Forest Lane Pediatrics Articles

AAP Updates Screen Time Recommendations for Children


The AAP has revised its recommendations regarding screen time for children and there are 4 main takeaways:

– Video chat does not count as screen time

– Screen time is ok for children 15 months and older as long as a parent is engaged with the child while watching the screen

– Children aged 2-5 should have a max of 1 hour of screen time per day

– Sesame Workshop and PBS kids can be trusted to have evidenced based educational media for children

For more information about the new recommendations check out this article.

Insect Repellent Guide


Keeping kids safe from mosquitos and other biting insects can be a challenge in the summer months. To keep your kids safe follow these helpful tips:

  • Keep your child’s play area free of stagnant water
  • Dress your child in lightweight pants and long-sleeved shirts when playing outside
  • For infants place a mosquito net over the carrier or stroller when outside in mosquito infested areas
  • For infants who are not yet crawling, an Off Clip can be used in close proximity to the child instead of spraying insect repellent on the child

For children who are mobile enough that an Off Clip is not effective, the following insect repellents are recommended:

  • DEET
    • The best mosquito repellent available
    • Recommended for children ages 2 months and older
    • Recommended to only apply once per day
    • Best to use 30% DEET like Deep Woods Off as it lasts longer (5 hours) than a 10% DEET product like Off Family Care (2 hours) and is just as safe
  • Picaridin
    • Similar effectiveness to DEET
    • Recommended for children ages 2 months and older
    • Recommended to only apply once per day
    • Maximum available concentration is 20%.
    • Refer to product label for duration of effectiveness
  • Oil of Lemon Eucalyptus
    • Natural product
    • Recommended for children ages 3 years and older due to skin irritation
    • Similar effectiveness to DEET
    • Ok to reapply
    • Refer to product label for duration of effectiveness

Safe Sunscreens for Children


There are a lot of sunscreens that advertise they are for children, but not all of these sunscreens contain ingredients that are considered safe for children. Every year the Environmental Working Group publishes sunscreen safety ratings. Click on the link to find out if your sunscreen is safe to use on your child.

We recommend the following for safe effective use of sunscreen:

  • Use mineral-based sunscreens. These will have the active ingredients Zinc Oxide and/or Titanium Dioxide
  • Avoid sunscreens with the active ingredient Oxybenzone
  • California Baby, Garden Goddess, and Blue Lizard are easy to find mineral based sunscreens
  • Sunscreen should only be used on children 6 months and older
  • For children under 6 months, use clothing and shade to protect them, however, it is ok to apply sunscreen to small areas like hands and feet that that can’t be covered by clothing
  • Apply sunscreen 15-30 minutes prior to sun exposure
  • Reapply sunscreen every 2 hours
  • An SPF of 15 to 35 is sufficient for most people
  • An SPF greater than 50 does not provide any additional protection

Tips for Returning to Work & Pumping



The first thing to know, is don’t make yourself crazy trying to store milk! You only need enough milk for two days’ worth of feedings (amount of time you are away from baby while you are at work). The first days’ worth of milk will be used the first day back at work. The rest is for emergencies—someone spills milk, or your supply drops a little for a day or two due to stress of returning to work. It can happen, but know it’s normal and your supply should bounce right back! When you’re pumping at home to build up your supply and a stash of stored milk, pumping once a day is plenty. The best time of day to pump is after your first morning feeding. Once you have enough milk to start introducing bottles, we recommend that you introduce the bottle within the first month—between 3 and 4 weeks is ideal. Just remember that when someone else gives a bottle to baby, you will need to pump in place of that feeding. You can then use that pumped milk for the next bottle feeding. Try to give baby a bottle at least every other day in order to make sure that baby will still take a bottle when you start back to work.


Once you go back to work, the common guideline is to pump one time for each missed feeding. In general, this works out to about 3 times in a standard 8-hour work day. We know that all situations are different. If you have questions, please call us and we can help you figure out a schedule!


Generally, you should pump until no more milk is flowing, or for increasing supply, pump a little while longer after the milk stops flowing. But, in general, pumping for 15 minutes should do it for most people. If you do not have enough time for longer pumping sessions, short frequent sessions are effective as well.


• Start with a short week: Arrange for your first week back to start on a Wednesday or Thursday. The first days back are always overwhelming, so starting with a short week will keep you from getting too tired. It also gives you a chance to practice pumping for a couple of days, without the intimidation of a whole week looming ahead of you.

• Invest in a hands-free pumping bra. This can make pumping much easier! There are many brands on the market to choose from, but our lactation consultants like the Simple Wishes pumping bra.


• Look into renting a hospital-grade breast pump.

• Nurse frequently when you are at home with your baby.

• Some mothers find it helps to take some time to prepare for pumping. Try using relaxation techniques, breast massage, and warm compresses for a few minutes before pumping. Stress and tension, as well as cool body temperature, can inhibit the milk ejection reflex and make pumping less productive.

• More short pumping sessions are more efficient than fewer longer ones.

• Make sure you’re eating and drinking enough, and get plenty of rest and breastfeeding time in when you and your baby are together.

List of tips compiled by Janis Wilbert, IBCLC & Paige Keates, IBCLC

What is Grastek?


