Let’s face it, coming up with craft projects can be a hassle. Watch this episode of Clever Parents TV for pre-packaged craft kits for kids ages 18 months to 11, tips for hosting a puppy party and learning to live with things that bite (and no, we’re not talking about that pesky two year old next door).

See the vidcast.

• Read the Fun Well Done column on Clever Parents for fun and easy craft ideas
• Visit the Fun Well Done website at www.FunWellDone.com
• Visit the Living With Kids and Dogs column on Clever Parents
• Read the Living With Kids and Dogs article: Living with Kids and Dogs: A Puppy Party for Kid-Friendly Dogs
• Visit the Pediatrician’s Perspective column on Clever Parents
• Read the Pediatrician’s Perspective article: Pediatrician’s Perspective: Learning to Live with Things that Bite – Part 1
• See vidcast #30 on Clever Parents TV.

Summer brings a welcome break from winter’s colds and flu and springtime pollen, but it too has its perils. We share the outdoors in summertime with all manner of insects, arachnids, snakes (most are harmless, but if they’re not…), and sea and lake dwellers. With preparation and a little luck, we can all enjoy being outside. We share the earth with these creatures, and for the most part, they do us no real harm. In this article, I will talk about insects and arachnids. The next article will deal with snakes and jelly fish and other water-dwelling creatures that bite and sting.

1. Stinging insects

Prevention consists wearing lightweight clothing that covers well, avoiding scents (perfumes, scented laundry detergents and fabric softeners, etc.) and using insect repellent. DEET-containing insect repellents are effective and safe for children if they contain less that 10% DEET. They can be applied to clothing as well as skin. Be sure give your child a bath that night. Other repellents are permethrins, Bite Blocker (a 2% soybean oil spray), and Skin So Soft (that contains citronella).

Mosquitoes, flies, fleas.
“Bug bites” can be impressive, but they are mostly annoying. In our area there is essentially no danger of serious disease from these insects. As for the “bite” itself, there is often a small central blister with a mound of red swollen skin around it. It can look very much like an infection or a boil, but the area doesn’t hurt when pressed. You usually know the child has been outside and exposed. And most kids can tell you that it itches or you will see them scratch.

For itchy bites, try to treat them before they have been scratched open. You can hold a piece of ice or a cold wash cloth to the bite for a few minutes. If they haven’t been scratched open, you can put some 1% hydrocortisone cream (available over-the-counter) on them twice a day. For children over 2 years old, you can give them benedryl, especially at night. Keep the skin clean, the fingernails short, and watch out for infection.

Bees and wasps and their relatives, and stinging ants.
These bites hurt a lot. They almost always cause several inches of swelling and redness around the site of the actual sting that is very painful, especially when touched. This is a normal reaction (though not a pleasant one) and is called a local reaction. Sometimes a whole arm or leg is swollen. This is called a severe local reaction.

Treating a bee sting involves removing the stinger (wasps and others in this family don’t usually leave the stingers in the skin). Then for all these bites, apply a cold compress. Take ibuprofen for pain, and try applying calamine lotion, topical steroids, or a paste made of 1 part meat tenderizer (papain) to 4 parts water. Benedryl may also be helpful.

Rarely, one can have a systemic reaction—one that involves the whole body—called anaphylaxis or bee sting allergy. This is very bad and dangerous. It may show itself by a swollen face, lips and tongue; problems with breathing that sound like croup or wheezing; hives or welts or itching all over; and/or a funny sounding voice. Immediate medical care must be sought—usually Benedryl, Epipens, and 911. After someone has had a severe systemic reaction, he should see his doctor to make a plan to deal with future encounters. Usually, once someone has such an allergy, he will remain allergic to the kind insect that bit him and perhaps its relatives. It is worth considering seeing an allergist to be desensitized.

Caterpillars and moths
Most of these creatures cause us no harm at all, but some carry thousands of tiny hairs or spines which they deposit in our skin when they touch it. These can cause stinging pain and a local reaction. There is a visible “track” where the caterpillar walked across the skin.

The first step in treating this is to use scotch tape to remove the spines. Then for pain and itching, use cold compresses, topical steroids, and antihistamines.

Very rarely, they can cause a systemic reaction. Seek immediate medical attention if your child has trouble breathing, has swollen face, lips, or tongue, or has a funny sounding voice.

2. Arachnids
This group consists of spider, chiggers, and ticks, among other creatures. Many of us suffer from arachnophobia, but in fact most of these creatures would rather have nothing to do with us, or will only bite us if we contact them.

Spiders
Very few spiders are able to bite us, and most of those that can cannot harm us. No spider will seek us out to bite us. We humans are not their natural prey. So don’t kill spiders indiscriminately. They are an important part of our world.

But…

There are 2 species of spiders in our area that can cause severe health consequences: black widows and brown recluses. Though these spiders would MUCH prefer to leave us alone, if provoked they can bite, and sometimes the bites have serious consequences.

