wake up as soon as you lay them down to sleep.  There are many methods for sleep training so I recommend reading through the various books about sleep to pick a method that works for you.  The key is to have a routine that is the same every time your child goes to sleep.  This will get the child ready for sleep and also signal to him/her that it is bedtime.

6 Months:

By now an independent sleeper takes 3 naps per day and should be able to sleep 10-12 hours per night without waking.  If your child is still waking, talk to your pediatrician about whether or not your baby still needs the feedings overnight.

9 Months -2 Years

Babies transition to 2 naps per day (mid-morning and mid-afternoon) and then to 1 mid-day nap over this time frame, still with 10-12 hours at night.

3-5 Years

Most toddlers will start to give up the nap during this time.  Be careful though: they will likely need an earlier bedtime once this happens.

School Age

Don’t underestimate the importance of sleep for these kids.  Sports and homework will definitely keep kids awake so time management will be important.  Most kids will need anywhere from 9-12 hours of sleep per night.

Many things can interfere with sleep.  Illness, teething, developmental milestones, new foods, and a wild imagination can all keep your child awake.  Furthermore, TVs in the room and electronics with lit screens also interfere with sleep by shutting off the body’s melatonin release.

Finally, the most important thing a parent can do is learn to recognize cues that indicate tiredness.  You want to get your children in bed when they are tired and ready to go to sleep.  Waiting to put your child to sleep will cause a cortisol release, keeping the child awake and causing the child to be “overtired.”

This child might actually appear to be energized and wide awake but is exhausted and is going to be the hardest child to get down for sleep.

Keep in mind that every child and family is different and one size does not fit all.  Also, keep that same advice in mind when reading the multitude of sleep books that are available.  If it doesn’t feel right for you and your child, don’t do it. When in doubt, consult with your pediatrician for questions.

So it’s cold and flu season and your child is sick.  How do you know what he/she has and then what do you do about it?

The term “flu” is commonly thrown around to describe anything from a runny nose to viral gastroenteritis, or the stomach flu.  In reality, the flu is caused by a very specific virus called influenza.  An infection with influenza typically causes sudden onset of high fever, body aches, chills and sometimes dry cough.  It is generally more severe than the common cold, which can be caused by any one of thousands of viruses.  Sometimes it can be quite difficult to tell the difference and some viruses that occur in spring and summer have similar symptoms to the flu.  Some red flags for the flu are as follows:

High fever

Fatigue

Body aches

Cough

A runny nose and cough with little or no fever (>100.4) is more likely to be a common cold.  The flu can be complicated by pneumonia or other bacterial infections that can be very serious and result in hospitalization.  Usually the common cold does not have serious complications.

Another respiratory virus commonly seen in winter is RSV, respiratory syncytial virus.  This tends to affect younger babies more than older kids and causes a lot of secretions.  Sometimes the secretions clog the airway and cause low oxygen, pneumonia and wheezing.  In older kids, who typically are carriers of RSV, the symptoms are that of a common cold.

Once a diagnosis is made, the next step is treatment.  When the flu is diagnosed early enough, medication called Tamiflu can be prescribed.  Treatment can help prevent spread and complications.  There is no treatment for a common cold and regular antibiotics are never needed for viral infections.  Symptomatic treatment, rest and fluids are the mainstay of care.

Prevention is the key to limiting the spread of colds and flu.  Wash your hands and avoid touching your face.  Flu shots are vaccines that help your body build immune cells that fight the flu if you are exposed.

If you are concerned about any of your child’s symptoms, call you doctor.

My job is fun. I get to spend time with babies, toddlers, school age kids and teenagers. In fifteen to 20 minute sessions, I spend my day traveling from the blissful state of the first few months of life to the conflict driven years of adolescence with multiple stops on the terrific twos.

The second year of life, called by many the terrible twos, is a wondrous time in the life of the child. And that is why I decided to call it the terrific twos. Many words can describe this period. Let me try a few and see if you can identify your toddler in them: rebellious, hilarious, exuberant, adventurous, frustrated, daring, frightened, annoying and delightful at the same time.

Yes, the second year of life is a dichotomy between love for life and fear of failing. Your young one cannot wait to do things by herself and refuses all supervision but at the same time internally fears that she will not get your approval. Growing up is hard work. It is not just gaining weight or stretching in inches but also mastering emotions, understanding the world around you, and conquering the fear of becoming separate from your parents. That is why the second year of life is filled with tantrums, tears and whining.

The second year is not only challenging for your child, it is also a period of growth for you as a parent. It pushes all your buttons. It triggers all your unresolved issues as a person and it challenges you as a parent. This is the parenting stage where you must explore your own upbringing to decide what is it that you value more: freedom of expression or respect for norms and conventions.

I can hear in my mind the collective answer: freedom of expression, right? So here is where I plant the seed for a future generation of loving, peaceful and generous adults. My mother always said that my freedom ended where my neighbor’s freedom began and that to keep a peaceful existence we had to respect each other. At 84 this very wise woman has many, many friends that love her very much.

That is what we hope for our children, that they grow up to be loving people and loved by many. The terrific twos is a challenging period in the life of the family. It is filled with wonder and sometimes frustration. The work of growing is arduous but rewarding.

Here are a few tips for parenting a toddler (or your own inner toddler because we all have one):

Know your boundaries ahead of time: there will be behaviors that you will never accept: kicking, biting, and hitting you or others.

Choose your battles: never argue with a toddler (she will always win) over superficial matters such as clothes or food preferences.

Strive for consistency and daily routines. Meal time and sleep time should be almost sacred.

Share your love and attention and praise her when she shares with others.

Parenting is all about creating boundaries and not about allowing the unlimited exercise of your child’s personality. The secret is to do it with love and a sincere desire to raise an adult with a generous heart.