Grastek is a new therapy designed to control grass pollen allergy in children over 5 years old. We have known for some time that grass pollen allergy can be controlled with immunotherapy (allergy shots). Forest Lane offers both allergy testing and allergy immunotherapy (allergy shots) for children and adults over 5 years old. Grastek is a new choice in the treatment of grass pollen allergy and has similar results to “grass pollen allergy shots” but without any injections. The therapy consists of sublingual (under the tongue) tablets taken every day during the grass allergy season as a way to alleviate your child’s symptoms. It also can be taken year round to fully suppress grass allergy reaction. In order to begin therapy, the child would require a visit with our physician and an allergy test. Though the therapy is not meant for everyone, the physicians at Forest Lane would be happy to discuss your child’s allergy symptoms and possible solutions for their symptoms. Please call the office to schedule an appointment or you can send a message through our secure portal.

To read more about grass allergies: The Pollen, N5 Grasses (PDF)

To read more about Grastek: click here

Should I Continue Using Miralax?

Should I Continue Using Miralax?

After the recent New York Times article about safety concerns regarding the use of Miralax in children, many parents are asking themselves whether or not they should continue using the medication for their child. The concerns about Miralax use in children came up after a consumer safety group in New York petitioned the FDA to investigate complaints of behavioral changes in children who were taking the medication. Miralax, like many other medications, has never been studied for safety or approved for use in children by the FDA. Unfortunately this is a common problem as drug companies do not want to spend the extra money to get approved for pediatric use. In these situations, pediatricians have to take the safety information available on adults and extrapolate it to children. In the case of Miralax, studies showed that the medication is not absorbed into the blood stream of adults and is very safe. We assume the same is true for children, but that has never been tested. Thankfully, a large study is now underway to definitively say whether or not Miralax is safe for kids. If there are side effects from Miralax it is possible they are due to absorption of the medicine into the blood stream, but it is more likely that any side effects would be secondary to impurities that develop in the manufacturing process resulting in small amounts of ethylene glycol (the active ingredient in anti-freeze) being present in the medication (Miralax is polyethylene glycol). The good news is that Miralax has been used in children for many years and the number of adverse events that have been reported has been incredibly low. This fact suggests that for the vast majority of children it is still safe to use and you should not have any concerns if your child has been on Miralax without side effects. However, as with all medications, it is wise to use the smallest dose possible for the shortest duration possible. Considering that the most likely cause of side effects is manufacturing impurities, it is also probably best to use the brand name medication and not a generic. Ideally every child’s constipation would be adequately treated with changes to their diet and not with medication. For most children, increasing the amount of fresh fruits (especially fruits that start with the letter “P”) and vegetables to a child’s diet and limiting dairy and other plain white foods like pasta, rice, and potatoes, will treat the constipation. For more information about diet changes to treat constipation, please see the Constipation Handout on our website. If diet changes are not sufficient to control your child’s constipation, please contact your child’s doctor. Every child is different and your doctor will be happy to work with you to treat your child’s constipation.

Dr. Mitchell

Dr. Mitchell speaks about Ebola


The first case of Ebola that was diagnosed in the US has been confirmed here in Dallas. Before you order a haz-mat suit from Amazon, it’s important to recognize that Ebola can only be spread through direct contact with bodily fluids from someone who is showing symptoms. No symptoms… no Ebola. No direct contact with bodily fluids… no Ebola. The excellent public health infrastructure we have here in the US will prevent the spread of this illness. Long story short, if you already bought your haz-mat suit, you won’t need it for Ebola, but at least you will have a very cool Halloween costume. ~ Dr. Mitchell

For more information: Ebola

What is Enterovirus D68?


The news is reporting a new outbreak of a respiratory viral illness in Illinois and Missouri. The virus has been identified as Enterovirus D68. So far there has been 16 cases reported in children and adolescents. The majority of the children have underlying asthma or other lung disease. All of the identified cases so far have been identified from patients in intensive care unit. There has been reports of this virus going back to the 1960s but this recent event is the largest outbreak to date.

Enterovirus D68 will start as a cold with cough and can lead to respiratory (breathing) difficulty in a few children. Signs to look for will include breathing difficulty, wheezing, lethargy, or poor appetite. At present time, there is no medication or vaccine available to treat for Enterovirus D68. As with many respiratory viral infections, the majority of those affected do not develop severe symptoms and recover without need for medical intervention. The virus has not yet been detected in Texas and the State Health Department is actively monitoring for new cases. We will update our post as more information becomes available.

If you have any concerns about your child, please feel free to call our office or schedule an exam.

For more information, please visit the CDC website.


Forest Lane Pediatrics

Dr. Kravitz reviews Autism’s False Prophets and Deadly Choices


Shortly after I started working at Forest Lane Pediatrics in 2008, I got an excellent book tip from a very smart man to read Autism’s False Prophets: Bad Science, Risky Medicine, and the Search for a Cure, a book written by the chief of infectious diseases at Children’s Hospital of Philadelphia about the movement to delegitimize vaccines. Since the tip was from Dr. Ron Blair, founder of the practice, I took his advice and was very glad I did. When Dr. Paul Offit then wrote another book on the topic, I read it as soon as it came out. With measles cases having now spread to 20 states from east coast to west and even to Hawaii, I thought now would be a good time to finally do the book reviews on Autism’s False Prophets and Deadly Choices.

The first book, Autism’s False Prophets, is about what Dr. Offit calls a controversy that isn’t. What he goes on to explain is that in a true controversy, there is data to support both viewpoints. The scientific community can point to legions of studies and data that show that vaccines are safe and effective. They can also point to numerous studies that came out in the face of the Wakefield study about MMR that show that vaccines do not cause autism. The vaccine refuters do not have evidence to support them. They have sad stories and videos, some of which are exceptionally well produced and certainly tug at the heartstrings and make people wonder. They just do not have any evidence.