If bitten by a black widow, there is usually a self limited reaction. But sometimes about an hour after the bite, a systemic reaction can begin—muscle cramps, abdominal pain, sweating, salivation, high blood pressure, facial swelling. Although there have been no deaths in our country from black widow bites since 1958, these symptoms clearly require emergency medical care.

The brown recluse bite also has the potential to cause a severe reaction though they usually don’t. When the rare (but well publicized) severe reaction occurs, the victim can have a serious evolving wound which takes weeks to months to heal. Flu-like symptoms with vomiting and sometime a rash can develop 12 to 72 hours after the bite. Even more rarely, hospitalization can be required for the consequences of these bites.

Usually for spider bites, good wound care and observation will produce a good outcome.

Ticks
Tick bites can be serious, but (again) they usually are not. If your child (or you) is bitten by a tick, you should remove it, clean the area as you would for any minor scratch, and note the date and the size and markings of the tick. The bites themselves look and feel like any other “bug bite”: a pink bump that itches. They can last a long time, and if the child scratches them, they can get the same superficial infections that well scratched mosquito bites can lead to.

In central North Carolina, there are some serious tick borne diseases that are common enough that we have to think about them. The most concerning is Rocky Mountain Spotted Fever (more common in NC than in the Rocky Mountains!). If you have RMSF, you are quite sick. It starts with fever, headache, and muscle aches. After a few days a rash usually appears on the wrists and ankles, and then it spreads up onto the body. Untreated, RMSF can be quite dangerous. If your child (or you) gets sick with a high fever in the summer, see your doctor. There are other tick-borne illnesses that are similar to RMSF but don’t have the rash. These too need treatment.

Lyme Disease, carried by the tiny deer tick, is not very common in our area, but plenty of North Carolinians travel to areas where it is encountered, so we need to keep it in mind.

Chiggers
Chiggers are the nymph form of tiny mites that hang out on briars, bushes, and grasses hoping to find an animal host to attach themselves to. They feed on the host (for example, you) for 4 days and then fall off. While feeding, they, like other stinging pests, inject juices that cause your body to react with a small red welt that is astoundingly itchy. They often bite along the places where clothing is tight, for example, along the waistband or where elastic circles the thighs.

Like mosquitoes, they are more likely to avoid you if you use insect repellent and are well covered. And after picking roadside blackberries, give the pickers a good bath with lots of scrubbing. Since chiggers can survive on clothing for an extended time, be sure to wash all exposed clothing in hot water. And like mosquito bites, they can be treated with hydrocortisone creams and oral benedryl.

So….
Play outside, wear your repellant, have fun, don’t scratch, and be mindful of but not overly worried about the possible health problems.

I believe that nothing gives parents more pain than watching their child face pain, especially medical pain. Even relatively small things—shots, bleeding cuts, stitches—give parents (and of course children) a hard time. When more daunting things are happening—surgery, serious illness, serious injury, or hospitalization—most parents are going to be suffering a lot. The child’s pain actually hurts you, his fear frightens you. Your children are the most important things in your life, and they are in peril. No wonder you are hurting. I don’t know many parents who wouldn’t gladly undergo twice the pain their child was facing if it would spare their child.

So it is a cruel irony that the most important gift you can give a hurting or fearful child is your strength and confidence, your absolute certainty that everything will be all right, that they can handle it, that the situation is under control, that you will make sure that they are all right, that you will be with them whenever possible, that the medical personnel have only their best interests at stake, and that they are wonderful and have your complete confidence. No matter what you’re feeling.

Projecting this existential stance is a tall order when you are somewhere on the spectrums of frightened, angry, ambivalent, conflicted, guilty, sick yourself, or whatever. It’s not easy even when you are confident that you are doing the right thing for the right reasons with the right people, simply because it’s upsetting when your child is upset.

Taking Charge of Yourself

To master the support role so vital for the parents of a hurting or frightened child, you need to take charge of your own emotions. You will feel, of course, what you feel, but you don’t have to display those feelings. You cannot be too wounded-acting yourself, and you can’t be too engulfing or too pitying toward the child. Indulging in the expression of your feelings of fear or uncertainty adds tremendously to the burdens that the child feels. Nothing is more frightening to a child than a frightened parent. And your display of fear or anguished pity authorizes his acting out his feelings of fear or desperation, which can easily snowball into panic or at least interfere with whatever needs to be done as expeditiously and carefully as possible. A parent in control also serves to relieve the child of the whole burden of self control. If he is thinking “I can’t do this, I can’t hold still for this, I can’t keep from trying to escape”, the parent is ready to supply the control. “I’ll help you hold still so it will hurt less and so it will be over sooner.” And then firmly though lovingly she contains the child and facilitates the procedure.

When a child sees the confident parent come in, there is such visible easing of the child’s distress. We had a little girl come in with her aunt. She had cut herself deeply in a scary accident, and her mother had not been at home. Of course, she was very upset, and it was almost impossible even to examine her and clean the laceration. Finally, her mother arrived, confident and calming, and the transformation was amazing. She cried more, but she visibly relaxed, and we were able to clean and stitch her wound.

