It’s become a little joke in my house. Whenever I see sunny, blue skies outside, I exclaim to my husband, “What a Day!” He usually replies with, “You’ve said that four times today.” This is just one example of how I make an active effort to be grateful during each and every day. Whether it’s simply acknowledging my family’s health; or taking a walk with my toddler searching for rocks as she exclaims, “I can’t believe how fun this is, mom”; or yelling “I love you” to my first grader on his way into school without him being embarrassed (yet) -- I am always aware that these precious moments in our lives are priceless, and they are fleeting. Granted, parenting is exhausting, and many nights, I can’t put the kids to bed early enough. But as often as I’m able, I take pause to appreciate and express gratitude for the moments that are so precious and fleeting. After all, when we teach our children to have a positive outlook in life, the value of that lesson that will never be fleeting. 

Like all things that come with parenting, teaching kids responsibility requires consistency; and as all parents know, consistency is exhausting! My husband and I have been talking lately about doing a better job of teaching our kids to be more responsible for themselves. We want to be confident that when they visit other people’s homes, they show respect. We realize, however, if we don’t enforce those expectations in our own home, how will they know what is expected of them outside the home?

It seems pretty straightforward and simple enough to implement; but oy, having the patience to teach children the responsibility of doing chores, for instance, is more exhausting than doing those chores yourself! Asking your children where their plates go after every single meal; having them clean up their toys at the end of each and every day; or asking them repeatedly to dress themselves for school – these things are just easier to do yourself. However, this does not teach them to have manners and responsibility. The exhaustion of constantly reminding children of appropriate manners and actions is just a necessary evil to growing little human beings who you will be proud to send to a friend’s house…or out into the world. 

Sometimes I say to myself, “What is wrong with me? Why are my kids the only ones acting this way?” The tantrums, the talking back, the everyday stuff.  I see the most beautiful families of five posing happily on Facebook, with all the children dressed to the nines and smiling ear to ear. I wonder - how do those moms do it? How do they get their children to behave so well?

Then, in my moment of clarity, I visit my own Facebook timeline, where every picture is of one or all of my children – all smiling and all getting along. And I realize those simultaneous smiling faces lasted about as along as it took me to snap the picture. And that’s what we see on social media – the best moments. Fleeting moments. Nobody posts the daily emotional breakdowns, like the ones that happen when I put syrup on the plate next to my daughter’s waffle and she didn’t want syrup that day. Or my son sprawled dramatically across the floor because first grade is “just too hard.”

I was talking on the phone the other day with a best friend from college who lives across the country on the other coast. We hadn’t talked on the phone in months, mainly because we each have three kids, including newborns. We got about two minutes into our conversation when her twins awoke from their naps. Then the dual tantrums began - one twin wanted a popsicle and one wanted crackers - and my friend didn’t have either. The incessant screaming and full-blown tantrums went on until she was forced to get off the phone with me. While I was sad we didn’t get to catch up, I was oddly comforted as I sighed and thought to myself, “oh good, it’s not just me.”

“Everything is relative”, they always say. And this rings truer with raising my children than with anything else in my life. Case in point:

2011: My first child is born. I can’t find time to brush my teeth till 2pm. I can’t get through the day without a nap. (And with just one newborn child, there’s plenty of time for it!) When my newborn cries for a bottle, I feel restless inside, like I can’t get a bottle made and to his lips quickly enough. I can’t get out the door on time, because inevitably, he has a diaper blowout as soon as I put him in the car seat. And the list goes on.

Cut to 2017: My third child is born. When my baby cries for her bottle, I tend to her needs as quickly as possible – which is now relative with two other children also pleading me for something.  In this round of the newborn phase, the screaming I heard in 2011 now registers in my ears as a precious little cry. The agony of waking for night feedings in 2011 now sounds only like a silent household -- music to my ears. I am able to enjoy the newborn phase so much more the third time around because I know that soon, my baby will be a toddler – and oh, what fun that brings!!

Today is the first day of the school year. My teeth were brushed and makeup on before 7am. Because of Murphy’s Law, my husband’s car broke last night, which meant five people had to get to where they were going by 8am.  And we managed!