The good Dr. Offit takes us on an extended and detailed tour of the “controversy” starting with his own medical history and why he wanted to be a doctor (he had a fantastic role model in his own caring family physician who diagnosed him with a ruptured spleen after a fall from a height at school). The fact that that he then had to live without a spleen, a distinct disadvantage against infection, may have had something to do with his choosing infectious disease as his subspecialty within pediatrics, although he had some early experiences with polio patients in his young life that also made infectious diseases so interesting to him. He also lets us into his life as a vaccine researcher and a staunch defender of vaccines as well as some of the harrowing situations that his role caused him as some of the vaccine refuters become more desperate and brazen.

The second book, Deadly Choices: How the Anti-Vaccine Movement Threatens Us All, takes the reader back to the beginning of vaccines and anti-vaccine movements that most of us had never heard of. He also shows us the media’s role in spreading fear about vaccines. He then details the spread of vaccine-preventable diseases by the unimmunized in several different outbreaks that have occurred to date. He finally goes on to handle a topic I find the most puzzling and repugnant, what I term the “turncoat physicians.” These are medical professionals who know the science and surely understand the studies but choose to come out on the anti-vaccine side, ostensibly for financial gain.

Dr. Offit is a gifted writer, and both books are very compelling and interesting reading, even if the reader has no scientific background. With the resurgence of diseases such as pertussis and measles, which were nearly eradicated decades ago, I strongly recommend both of these books for all parents. We hope you will read them and recommend them to your friends as well. Since we are all in this world together, the more people who are vaccinated, the safer we all are.

Why vaccines are important!


A major outbreak of measles is occurring in Ohio this month. At this point, 68 individuals are affected. The viruses had originally infected US missionaries in the Philippines who unknowingly brought the virus to Ohio. Since measles is rarely seen in the United States, it is often misdiagnosed when first seen. The main cause for the spread in Ohio is thought to be from unimmunized individuals. This is just another reminder why it is important to vaccinate yourselves and your children. If your family is planning international travel this year, please discuss your plans with your doctor and make sure that you are fully protected for your trip. For more information about the vaccinations go to our preferred website page and click trusted immunization website links. To read more about travel health, Forest Lane recommends to go to the CDC travel site.

Rear-Facing Car Seats Until Age Two by Dr. McGonnell


When our kids reach their first year of life, we as parents look forward to many important milestones including first steps, first birthday, and possibly a few words. We are also excited to turn the car seat forward. We will finally get to see our children in the rear-view mirror and hopefully end those screaming fits. But recent information may make you wait on this change.

Last year the National Highway Traffic Safety Administration (NHTSA) revised its recommendations for infant and children’s’ car seats.  Most people are aware that infants under 1 year old and less than 20 lbs should stay in a rear-facing car seat.  The newest change in our advice is to leave children in a rear-facing car seat until two years old.  The change was based on recent NHTSA research which looked at car crashes involving toddlers in both rear- and forward-facing car seats.  The results showed a significant decrease in serious injury or death when a toddler was in the proper size rear-facing car seat.  Though the recommendation is not required by law, the doctors at Forest Lane Pediatrics agree with this new recommendation based on the strong evidence.

So as you start to look to “move up” from your rear-facing infant carrier, look for a convertible car seat which will allow you to position your child both rear-facing and forward-facing.  Keep the seat rear-facing until age two unless your child has reached the weight or height limit of that specific car seat.  In addition, you may want to check out the website from the National Highway Traffic Safety Administration to read more about the recommendation.  The site also has additional recommendations on child car safety including how-to-install videos, recalls on car seats, and car seat inspection centers in the Metroplex.  And most importantly, drive safely.

Chris M. McGonnell, MD, FAAP

Tylenol® (acetaminophen) Recommendations by Dr. Michelle Kravitz


When I was in pediatric residency training in the early 1990s, we routinely recommended giving Tylenol® (or acetaminophen in the generic form) around-the-clock to prevent vaccine side effects such as fussiness and fever. In October of 2009, a study was published in the British journal Lancet that forced me to change my recommendations. The study showed that many of the children who received around-the-clock acetaminophen had lower antibody levels from many of the vaccines than those who had not received acetaminophen.

Since that study, I still recommended Tylenol use as needed for significant fever or fussiness, but I no longer recommend using it preventatively or around-the-clock. Recently, a new review article has been published in Pediatrics that has forced me to think even harder about recommending Tylenol. This article reviews several adult and pediatric studies that suggest that Tylenol use in children is actually linked to increasing asthma prevalence and severity. While the causality of the relationship is not yet proven, enough evidence of the association exists to make us wary about continuing to use Tylenol as freely as we had once recommended.

My current recommendation is to use Tylenol in children under 6 months only if needed for moderate to severe fever and/or fussiness. For children 6 months and above, I would recommend avoiding Tylenol as much as possible and using ibuprofen if needed for moderate to severe fussiness or fever. This is especially true if the child or a family member has a history of wheezing or asthma. While acetaminophen has been a generally well-tolerated, apparently safe medication for years, the new information leads us to try to avoid it if possible. Further studies need to be done to find out whether there is a true causal connection between Tylenol and asthma and whether acetaminophen really is as safe as we had thought.