How to Help—Some Suggestions

There are many ways to help a hurting or frightened child; a few are listed here. Some are more helpful in a given situation than others.

Acknowledging—If your child is giving you clear signs of pain or fear, acknowledge what he is experiencing. “I bet that hurts.” “I think anyone would be scared about that.” “I don’t think I’d like that either”. But don’t suggest fear or pain, and don’t undermine your child’s effort to be stoic or to cope with the fear.

Reframing—Try putting a positive spin on something that worries or hurts a child. One little boy was going to have surgery. At the pre-operative appointment, he encountered masked men in green suits (surgeons). He told his mother that he was scared of the men in greens suits. She said, “Oh no. They’re good guys. They will help you. They wear the green suits to keep germs off you.”

Don’t overload—Too much information can overwhelm, and giving it too soon can allow prolonged and unnecessary worry.

No promises—Never bargain, never promise. Some things have to be done, and no one can anticipate all that will happen. Never say that there will be no shots or no pain unless you are at least 1000% sure that there won’t be. “I’m not sure exactly what will happen, but I’ll be with you, and we’ll handle it together.” “We’re going to the right place to get this fixed. You will be all right. We’ll be with you.”

Don’t ask—When faced with a necessary medical event, never burden the child by asking his approval or by giving in to his protests. That gives the child power he knows he shouldn’t have.

Don’t deride—Never belittle your child. Never say “Don’t be a cry baby” or otherwise diminish him. Be low key, positive, and reassuring about his ability to get through this.

Interpret—Keep a running commentary of what is happening. It helps the child prepare himself for the hard parts, and relax (a little) during the less difficult parts. “This is the cold part …this is the tickly part …this is the hurting part.”
Looking to the future—Keep an endpoint is sight. “In 3 minutes/ in an hour/ in a month/ in a year….” During brief procedures, count or count backwards, or sing a song. For longer or repeated matters—like hospitalizations, dressing changes—mark the event or the day off on a calendar or have a small ceremony each time (a ritual chewing of a piece of gum, applying a small sticker to a notebook)

Recapping—Talk about the painful/frightening event after it’s over, praising the child. “Hey, you did it.” “That was rough, wasn’t it? But you made it. I’m proud of you.” Remember, fear is OK, crying is OK. Getting the thing done is all that matters.

With tiny babies and toddlers and non verbal children, talk positively and supportively and give them good physical containment. Positive talk helps them and helps you too, and they will hear and feel the reassurance. And they will learn to understand.

And for the very young or nonverbal, it helps sometimes to keep recurrent painful experiences separated from other experiences. Don’t do painful dressing changes in the same place you change the diapers. If you do, diaper changing will become frightening too.

So …

To help your child get through difficult encounters with fear and pain, model calmness, sureness, and positiveness. Keep your own (very understandable, but counter-productive) fear and pain and pity (for him and for yourself) under tight control. Be quietly optimistic. Be someone to hang onto, the stable and safe place in a frightening world.

If your child is in quicksand, you don’t jump in and sink with him. You offer him a hand and pull him out.

There are coughs and there are coughs. Some are annoyances, some signify important health problems, some interfere with sleep. But few coughing illnesses can compare with whooping cough, a disease that had become uncommon but that is now making a comeback.

It is exhausting to have a cough for a few days. But whooping cough has been called the 100 day cough. Can you handle one that lasts for months, or watch your child in an awesome display of desperation and air hunger as he tries to fit a breath of air into the paroxysm of coughing? Over and over, day after day, the whoop, the exhaustion. It’s a scary disease and can be a deadly disease, especially for the very young.

Whooping cough is back.

Back in the olden days—the 1930s and 40s—thousands of American babies died each year from whooping cough (whose medical name is pertussis, caused by a bacteria called Bordetella pertussis). With the advent of immunization, whooping cough became very uncommon. In 1976 there were only 1000 cases reported in our country. But the number of cases has steadily increased, and in 2005 there were 25,000 cases in the USA. Even now whooping cough leads to many hospitalizations and even deaths from asphyxiation, stroke, seizures, pneumonia, collapsed lungs, broken ribs.

The signs of whooping cough
In the past weeks, several cases of pertussis have been reported in the Triangle area. In older babies and children it starts with what seems to be a regular cold with an unremarkable cough. After a week or two the cough gets much worse. There are coughing spells or “paroxysms” that are often ended with a “whoop” as the child tries to pull air into his lungs at last. This stage can last for 6 weeks of longer. Then there is a convalescent stage when improvement starts. This stage can last weeks to months.

Very young babies—under 6 months old—may not present with the typical coughing spells and whoop. Sometimes they just act sick and have periods when they don’t breathe. The very young baby—0 to 3 months old—almost always needs to be hospitalized. Whooping cough is most common and most severe in these youngest babies, and this is the age-group in which most deaths occur. Older children and adults who were immunized as young children may also have a milder disease, but they can still give regular old whooping cough to others, will have a prolonged and significant cough, and will undoubtedly miss work or school.