Because everything is relative!

Sometimes the smallest parenting successes can seem like major victories. Case in point: leaving the house in the morning for school. Being on time for school drop off feels like a major victory each morning. Let’s be clear - being early isn’t an option, but being on time makes me feel like I can – or have - conquered the world. Because my kids were clothed. My kids (may or may not) have been fed. My kid have completed their homework.  And, most likely, we’ve enjoyed a peaceful ride to school…thanks, Steve Jobs!!  So, as I wave goodbye and wish my kids a great day, I give myself a mental high five that I’ve done it once again! Alas…till tomorrow morning.

Germs

Why does it sometimes seem so impossible to escape the cesspool of germs that comes along with children?!  I know it’s technically called cold and flu season, but I’m more referring to the feeling that no matter what you do to sanitize your home and everything in your life, someone in your family will inevitably bring home a virus – which will inevitably get passed on to every other member of your family.  Sometimes I feel like a crazy person about using sanitizing wipes and asking my children to do the same after touching anything in public. It’s just part of me doing my best to keep my family healthy – by washing hands, eating well and getting adequate sleep.  But I have to resolve that sometimes a yucky virus – just like our love – will be shared among the family!

A Real Mom Like You

My Messy Home

It’s Monday morning and I look around my house.  If I didn’t know any better, I’d think I should file an insurance claim because either a tornado or a robber has ripped through my home. Alas, it’s just the result of a weekend at home with children. In order to keep a tidy home, I’d literally need to attach myself to my children and clean up after them as we’re both on the move. I wonder if it’s possible to achieve a healthy balance of letting my children use their imaginations for creative play (which involves my living room and dining room furniture) and teaching them the responsibility of cleaning up after themselves from a young age. On this Monday morning, I’m willing to admit there was no balance achieved this past weekend – imagination won over responsibility. There’s always next weekend. 

A Real Mom Like You

Temper Tantrums.

They’re a rite of passage for toddlers. And for parents. This morning’s temper tantrum - and I use the term conservatively - was over a $.97 plastic bowl with an attached straw: the “red bowl”. There is only one “red bowl” in our home, yet there’s two toddlers. The math simply doesn’t add up. Alas, immediately after drop-offs at school, I set off on a mission to find another “red bowl”; not in an attempt to give my children everything they desire, but rather in an attempt to regain my morning sanity!

What’s the simplest thing your children has ever thrown themselves on the floor over??

A Real Mom Like You

What we do to create smiles and joy

What most people will tell you if you ask what they want for their children, they’ll tell you happiness. I didn’t truly understand this until becoming a parent. There is no way to describe the feeling you get when you see a smile cross your child’s face, or when you witness their excitement or their pride after a job well done. We want our children to experience the best in life, to fit in, to succeed. We want our children to know joy.

This past Halloween, as we walked door-to-door trick or treating, I was thinking about the many, many, many, many things we do for our children in order to bring them joy. I realized how much joy I actually got from this occasion because I saw the joy on the children’s faces. The same goes for other holidays and just everyday events – the fun for parents is amplified by children and their joy.  Sure, it’d be nice to sometimes have no activities planned – to just sit on the couch and enjoy a day of relaxation. These days are few and far between, yet all the hustle and bustle is made worth it when little smiles are the reward at the end of a busy, joy-filled day. 

A Real Mom Like You

Teaching Children Kindness

Raising kids is HARD. It’s exhausting and frustrating and overwhelming. There are of course challenges that come with every age and stage, from terrible twos to teens breaking curfews.  We know a critical part of successful parenting is consistency, specifically consistency when it comes to discipline. This can be SO exhausting, though. Sometimes you just want to throw up your hands and give in, to save yourself from incessant whining and to buy yourself a couple of moments of peace and quiet.  And I’m guilty of that!  But while I often pick my battles as I raise my young children, there is one thing I can never be inconsistent about, and that is teaching my children the importance of being kind. Kindness is defined as the quality of being friendly, generous, and considerate. So much unnecessary hurt can be eliminated if we are all kind to one another. We can consistently engrain this message into our children. Of course our children will slip sometimes – heaven knows WE slip quite often. But if we consistently talk to our children about being kind, and most importantly set the example for them, they will innately come to choose their words selectively. And we can only hope that our children will come to treat others the way we want others to treat our children.