Tylenol® (Acetaminophen) and Motrin® (Ibuprofen) Drug Dosage Chart

Michelle B. Kravitz, MD, FAAP – Dallas Pediatrician

Sunscreen Update – Summer Vacation Edition


Now that most schools are out for the summer, I suspect everyone is gearing up for a sunny vacation, time at the pool, or just having fun outdoors.  The Environmental Working Group has always been my favorite resource for sunscreen advice, and they have just released their 2012 Sunscreen Guide.  The good news is that we now have more safe and effective options available in stores.  You can purchase a printable shopping guide, or better yet, the iPhone app to take with you to the store so you can sort through the myriad choices out there.  My take-home messages about selecting a safe sunscreen remain the same from last year:

  • zinc oxide and titanium dioxide remain the safest and most effective ingredients
  • avoid oxybenzone, a possible hormone-disrupting chemical sunscreen ingredient
  • avoid retinyl palmitate, a vitamin A derivative that can heighten skin cancer risk
  • make sure your sunscreen has good protection for both UVA and UVB rays

As a reminder of why we need to worry about sunscreen in the first place, check out this article from the New York Times about the risks and challenges of childhood sun exposure.

Have safe fun in the sun!

Toilet Training by Dr. Damien Mitchell


We have all met, or at least heard of, the parent who proudly shares that her child was potty trained at 24, 18, 12, or even 6 months of age. If you are that parent, congratulations, getting your child toilet trained is something to be proud of no matter what the age. But if you are the parent who feels a slight twinge of failure when confronted with the toilet training accomplishments of your friends, this article is for you.

If you take nothing else from this article, I want you to take home the message that children toilet train on their own time, the age at which a child becomes toilet trained has no relationship to his intelligence, and the age at which a child becomes toilet trained says nothing about how “good” a parent is.

If toilet training happens when the child is ready, when is that? Before children are 12 months of age, they do not have control over their bladder or bowel movements. Some parents are able to recognize the signs that their child is about to urinate or have a bowel movement, and as a result, are able to achieve a form of pseudo-toilet training at a young age. True toilet training, however, cannot occur until a child is able to control her bowels and bladder, which often occurs between 18 and 24 months. However, some may not achieve this control until 30 months or older, which is normal. Even if your child is able to stay dry during the day, it is important to remember that it may take months or years for your child to be dry at night. For most children, the ability to stay dry at night does not come until after they are 5 years old.

Regardless of your child’s age, the following are signs that your child may be ready for potty training:

  • Your child stays dry at least two hours at a time during the day or is dry after naps.
  • Bowel movements become regular and predictable.
  • You can tell when your child is about to urinate or have a bowel movement. Your child can follow simple instructions.
  • Your child can walk to and from the bathroom and help undress.
  • Your child knows the difference between wet and dry.
  • Your child asks to use the toilet or potty-chair.
  • Your child asks to wear “big–kid” underwear.

If you have determined that your child is ready to begin the toilet training process, the following tips from the American Academy of Pediatrics can help you achieve success.

1) Training Vocabulary
Decide what words to use to describe body parts, urine, and bowel movements. It is best to use proper terms that will not offend, confuse, or embarrass anyone.

2) Pick a Potty Chair
They are logistically easier for a small child to use because there is no problem getting onto it, and a child’s feet can reach the floor. If you use a child-size seat attached to an adult toilet, make sure you provide a step stool to support the feet so she can push down during bowel movements.

3) Be a Role Model
Children are often interested in their family’s bathroom activities. It is sometimes helpful to let children watch the parents when they go to the bathroom. Seeing grown-ups use the toilet (and wash their hands afterward) makes children want to do the same. If possible, mothers should show the correct skills to their daughters, and fathers to their sons. Children can also learn these skills from older brothers and sisters.

4) Know the Signs
Before having a bowel movement, your child may grunt or make other straining noises, squat, or stop playing for a moment. When pushing, his face may turn red. Explain to your child that these signs mean that a bowel movement is about to come. Your child may wait until after the fact to tell you about a wet diaper or a bowel movement. This is actually a good sign that your child is starting to recognize these body functions. Praise your child for telling you, and suggest that “next time” he let you know in advance. Keep in mind that it often takes longer for a child to recognize the need to urinate than the need to move bowels.

5) Make Trips to the Potty Routine
When your child seems ready to urinate or have a bowel movement, go to the potty. It may also be helpful to make trips to the potty a regular part of your child’s daily routine, such as first thing in the morning, after meals, or before naps. Keep your child seated on the potty for only a few minutes at a time and explain what you want to happen. (It is better for boys to learn to urinate sitting down first.) In the beginning, many children have bowel movements or urinate right after getting off the toilet. It takes time for children to learn how to relax the muscles that control the bowel and bladder. If this happens a lot, it may mean your child is not ready for training.

6) Teach your Child Proper Hygiene Habits
Show your child how to wipe carefully. (Girls should wipe thoroughly from front to back to prevent bringing germs from the rectum to the vagina or bladder.) Make sure both boys and girls learn to wash their hands well after urinating or after a bowel movement.

7) Praise your Child
Encourage your child with lots of hugs and praise when success occurs. When a mistake happens, treat it lightly. Punishment and scolding will often make children feel bad and may make toilet training take longer.

8) Incentivize Staying Dry
If you are going to use incentives to encourage potty training, give them for staying clean and dry, and not for using the potty.  Giving rewards for using the potty creates a situation where the child is in control because only she can decide if she pees or poops. If your child should decide she does not care about going to the potty, the incentive becomes useless. By incentivizing staying clean and dry, the parent is in control of the training process and is able to continually remind the child of the importance of staying dry.