How we get whooping cough
Whooping cough is very contagious. It is spread from person to person on respiratory droplets broadcast by coughs and sneezes. About 7 to 10 days after exposure, the next victim can come down with whooping cough. Whooping cough is most contagious during the earliest weeks—before the whooping begins—and it remains contagious for at least 6 weeks.

Although whooping cough can be tested for and to some extent treated, it is so like an ordinary cold in its early (and most treatable) phase that we often don’t think of testing for it. Treatment, if begun in the early stage, can make the disease get better sooner and it can reduce the chances of it being spread to others. Treatment begun later—after the cough becomes paroxysmal—will help prevent the spread of the disease, but the cough will persist.

Whooping cough in the Triangle
Dr. Fred Henderson of the division of Pediatric Infectious Diseases at UNC says that we always have some whooping cough around here. The reservoir is older children, teens, and adults, because their immunity has waned. The immunity achieved after getting immunized or getting the actual disease become becomes ineffective to fight off whooping cough after 5 to 15 years. The older children and adults, with their partial immunity, suffer a less severe illness than tiny babies, but it is still a significant and very distressing and exhausting disease, with loss of work time or school time and the potential for serious complications.

Prevention
Young babies can only be protected by reducing exposure, at least until they can be immunized themselves. Whooping cough immunization is part of our standard immunization program, with shots at 2, 4, and 6 months, 15 to 18 months, and 4-5 years. Though no immunization is perfect, these shots are pretty effective at containing whooping cough from mid-babyhood to late childhood (when the immunity starts to wane).

In the last year a new immunization has been introduced that can boost immunity in teenagers and adults up to age 64. It is called Tdap (tetanus, diphtheria, acellular pertussis) and can be given in place of the old Td shot, the regular old “tetanus shot.” This is great news for 2 reasons: teenagers and adults will be much less likely to get whooping cough themselves (and if you have had a bad cough of any kind lately, this will be welcome news), and the teenagers and adults will not be sources of infection to tiny babies. Dr. Henderson stressed that all new parents should get the Tdap to protect their vulnerable newborn. Anyone who works with young babies should also get the booster, and of course anyone who does not think they would enjoy several weeks of a terrible cough.

Whooping cough is coming back, but we don’t have to welcome it. We have the tools to stop it. Since it’s hard to diagnose—for the first week or so it looks like any other cold, and the test for pertussis is somewhat unpleasant—prevention is key. We can continue immunizing babies and now we can immunize everyone (up to 64 years of age). If a baby cannot be immunized for some reason, it is doubly important that parents and other older people in the baby’s world get immunized.

What happens when we get an ear infection?

Ear infections occur in the middle ear—the part of the ear that has the little bones that conduct the sound from the ear drum to the inner ear. The middle ear is a small, completely enclosed chamber with a tube (the Eustachian tube) that is able to open and that connects to the back of the throat behind the nose. When things are going well, the chamber is filled with air and the tube can open and allow the pressure inside the middle ear to be equal to outside air pressure. The tube also opens and closes to allow the middle ear to keep itself clean and empty.

But there are several ways that problems can occur. The nearby nose and throat are full of bacteria that have been trapped there as they try to enter our bodies. These bacteria live in uneasy harmony with us, but they are always ready to infect us if they can find a way to do so. Some of these bacteria will find their way up the tube to the middle ear, but in a healthy person with a fully functioning response system and Eustachian tubes, the bacteria will be repulsed or killed.

So ear infections happen when an environment is created that allows the bacteria to get into an area where it will be safe, where it can grow and expand and “raise a family”. That area is often the middle ear. Most commonly this occurs when we have gotten a cold. The cold virus weakens our ability to fight off bacterial infection in many ways. And the virus irritates the linings of our nose and throat. The irritation can make the Eustachian tubes function poorly. Tonsils and adenoids get large in an effort to fight off the virus, and so they too can block the function of the Eustachian tubes.

Now we have irritating viruses and possibly irritating bacteria in our middle ears. Just as our eyes and noses pour out fluid to wash away irritating substances (the runny nose of a cold, the tearing eyes when exposed to smoke), our ears produce fluid which they hope will wash away the bacteria. Also, a blocked Eustachian tube prevents the entry of new air, and after a while, the oxygen in the air in the middle ear is used up, creating a vacuum and causing the ear to produce fluid to compensate for that vacuum.

The bacteria now think they are in heaven. They have warm fluid with lots of nutrients, and they can flourish. But our body is gathering its resources. It increases the blood flow to the area (so the ear looks red). It may give us a fever to make things uncomfortable for the bacteria. It sends certain blood cells to the middle ear to fight the invaders, which makes pus. Things are getting pretty crowded now, with the fluid, the growing bacteria, and our cells that have come to fight. The eardrum bulges and there can be significant pain if the bulging has come on rapidly. Pain is also caused by the bacteria’s action on our tissues and by the resulting inflammation.

Usually it all ends happily for us. People with reasonably good immune systems—and that is almost all people—will ultimately recover in most cases. Very occasionally, however, there are complications that can endanger your hearing, your health, and even your life.