A Real Mom Like You

Kids hear the darndest things

I’ve written before about kids saying the darndest things, which got me thinking: where do those little words come from?  Kids are sponges, and they’re ALWAYS listening!  

Yesterday, when I picked up my son from school, he came running to me exclaiming, “I have really exciting news!!” His enthusiasm literally made my face and my heart smile.  I realized that I talk to him with that same enthusiasm, and I get excited to the point of ridiculousness over “little” things, which of course to him are so big.  His exciting news was that he got a special note and sticker because he was a good boy in school. If only this naiveté could remain forever…sigh.

A friend recently told me how her 2-year-old daughter keeps using the word “lovely”, and it only then dawned on her how much she uses the word. Her daughter has even picked up her sarcastic tone, spilling a bowl of cheerios and saying, “Oh…lovely!”

The lesson is our children are ALWAYS listening! Someone is going to pour their influence into our children – let’s make it us and let’s make it good!

A Real Mom Like You

Back to school

Back to school time is bitter sweet. There are stress trade-offs between the summer months and the school year.  Many parents scramble during summertime to arrange for child care and activities to stimulate their children through the summer months, when academics take a back seat to mindless play. In the summertime, however, you lose a lot of the stress from the school year: sports practice after school, drive-through dinners, rushing to complete homework at night, earlier bedtimes and the ever-stressful morning rush to beat the morning school bell. So…which time of year do you prefer? Leave a comment below to let us know.

A Real Mom Like You

To Play or Not to Play

I feel a constant push-and-pull in my daily life when my children ask me to “pleeeease” play with them. I find myself too often saying, “hold on.”  Of course, there I things I need to get done – responding to work emails, paying bills, preparing dinner, doing laundry – and the list goes on. I’m sure any parent can relate to seeking those moments when taking the time to play with the kids can be a priority to the other responsibilities in life.  But, the key is also understanding that sometimes it can’t be the priority.  Adults have to work while kids get to play. I cherish the times I also get to play with my kids, and I try not to feel so badly about the times when I just can’t. The best I can do is to do my best to balance my children’s desires with my life’s expectations. 

A Real Mom Like You

More lessons learned from raising children

-The emotional rollercoaster of being a parent is difficult to avoid. For instance, the frustration of getting my children ready for their day and out the door in the morning very swiftly turns into missing them wildly and counting down till school pick-up time.

-It’s better to surround myself with parents who understand my children’s tendencies to act like maniacs. They don’t judge, because they’ve been in my shoes way too often.

-‘It takes a village’ is not just a cliché. How does anyone do this parenting thing alone?

-Parenting: How can something so hard to do be something so easy to love doing?

A Real Mom Like You

Saying No

One of the most exhausting things about parenting is consistency, namely repeatedly saying “No.” Whether it be the answer to an extra bowl of ice cream, a later bedtime, giving your child a cell phone because “everyone else has one” or an extended curfew – saying “no” to your children can be exhausting. Sometimes it’s easier to just give in, and I’d bet there’s not a parent out there who hasn’t done just that – said “yes” for the mere sake of not listening to incessant whining! Now I’m a parent to toddlers, so I’ve learned that although it might seem like giving in to requests (er, demands) is the only way to avoid a whiney situation – I’ve found that my toddler may beg and beg, but if I stand my ground long enough, he’ll soon get over it…and move right along to the next request (er, demand). So I urge you parents – when you have the energy to do so – to stick to your guns!

A Real Mom Like You

Raising Grateful Kids

I’m reading a great book: “Raising Grateful Kids in an Entitled World,” by Kristen Welch.  It’s a book every parent can most likely relate to. Just a few pages into the introduction, I felt like I was watching my own life. The author points out if you ask most parents what they want for their children, they will tell you they just want their children to be happy. I know without hesitation that would be my response.