9) Try Training Pants
Once your child starts using the potty with some success, training pants can be used. This moment will be special. Your child will feel proud of this sign of growing up. However, be prepared for “accidents.” It may take weeks, even months, before toilet training is completed. Continue to have your child sit on the potty several times during the day. If your child uses the potty successfully, it is an opportunity for praise. If not, it is still good practice. Some children who are not ready for training pants will still feel that they are more “grown up” if they wear disposable training pants (Pull-ups is one brand name) as a step forward in the training process.  Some children will want to go back to diapers, especially for bowel movements. Instead of looking at this as a failure, praise your child for knowing when he needs to go. Suggest that he have the bowel movement in the bathroom while wearing a diaper. Encourage improvements, and work toward sitting on the potty without the diaper.

10) Avoid a Power Struggle
Children at toilet training ages are striving for independence and are becoming aware of their individuality. They often look for ways to test their limits, and some may do this by holding back bowel movements. Do your best to stay relaxed about toilet training. Remember that no one can control when and where a child urinates or has a bowel movement except the child.

11) Understand their Fear
Some children believe that their wastes are part of their bodies, and seeing their stools flushed away may be scary and hard to understand. Some also fear they will be sucked into the toilet if it is flushed while they are sitting on it. To give your child a feeling of control, let her flush the toilet. For those children who are still having bowel movements in their diaper, it may be helpful to empty the contents of the diaper into the toilet and flush it as the child observes. This will lessen the fear of the sound of rushing water and the sight of things disappearing, while reinforcing that bowel movements belong in the toilet.

Hopefully these tips give you the tools you need to approach toilet training successfully and with minimal stress. These tips are helpful for all children and provide an easy introduction into the toilet training experience. There are other more aggressive strategies for toilet training children that take only “three days,” however; these strategies are intended for the child who has already demonstrated some potty training success or ability to control bowel and bladder function.

Should you feel like your child is struggling with toilet training, talk with your pediatrician. Most of the time the problem is minor and can be resolved quickly, but sometimes physical or emotional impairments will require treatment. The most common physical impediment to successful toilet training is constipation. If your child has frequent accidents, pay close attention to the character and consistency of her bowel movements. If her stools are consistently hard, large, or look like pebbles or rocks, then constipation is likely, and she would benefit from treatment by your pediatrician. You should also keep in mind that major changes in the home, like moving or the birth of a sibling, may result in toilet training regression. Should you notice a change in the home environment affecting your child’s toilet training, take the time to address his emotional needs before trying to advance.

If you find that all of the tips and strategies that friends, family, and your pediatrician provide are not helping, consider reading the book Stress-Free Potty Training: A Commonsense Guide to Finding the Right Approach for Your Child by Sara Au and Peter L. Stavinoha. This book is unique in that it does not provide a singular approach to toilet training. Instead, it provides five different approaches specific to different personality types. For the child who is resistant to conventional toilet training strategies, I find this book to be very helpful.

Good Luck!

Dr. Damien Mitchell of Forest Lane Pediatrics.

Increasing Awareness About Overweight Kids


There has been a flood of activity in the pediatric literature about childhood obesity recently. The rate of overweight children continues to increase, and we are continuing to recognize the short-term and lifelong health impact of this. In the current issue of the journal Pediatrics, a study finds that children who eat meals regularly with their family, get adequate sleep, and limit their TV time to no more than two hours per day had a 40% reduction in obesity compared to kids who had none of these routines. I would also add avoiding high-fructose corn syrup to this list. High-fructose corn syrup is a cheap industrially manufactured (i.e., not natural) sweetener that is an indicator of highly-processed, low nutritional value foods. It is also extremely common and challenging to avoid, but it is worth looking for this on the ingredient list when you are shopping.
Other new resources for you: — A new website from the American Academy of Pediatrics with information on multiple health topics, not just obesity. — First Lady Michelle Obama is leading a new initiative to improve access to healthy food and exercise opportunities. — The Dallas Area Coalition to Prevent Childhood Obesity is sponsoring “Get Kidz Fit” on Saturday, April 24 at Fair Park in Dallas. This is a free festival to engage children and families in fun ways to exercise and eat well.

AAP Revises Swim Lessons Guidelines


The American Academy of Pediatrics has issued a revised policy statement regarding the prevention of drowning.  The Washington Post has a nice summary, but I would encourage you to read the full statement in Pediatrics here, especially if you have a pool or hot tub at home.  This statement now allows that children between ages 1 and 4 who are developmentally ready may benefit from swimming lessons.  Previously, the AAP had advised no swim lessons under age 4, reasoning that there was no proof that swimming lessons for younger kids prevented drowning, that lessons might provide a false sense of security, and that lessons might reduce a child’s natural fear of the water and encourage them to go in without supervision.  New data have emerged from small studies indicating that swimming lessons in the 1-4 year age group did decrease the rate of drowning death.  The policy statement also draws attention to other less recognized hazards:  drain entrapment and hair entanglement in regular pools or hot tubs, and the drowning risk in portable or inflatable pools.  If you have a pool at home, I would encourage you to review the safety of the pool and its surroundings.  There are many specific recommendations and resources in the AAP policy statement.  Ultimately, there is no substitute for close and constant supervision when your young children are around the water.

Everybody Likes Pediatrics Quick Hits


I have been stockpiling blog ideas for a few weeks in hopes of producing lengthier commentaries, but it is time to just post a bunch of “quick hits.”  As baby #4 quickly approaches, maybe this is my form of “nesting.”

The Risks of Parenting While Plugged In” — a cool New York Times article about texting while parenting.

Nurture Shock by Po Bronson and Ashley Merryman — a fascinating book about how the conventional wisdom of various aspects of child-rearing may be wrong.  A very fascinating book, highly recommended, 5 stars.  Dr. Mitchell has read it and loved it too!