Babies and toddlers get far more ear infections than older children and adults. Why is that?
There are lots of reasons why ear infections are so much a part of many young children’s lives. They get frequent colds, both because they are immunologically immature and because they are meeting the cold viruses for the first time and haven’t yet made the cells to fight them off. Many children are in daycare or group activities that expose them to colds. (Though if they aren’t in daycare, they will meet the viruses later and will need to learn how to deal with them then.) Tubes, spaces, and passages in babies are smaller and easier to block.

There are lots of reasons why ear infections are so much a part of many young children’s lives. They get frequent colds, both because they are immunologically immature and because they are meeting the cold viruses for the first time and haven’t yet made the cells to fight them off. Many children are in daycare or group activities that expose them to colds. (Though if they aren’t in daycare, they will meet the viruses later and will need to learn how to deal with them then.) Tubes, spaces, and passages in babies are smaller and easier to block.

The “architecture” of a baby’s ears, nose and throat is different from an older child’s or adult’s. In an older child, the Eustachian tubes have a down hill course, so gravity helps them drain. In babies, the middle ear and the point where the Eustachian tube enters the back of the throat are nearly level, so they drain less well. It is possible that sleep position, reflux, and feeding positions can increase the irritation at the exit of the Eustachian tube and make it function less well. Allergies are a lot like colds in their effects on the throat and nose, and like colds, they can produce an environment that makes ear infections more likely.

Inherited predisposition may play a roll. Many families report that one or both parents had a particularly hard time with ear infections. Their child is probably at greater risk.

What to do about ear infections.
Like many problems involving our health, it is not easy to decide what to do when a child develops an ear infection. There are lots of options: no treatment, pain relievers, antibiotics, tympanocentesis, Pressure Equalization Tubes (PE tubes). Most children will do fine no matter what we do, but it isn’t easy to pick out in advance the children who will go on to have serious complications.

There are pluses and minuses with every course of action. When I was a child, ear infections were not treated. Most children did well, but many didn’t. Those who didn’t got permanent hearing loss, chronic active infections, destruction of their ear structures, mastoiditis, meningitis, but there are many differences between then and now. In those days there was almost no daycare and societal patterns were very different, so children did not get infections as early as they do now. There was less antibiotic resistance (good), but fewer antibiotics to treat complications effectively (bad). We now have immunizations that can prevent serious invasion of some key bacteria that cause meningitis (good). We also now have more mothers breastfeeding. Breastfeeding reduces the number of ear infections but does not prevent them all. And there are probably many other changes in our world that impact the patterns of ear infections that we either don’t perceive or don’t perceive the importance of.

Ear infections, even uncomplicated ones, cause pain and fever and disruption of sleep and behavior and family schedules and obligations, and that can be pretty miserable for every one. Prolonged or recurrent ear infections undoubtedly reduce hearing acuity for the duration of the infection and recovery period (that can extend for weeks to months), and this could possibly impact speech and language development.

We—both parents and pediatricians—want to fix things. What should we do? Studies are done and experts confer. Guidelines are drawn up, changed, and drawn up again. We worry both about antibiotic resistance and how we’ll live with this child until he gets better. And what are the chances of complications?

So
I recommend Antibiotic treatment if the baby is under 1 year old, all babies and children with other health problems that make it harder for them to conquer the infections, babies and children whose have a history of significant problems with ear infections (for example, perforation of the ear drum, or febrile seizures), and children who respond well to treatment and whose parents desire it. If we elect not to treat a baby or child, it is important to see him in a day or two to be sure he is not getting sicker. As we get to know a baby or child, we know if he clears up quickly with antibiotics or if he needs more aggressive therapy. If a child has recurrent or persistent ear infections or persistent and prolonged (uninfected) fluid in his ear, we may recommend exploring the option of PE tubes with an ear specialist. For all children who get significant or frequent ear infections, we will need to pay close attention to speech and language development and other signs that the child is not hearing well. We are also lucky that we have the immunizations against the two most common causes of meningitis in babies and young children—Haemophilus influenza B and Pneumococcus—and hope all babies are getting them.

Q. What is cradle cap, how can it be avoided and how do you treat it?

Cradle cap is a form of seborrheic dermatitis, a skin condition that causes yellow crusty scales to appear on the skin. In babies, it usually occurs on the scalp and behind the ears. Sometimes it can also involve the eyebrow and eyelid areas. Rarely, it can be an extensive rash on much of the body. When it just involves the head, it is usually mild, not life threatening, not scarring, and will usually resolve by about 1 year of age. The causes and cures of cradle cap are not well studied and not well understood, and for this reason, there are a multitude of conflicting recommendations and cautions about its management.

The causes:
There seems to be a certain fungus that either causes the cradle cap, or likes to grow in it. It has the rather silly sounding name Malassezia furfur. And cradle cap and seborrhea tend to run in families, so there is probably an inherited predisposition to get it. Since it is “outgrown” at about a year of age, there may be a component of immune insufficiency that resolves as the immune system of the skin matures.

Avoidance:
It is unlikely that it can be avoided by any maneuvers known to us.

Treatment:
It is a legitimate option to do nothing but wait for the cradle cap to go away. But if the skin condition worsens and causes breaks in the skin and which would allow super-infection, I think it is worthwhile to try to treat it.

Keeping in mind that most cradle cap treatments are products of our Culture, not of our Science, and thus have the status of folk remedies, there are some things to do that seem to work for many people and babies.

I usually recommend to those who have failed to improve by washing the scalp with baby shampoo that they try the following every other night:
1. Rub baby oil into the scalp and behind the ears and leave it there for about an hour.
2. Wash the baby’s scalp and behind the ears with Selsun Blue shampoo.
Be very careful not to get it into the baby’s eyes. Rinse well.
3. If irritation occurs, or if the scalp looks worse, stop whatever you are doing.

And my usual closing remark: If the cradle cap is very concerning to you, bring it up with your pediatrician. Every once in a while, seborrheic dermatitis is associated with serious conditions.

Q. What is the best way to treat a diaper rash?

Diaper rash is usually caused by irritation and/or yeast. Changing the diaper soon after soiling or wetting, gentle cleansing with a well-tolerated cleanser, and application of barrier creams, such as Desitin or A&D ointment, and/or anti-yeast creams such as Nystatin, can be helpful. Soaking in a warm bath or exposing the area to the air can also be helpful and soothing to irritated skin.

But as with everything in medicine, there are occasions where a diaper rash may be more concerning. Sometimes the irritated skin can get infected and will need other treatment. Sometimes the rash may be the sign of an illness that may or may not be important. If the rash does not improve with the above care, it would be a good idea to see the baby’s pediatrician. If a child is having a rousing case of diarrhea, you can be sure you are going to be dealing with diaper rash despite your best efforts as long as the diarrhea persists. Prolonged diarrhea (10 to 14 days), bloody diarrhea, diarrhea associated with fever, or diarrhea that has resulted in dehydration should suggest a trip to the pediatrician.

Q. What tips do you have for parents with newly potty-trained children regarding occasional nighttime bed-wetting?

The short answer is: Don’t do anything and don’t worry about it. Down-play it and deal with it. “That happens sometimes. Don’t worry about it. Let’s clean it up.” Sometimes it is helpful to cut down on late evening fluid intake. Some people find it helpful to get the child up to urinate before they go to bed.

The longer answer involves thinking about other factors:

How occasional is ‘occasional’? Many children become day trained long before being night trained. Don’t martyr yourself on a pile of laundry. Put him back in pull-ups (very matter-of-fact-ly, not as a punishment) and wait till he is usually dry at night to try again. Low-key, small rewards for dry nights may add some incentive in borderline cases.

How long has he been toilet trained and how long has he been dry at night? Recurrence (as opposed to persistence) of nighttime wetting can signal urinary tract infections or can be a response to significant stress. If these are concerns, see your child’s pediatrician.

One of the most distressing illnesses that commonly strike children (and other humans) is vomiting.

No one likes to vomit, and no one likes to deal with someone who is vomiting. But like most physiologic responses that have been around (we assume) since the beginning of mammals, vomiting has important disease-fighting or life-sustaining functions. We mammals use it to empty a non-functioning GI tract, or to rid ourselves of things that we have eaten but cannot tolerate. Vomiting must be an important piece of our ability to exist, because there is even a “vomiting center” in the brain that when stimulated causes us to vomit.

But despite its helpful role, like other disease-fighting responses (such as fever and inflammation), vomiting can be dangerous if too extreme or too prolonged.

The most concerning negative effect of vomiting is the potential for dehydration. Other concerns are changes in the body’s balance of chemicals and little tears in the esophagus from the violence of the act of vomiting. Vomiting is also often a sign of disease in the vomiter, and it may accompany any number of illnesses from “stomach flu” to strep throat to ear infections to appendicitis to profound metabolic problems.

So your child has vomited. What should you do? What should you think about? Should you call the doctor? Should you go to the doctor? Can it wait till morning? Can it wait till Monday?

Vomiting is usually not an emergency. The most common cause is gastroenteritis or “stomach flu.” This can usually be managed at home.

The most important thing is to pause and assess. Don’t rush to replace the lost fluid or the vomited food. It won’t work. His stomach has just sent you a message: “I want to be empty!” Don’t try to give him anything by mouth for at least 30 to 60 minutes.

Ask yourself:

Is your child in pain? Does his stomach hurt? Does his head hurt? Does he have a fever? Is he normally “tuned-in” and aware for his age and the time of day?

As the day progresses and if the vomiting continues or is joined or replaced by diarrhea, start thinking about whether he has lost too much fluid, whether he is looking sicker.

Dehydration
The younger the child, the more quickly he can become dehydrated. A fever increases the potential for dehydration. But it takes hours at least to become dehydrated. A few vomiting episodes are not going to cause dehydration.