Can Dirt Do a Little Good? — a great Wall Street Journal article discussing the documentary “Babies” and the interesting concept of the hygiene hypothesis.  My wife and I saw “Babies” and really enjoyed it — catch it quick while it is still in the theaters.  (I know what you are thinking, don’t I get my fill of babies at work and at home???) — increasing awareness about the increased sensitivity of children to the dose of radiation from commonly used CT scans and x-rays.

Cord Blood Donation at Medical City Dallas — did you know that since 2006, any baby born here at Medical City Dallas has had the option of donating their cord blood to the public cord blood bank?


More than you wanted to know about the bacteria in your body


Check out this interesting article in the New York Times about all of the microbes that live on and in our bodies.  You may be aware now of probiotics, but that may be just the tip of the iceberg in our understanding of the normal flora in our intestines.  Beware, the opening vignette discusses fecal transplantation, but if you can fight through it, there are lots of fascinating questions raised by this research.

Do you really have to have a repeat C-Section?


Admittedly this is a controversial topic outside of my area of expertise, but the American College of Obstetrics and Gynecology has issued a new policy advocating for increased consideration of vaginal delivery if a woman has previously had a Caesarean Section.  Vaginal Birth after C-Section (VBAC) does have potential risk, both for mother and baby, but well-equipped hospitals and experienced physicians can manage this risk successfully.  As this is outside of my area of specialty, I merely bring this to your attention so that you can have an informed discussion with your doctor.  Check out this article from The New York Times, as well as the follow-up Letters to the Editor, for more detail.

Vitamin D gets an A+


The evidence continues to roll in about our need for more vitamin D. This New York Times article neatly summarizes the vitamin D issues, from kids to adults.  We have also revised our practice’s standard advice to reflect this new evidence.   We now recommend that unless a child is receiving more than 32 ounces of infant formula per day, all infants and children need a vitamin D supplement containing at least 400 International Units of vitamin D daily.

Celebrate World Breastfeeding Week!


Every year, the World Health Organization celebrates World Breastfeeding Week to raise awareness about the importance of breastfeeding. This year, they are focusing on their Ten Steps to Successful Breastfeeding, a list of guidelines for hospitals designed to encourage a good start to breastfeeding in the newborn nursery. Our area hospital shave already incorporated many of these measures into their routine newborn practices. Coinciding with World Breastfeeding Week, there is an article in the New York Times about the discovery that certain sugars in breast milk are not digestible by the baby, but are designed to feed and stimulate protective bacteria in the gut. Here are the WHO’s Ten Steps:

1.    Have a written breastfeeding policy that is routinely communicated to all health care staff.
2.    Train all health care staff in skills necessary to implement this policy.
3.    Inform all pregnant women about the benefits and management of breastfeeding.
4.    Help mothers initiate breastfeeding within a half-hour of birth.
5.    Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.
6.    Give newborn infants no food or drink other than breast milk unless medically indicated.
7.    Practice rooming-in – allow mothers and infants to remain together – 24 hours a day.
8.    Encourage breastfeeding on demand.
9.    Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10.    Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Puberty starting earlier in girls?


In the early release online version of the journal Pediatrics, a new study demonstrates that puberty in girls appears to be starting at an earlier age than previously reported.  This New York Times article summarizes it well, with some theories as to why this is happening.  This study chronicles the development of breast buds, generally the first sign of pubertal progress, reporting that a significant percentage of girls start showing development by age 7 or 8.  At age 7, approximately 10 percent of white girls, 15 percent of Hispanic girls, and 23 percent of black girls were developing breast tissue.  By age 8, the figures rose to 18 percent of whites, 31 percent of Hispanics, and 43 percent of blacks.  It is important to note that the average age of first menstruation has not changed significantly in recent years; the usual range is age 11 – 14, with a median age of 12.4 years.  Over the past century, the age of pubertal onset has gradually declined, and it was felt that this was due to improved nutrition and overall better health.  In recent decades, however, we have become increasingly concerned that negative health factors such as obesity and environmental exposures are the cause for this.  This is an area of ongoing research without definitive answers; for now, if you are concerned that your child seems to be developing earlier than you would expect, please come in so that we can discuss this fully.

Too Old to See the Pediatrician?


We are definitely in the midst of all of the back-to-school checkups, so the question often arises:  When will my child be too old to see the pediatrician?  My half-joking response is, “When they get sick of reading Highlights in my waiting room!”  An article in the Wall Street Journal this week addresses this question.  We do not accept new patients after 18 years of age, but for our existing patients, we are happy to continue seeing them at least through college.  I suppose there will come a time when I recommend that a young adult patient should find a new doctor, but as long as they don’t mind coming here, I am still happy to see them.

All New Parents Need Food


No, this is not a solicitation for people to bring us a meal (but since we do have a newborn, and if you are in the neighborhood…). One of my favorite foodie websites is Chowhound — useful local restaurant advice, recipes and helpful message boards, and good tips for where to eat when you travel. A recent article posted on Chowhound discusses “What Food to Bring New Parents.” If you feel like doing something nice for any new parents that you know, check it out. All New Parents Need Food

It’s an appendix!


Any time a child develops a severe stomach ache, one question on parents’ and physicians’ minds is whether it could be appendicitis.  In spite of all of our high-tech medical advances, the diagnosis and treatment of appendicitis is still a challenge.  This article in the New York Times highlights this difficulty and gives a fun shout-out to the classic children’s book Madeline while they are at it.

Giving Thanks Edition


As Thanksgiving nears, I am grateful for many things — first and foremost, my family, which has grown over the past year.  I am also thankful for our patients and families.  There are so many interesting topics to discuss and share, and we hope that we can enrich your children’s’ lives over the years.