The signs to look for are: thirst, urinating smaller amounts and less frequently, dry mouth, no tears when crying, fontanel sunken more than usual, sunken eyes, ill and washed out appearance, limpness and lack of energy.

Management
After giving your child’s stomach a chance to rest, start cautiously to give fluids. The best fluids are the electrolyte-containing fluids because they are the easiest to absorb.

Babies should be given ½ to 1 oz of oral electrolyte fluid (such as Pedialyte) every 15 to 20 minutes. If they vomit again, give them another 30 minute rest and then give 1 to 2 teaspoons every 10 minutes. If they tolerate an amount for an hour, they can get more the next hour, but go slow. After 8 to 12 hours without vomiting, you can let them breastfeed or formula feed small amounts. If appropriate, you can give food but keep the amounts small and the food bland.

Older children can have oral electrolyte fluids as well as other clear liquids or ice chips. Start with small quantities (1 to 2 ounces) with 15 to 30 minute breaks. If they continue to vomit, again give nothing for 30 to 60 minutes and then try again with half the amount twice as often. After 12 hours without vomiting, cautiously introduce bland foods.

Sleep is a great anti-nausea agent. But keep a wastebasket or basin by the bed for further episodes.

Take your vomiting child to the doctor
If you are very worried.
If your child has severe abdominal pain or severe headache or severe sore throat.
If your child has more than a day of fever.
If your child seems sicker than you expect.
If you think he is getting too dehydrated.
If he is a baby under 2 months old with persistent vomiting.

What are good questions for expectant parents to ask in selecting a pediatrician for their new baby?

• Experience: You can ask about the pediatrician’s training and experience and areas of interest.
• Compatibility: Try to find out if you are philosophically compatible.
• Availability: Find out how to get in touch with him/her at various times of the day and night and how you can deal with emergencies. As you talk, assess his/her ability to communicate. It’s important to get someone who understands you and who talks so you can understand him/her. Definitely choose someone you like.
• Ask Others: It is also wise to ask others about their experiences with that physician/practice. You can also learn a lot through observation.
• Environment: Other things to consider are the physical environment of the practice. How are you treated by the staff? Are interactions with patients age-appropriate? Often you can get a “feel” for the doctor/office by taking a tour.

What are the most common sports related injuries in children? What can parents do to help their kids avoid injury?

The most common injuries are sprains, cuts, bruises, simple fractures, and overuse problems. Most are not particularly dangerous to the child or his/her sports future. Concussions and other head injuries, neck injuries, and injury due to overheating and dehydration, while less common, can be quite dangerous.

Preventing serious sports injuries requires a many-pronged approach. The good thing about organized sports is that they are organized! They have set rules, playing fields and protective equipment. And children who participate in them develop their skill and their muscular strength which makes them less likely to be injured. Strive for a healthy level of competition and have realistic goals for accomplishment. Make sure that the coach understands children and their strengths and limitations as well as he understands his sport. Many injuries occur when children are pushing themselves beyond their skill or comfort level. Be sure your child has proper and well maintained equipment and clothing, including appropriate shoes that fit well and are tied.

Dehydration and heat related injuries occur when children lose more fluid than they ingest. Frequent breaks to cool down and drink water will prevent problems.

Pre-participation physicals are required by most middle and high school teams, and they are a good idea of you have any concerns about the sports-worthiness of your younger child.

Parents can help prevent injuries by encouraging their child’s regular participation in physical activity, providing them with appropriate clothing and shoes and planning schedules to prevent a rushed or frantic afternoon. Be sure your child gets in shape intelligently but don’t let him over-train. If your child gets injured, get proper evaluation and rehabilitation, and give him time to heal before her resumes full participation. Most important of all, let your child set the pace and determine his/her strengths and interests. Don’t push them beyond their ability or comfort level.

Now that school is back in session, what can parents do to help avoid spreading germs?

Whenever people encounter each other they can easily pass germs back and forth. Most of them are relatively benign, but some can cause significant and even serious disease. You can protect yourself to some extent from those germs that cause disease by frequent hand washing and by keeping hands away from your face and nose and out of your mouth (not an easy thing to do). To protect others, again wash your hands often, cover your mouth with your elbow when you cough or sneeze, discard Kleenex appropriately, and keep your children home when they are sick. Avoid crowded rooms and flying on airplanes, especially during winter and cold season.

But also, trust your child’s body. In childhood, we meet numerous viruses and bacteria, and thus our bodies can learn how to fight them off. Children often do much better with diseases than adults do, and childhood is the time to arm oneself against many diseases for life. If you live in a bubble, you might not get sick, but you won’t learn to protect yourself either.

So pace yourselves. Take care of yourselves when you are sick. Live so your body is equipped to respond well if a disease does infect you—good nutrition, good rest, good exercise, good fun, not too much stress. And be wise. Some people, and all people at some times, need to avoid certain diseases. Some people have degrees of impaired immune function that make them especially vulnerable. Some diseases are too dangerous to risk getting. If you find that your child is not handling an illness well, seek medical attention.

What can parents do to minimize school anxiety in their children, especially those who are just starting?