Two topics that I have found fascinating over the past few weeks:

This pair of articles from the New York Times discusses a wide variety of ways to make vegetables more enticing.  This is not necessarily specific for kids, but I do encourage families to share the same family meal instead of making separate “kid stuff.”

This week, the New York Times describes the increasing ways that our digital world changes the way our kids think and work.  “Growing Up Digital, Wired for Distraction” provides plenty of food for thought about the impact that screen time plays in the teenage years.

Higher Education Grab Bag


Although many of my posts tend to focus on younger children, a trio of recent New York Times articles caught my eye regarding our young adults.

The first article analyzes the stress high school students experience in the race to do everything.  The article was spawned by the release of a new documentary on this subject, “Race to Nowhere.”  When considered along with “Waiting for Superman,” another recent documentary which addresses the failures of our educational system, there seems to be a great deal of current interest in improving our high school educational system.  It looks like the only local screening of “Race to Nowhere” will be on January 20 in Fort Worth, so if you are interested, try to track it down.  “Waiting for Superman” will be available on DVD on February 15.

The next article, entitled “Is Going to an Elite College Worth the Cost?”, has been stuck in my brain over the past week.  I faced this issue in high school, choosing to go to Texas A&M instead of piling up a large debt of school loans to attend a private university.  I like to think that I turned out okay, and ultimately A&M was a great fit for me.  Since that time, college tuitions have skyrocketed further, raising further the question of whether the return on the investment of an elite private institution is worth it.

Lastly, at whatever college your child does attend, this article looks at the issue of grade inflation.  My brother-in-law and his wife are professors at an expensive private university, and there is frequently a sense of entitlement along the lines of, “My parents are paying a lot of money for me to come here, so you better give me an ‘A’.”  I am reminded of a quote I heard recently from Jason Garrett, interim head coach of your Dallas Cowboys — (paraphrasing) — “I was a mediocre quarterback.  The coaches who told me I was great weren’t doing me any favors.”

In summary, to all my young adult patients out there:  good luck surviving high school, getting into the affordable college of your dreams, and learning for the sake of intellectual curiosity and self-improvement.  Oh, and I hope you truly earn an “A”!!!

Healthy Nutrition Round-Up


Lots of ideas on my mind that haven’t quite made it to the blog – hope you haven’t missed me too much. The ongoing goal of healthy nutrition is always at the top of the list of challenges for my family and yours. The government recently released their latest recommendations, entitled “Dietary Guidelines for Americans 2010.”  For a government document, it is uncommonly straightforward and helpful. The New York Times nicely summarizes these guidelines here and here.

In my summary of their summaries, I say:

  • Eat Less
  • Eat real food, not processed junk
  • Get more active

Admittedly, this is easier said than done, but I have discovered a few tricks that have helped get more veggies into my notoriously picky boys. When faced with a picky toddler, two basic strategies are:

  1. Prepare healthy foods in a new but straightforward way tastes good.
  2. Sneak healthy foods into something else that they like so that they don’t notice the difference.

My first breakthrough in Strategy #1 occurred when I heard about baked kale chips. Kale is one of those super foods that is supposed to be great for you, but I haven’t really known how to prepare it until now. Last week, the Dallas Morning News ran an article about the virtues of kale. Baked kale chips are a little bit ugly but addictively tasty. They end up very light and crispy, and my kids demolished an entire bunch of kale in “chip” form.  The recipe at the bottom for orecchiette pasta with kale and tomatoes is also easy and tasty.

My new favorite method from Strategy #2 is mixing vegetables into fruit smoothies. Whole Foods has a recipe for a fruit smoothie that blends in raw baby spinach and kale. I have modified this to use a little less kale, more blueberries (to mask the green color), and a little honey. Feel free to use whatever you have on hand – throw in lots of fresh fruit, a few handfuls of greens, and buzz the whole thing in the blender. I also like to strain it through a fine-mesh strainer to make the smoothie nice and smooth.  It also helps to serve it in an opaque cup with a straw, in case the color ends up being too green for your child’s liking.

I hope some of these ideas can inspire you to make some healthy changes!

Things that Wake Up Pediatricians in the Night


If you ask any pediatrician the most common reason for a middle-of-the-night call, I am sure it would be fever.  For obstetricians, the answer must surely be a mother in labor.  With fever, we do our best to identify the source of the fever, help with the child’s comfort, and reassure parents that fever is not harmful.  In fact, fever is the body’s natural, appropriate response to an illness.  This week, the American Academy of Pediatrics released helpful guidelines to educate physicians and families about “Fever Phobia,” and the Wall Street Journal presents a nice summary “Sweating Out A Fever“.

In modern times, obstetricians have managed some of their middle-of-the-night issues by recommending induction of labor during daylight hours.  The “discomforts of pregnancy” are admittedly substantial, so many moms are relieved to consider this option.  Induction of labor prior to 39 weeks gestation has proven to have some drawbacks, however, so there is a current push to limit these pre-term inductions. The Journal summarizes this issue here.  An induction before 39 weeks increases the rate of complications for the baby, and also increases the rate of a “failed induction,” leading to more C-Sections.  Ultimately, the Good Lord and Mother Nature know best, and they figured out this “40-week pregnancy” thing for a reason.  Waiting until the baby is good and ready ends up being better for both mom and baby.

5-2-1-0 = Healthier Kids


When speaking with families about ways to combat childhood obesity, I sometimes struggle to find the right level of advice.  It is possible to be too simple (“Eat Less, Exercise More”) or too complicated (a long list of “do this” and “don’t do that”).  The Wall Street Journal reports on “Let’s Go!”, a community initiative in Portland, Maine that increased awareness about healthy eating and exercise habits.  Since they started the program five years ago, they have seen some modest success in reducing the numbers of overweight and obese kids.  Their concept is simple enough to grasp and remember, but sophisticated enough to make a difference.  5-2-1-0 represents a daily scorecard of do’s and dont’s:

5 servings of fruits or vegetables per day
2 hours or less of screen time per day (TV, computer, video games, etc.)
1 hour of exercise per day
0 sugary drinks (sodas, processed fruit juice, Kool-aid®, sports drinks, etc.)

See if these rules of thumb can help you set specific goals for your day!

That’s probably not just from teething…


“Well, she has a runny nose,  and she has been fussy for 3-4 days, and we thought it was teething.  Now she has fever to 102.8, and she is more unconsolable and she can’t sleep.  What do you think, doc?”

Teething can be an uncomfortable part of growing up that may affect babies off and on throughout the first two years of life. Teething is unlikely, however, to be the explanation for more severe or serious symptoms.  A new study published in Pediatrics demonstrates this nicely — the researchers followed a group of children and monitored them for symptoms in the days before, during, and after tooth eruption. It turns out that fussiness, drooling, decreased appetite, loose stools, and sleep disturbance are common with teething, just like Grandma says.  Fever or more severe symptoms should not be attributed to teething, though — such symptoms should prompt a search for some other cause.  The bottom line:  for fever of 100º F or higher, some other illness should be suspected.

Cervical Cancer Vaccine for Boys?


On October 25, the CDC’s Advisory Committee on Immunization Practices officially recommended that boys should receive Gardasil, a vaccine for Human Papillomavirus, at age 11 – 12.  (See New York Times article here.)  HPV causes cervical cancer in women and various other cancers in both genders. The new recommendation is an important step in the effort to improve utilization of this cancer-preventing vaccine.  The HPV Vaccine has been recommended for girls since 2007, but many families have been slow or reluctant in vaccinating their girls.  Some families have a hard time thinking about this at age 11 or 12. It is therefore worth mentioning a few plain facts about human papillomavirus, the HPV vaccine, and sexual activity:

  • HPV causes a variety of diseases; in addition to cervical cancer, it causes throat cancer, anal cancer, and genital warts
  • The HPV vaccine works best when it is given before the age of sexual activity
  • The vaccine gives the best immune response when given at age 11 – 12 (100-times better immune response compared to age 26)
  • 43% of teenagers have been sexually active
  • Only 78-85% of teenagers used contraception during their first sexual activity

So as you can see, this is an extremely common infection, and the vaccine works best when given at a younger age, well before the initiation of sexual activity.  To put it another way, would you advise your teenage driver to start wearing their seatbelt only after their first accident or two?  For any of the standard vaccines that we give, the goal is to protect our kids before they are exposed to the illness — the HPV vaccine is no different.

Discussing the HPV vaccine is also an opportunity for you to begin an ongoing discussion about sexuality with your child.  Who do you want your child to learn about sex from?  If you are waiting to discuss it until puberty, or when you perceive that your child may be sexually active, you are waiting too late.  One resource in this discussion is Mary Flo Ridley, a local speaker and author who has become a nationally recognized expert in advising parents on how to talk to their kids about sex.

Baseball season and caring for young arms and minds


My oldest son is about to turn seven, and I am of course proud of him in so many ways.  First grade is going well, and he has grown more independent and self-sufficient.  This is a particularly wonderful practical development, seeing as how his three younger brothers are decidedly high-maintenance and not self-sufficient at all right now.  An article in the New York Times a few months back still resonates in my mind, as it describes the hormone surge that occurs in the early elementary school years:

“Middle childhood is when the parts of the brain most closely associated with being human finally come online: our ability to control our impulses, to reason, to focus, to plan for the future.”

Simply put, one of my little monsters has grown more civilized.  The article, entitled “Now We Are Six,” is a fascinating look at an under appreciated age of child development.  Believe me, I appreciate it very much.

Another turning point has to do with sports — for the first time, we are transitioning to Little League baseball instead of YMCA tee-ball.  After our first practice, I can tell you that there is still plenty of running to the wrong base and picking daisies in left field, but the thought that this eventually could lead to the Little League World Series on ESPN is a mental milestone for me.  This leads to the potential pitfall of becoming “one of those” sports parents — the yelling, screaming at the ref, overly critical parent that drives the joy out of it for everyone.  This essay from Kids in the Game summarizes nicely how we ought to behave.  After the next pee-wee soccer game, try saying, “I love watching you play” instead of “Why didn’t you…” or “How many goals did you score?”

Lastly, I wanted to mention this article from the New York Times entitled “Young Arms and Curveballs.”  Even when I was playing Little League, the cautionary tale held that throwing curveballs at a young age would ruin your elbow.  This has become conventional wisdom, leading some leagues to ban young pitchers from throwing the curve. Recent scientific studies seem to question this however, reporting that throwing a curveball does not put any greater stress on the arm compared to straight fastballs.  Instead, it is simply overuse that injures young arms. Throwing too many pitches of any type, at too young of an age, is what causes the trouble.  It is often the most talented kids who are at highest risk; what parent or coach doesn’t want their star player on the field as much as possible?  Which brings me back to my earlier point — we need to remember the fun in sports and not push our kids too fast.  “I love watching you play” is a healthier attitude for our young athletes’ bodies and minds.

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