Every one experiences some anxiety when starting something new, so it is not surprising that someone starting kindergarten or starting in a new school is going to feel some concerns.

The basic response should be low key and positive, but can also acknowledge the child’s concerns. “It is scary to start something new, but in a few days you’ll know just what to do.” Make sure you project no anxiety about it yourself. Parents often have mixed feelings about sending their child out into the world. I remember bursting into tears as the school bus pulled away when my daughter went to Kindergarten.

Give the child strategies to cope with problems. “If you need to use the bathroom/you forget what bus you’re on/you didn’t understand what you are supposed to do, tell the teacher or the aide.”

Persistent anxiety is a little more difficult. Sometimes the child is anxious or worried about losing contact with the parent, not being at home. Before school, show the child as you give a big showy kiss to a Kleenex, then let the child take it to school and hold it to his face “to get a kiss” whenever he is missing home. Or let him take a small possession of yours to school. It can be a reminder for the day.

Every once in a while, there is a good reason for the child’s anxiety—a bully in the class room, some expectation that the child simply can’t meet. Sometimes the child can tell you what’s wrong. Sometimes you can talk to the teachers and get a feeling for how distressed your child really is and what’s causing it.

Many schools like parent involvement in the classroom. Some will let you observe. In some you can join your child for lunch. Your presence can reassure the child, can give you a better idea of what is going on, and can be very helpful to the teachers.

Older children often stress about meeting the demands of a higher grade. Keep expectations reasonable and kind. Offer support and assistance as indicated.

While just about anyone will benefit from a flu shot, those at highest risk—children less than 5 years old, the elderly, and those with many common chronic health conditions (for example, asthma, heart problems, diabetes)—should definitely be immunized.

The very best way to protect yourself from the flu is to get a Flu Shot.
Like most immunizations, flu shots work on the principle that if your body meets a part of a disease organism—a piece of a virus or bacteria that is itself altered so that it can’t cause disease—then your body can get started on the process of responding, by making antibodies, the little biochemical agents that are an important part of our immune response. Then when the real thing comes along, your body already has custom-made warriors to combat that disease. The process of making antibodies is a long and complicated one that takes weeks to accomplish.

But flu shots cannot guarantee that you won’t get the flu.
Seeing the Future
Creating the right flu shot, the right mix of virus pieces for any year’s flu shot, requires a crystal ball. We need to figure out which types of flu are going to come to our country in the next year. But since we can’t see into the future, we turn to epidemiologists and experts in infectious diseases to tell us what strains of influenza are most likely to affect us each year. Sometimes their predictions are good, but sometimes they are not. Sometimes an unanticipated strain makes it to our shores, and then we have more widespread flu outbreaks.

Individual response to the vaccine
And no immunization is 100 % effective. If you give 100 normal people one flu shot in a given year, between 10 and 40 of them will not respond and they will not be protected.
People who have a suboptimal response to the flu shot might get a milder case than they would have had they not gotten a flu shot at all. Children under age two still have immature immune systems, and may not be able to make as good an immune response as older people. And elderly people may lose their immunity faster than younger ones.

Immune response takes time
Even if you are going to respond to the flu shot in the desired way, it takes about 2 weeks to achieve immunity. But every additional day your body is able to work on its immune response to the virus pieces in the shot probably gives some benefits when you are exposed to the flu itself.

Herd immunity
Children under 6 months of age cannot receive flu shots, some people do not have an adequate immune response to the flu shot, and some people don’t get the flu shot. But all may not be lost. If enough people around them get flu shots, the unvaccinated or under-vaccinated are less likely to be exposed to the flu, and so are less likely to get infected. And for a disease to spread, it has to find another person to spread to before it has been recovered from by the initial victim. If there are only a few or only widely scattered people who can get the flu, the flu will have a hard time finding new hosts, and may die out. These factors contribute to “herd immunity.” This concept explains why we vaccinate those who live with or work with babies. And it reminds us why diseases spread better in crowded conditions.

Other ways to protect yourself
Many times in recent years there have been problems getting enough flu shots for the people who need or want them. And many people chose not to get them or can’t afford to get them. Of course, there are other ways to protect yourself, the most obvious (and most effective) being hand washing and the avoidance of crowds. Certain medications can be taken during periods of exposure to prevent getting the flu.

How do you know if you’ve gotten the flu?
The flu is a very significant illness. It usually comes on suddenly—over hours—and you feel like you’ve been hit by a truck. Classic symptoms are fever, headache, red eyes, runny nose, sore throat, cough, and muscle aches.

Ways to treat flu
And if you do get the flu, unless you have some serious underlying health problems, you will probably do fine if you use common sense, take it easy, and remember not to expose others. For children, aspirin-containing products should be avoided, because they can cause severe complications. It’s OK to use acetaminophen or ibuprofen for fever control and comfort. There are quick and easy tests to diagnosis flu, and there are medications that can treat it. These medications have to be started in the 1^st two or three days to be effective, so if you are really suffering, see your doctor quickly.

Margaret Morris, MD
September 25, 2006