But in deeper thought, is what makes our children happy – in the moment – what’s best for them in the long term?  As an example, my son would be happy if I gave in to his every request: a new toy, another treat, a later bedtime just this once, and the list goes on. These things would certainly make him happy in the moment, but they might also NOT prepare him for the real world – of inevitable “No’s”.  If he comes to expect his every wish – and demand – will be accommodated, I am doing him an injustice.

By instead re-focusing my efforts on making my children grateful; this in turn, I believe, will ultimately lead to his happiness.  We must teach our children to be grateful for each of their blessings; to not feel entitled to everything they may want, but rather to be grateful for what they’ve earned. This is certainly the more difficult route of parenting. Saying no can be hard. But the fact is, gratitude begins with us as parents.  The author points out that the entitled notion our children instinctively have -- “is that all?” -- can be addressed with a simple yet powerful response: “Yes, that is all. We don’t need more.”  

A Real Mom Like You

Love & Embarrassment

There are emotions that are first experienced when you become a parent. Unconditional love is the main one that comes to mind.  It’s difficult to grasp the true meaning of ‘there is no love like a mother’s love’ until you become a mother.  

Another emotion often felt with parenting is embarrassment, and we’ve all been there with the screaming, unruly child acting out in public. When it first happens to you, it’s hard not to feel overcome with embarrassment.  You feel eyes watching you. You feel judgement.  But as time goes on, I think a mother learns and understands there isn’t one other mother who hasn’t been there; who hasn’t felt that embarrassment due to her child’s poor behavior.  And sadly, we’ve probably caught ourselves glaring at that mother with the unruly child.  Knowing how hard parenting truly is, we must try not to judge one another.  

So, the next time you begin to feel embarrassment at your child’s “childlike” behavior, try to stop and remember you’re not alone.  And maybe even more importantly, the next time you are witness to another mother in such a moment, make the effort to give her a nod, a smile or even drop a line, ‘I’ve been there!’ to let her know she’s not alone.

A Real Mom Like You

Why do we have environmental allergies?

Our immune systems play the biggest role in causing allergic reactions. To be honest, we don’t really know why people have environmental/seasonal allergies but there’s a very interesting theory proposed by allergy researchers. The Hygiene Hypothesis speculates that the very young immune system is primed to recognize and defend against substances or organisms that are potentially harmful to the body, especially parasites and bacteria. In undeveloped countries and rural areas where children spend more time in the dirt and around animals, environmental allergies are very uncommon. It’s thought that this is because the immune system is being exposed to the triggers it’s “programmed” to fight against to protect the body. If the immature immune system isn’t exposed to those triggers, it’s still ready to fight, so other triggers start to set it off. This is demonstrated by the fact that in developed countries, where there is good hygiene and little exposure to parasites and environmental bacteria, there is a much higher rate of environmental allergies. Essentially, our sterile, sealed, hygienic world makes our immune systems respond to triggers that aren’t inherently harmful to us because they’re not exposed to as many triggers that are harmful. It is the immune system’s recognition of, and reaction to, these environmental triggers as “enemy” instead of “friend” that gives us the symptoms that make us so miserable and are at times even dangerous.

Here are some common misperceptions about environmental and seasonal allergies:

1. People are born with allergies – Fiction
   Although certain types of allergies tend to run in families (especially foods and medications), most allergies show up after people have been exposed over and over to the things they eventually become allergic to. Allergies may be developing and cause no symptoms, or very low-level symptoms, for years and then suddenly reach a point where the immune system reacts vigorously,   causing the commonly recognized symptoms. Allergies may show up at any time in life, even after years of frequent and harmless exposure to the offending substance.

2)    You can grow out of your allergies – Fact (sort of)

Some allergies can seem to go away over a period of years, BUT there’s always a risk that those allergies will come back later in life.

3)      If you take your allergy medicines, your allergies shouldn’t bother you – Fiction

Your symptoms often depend on how much exposure you’re getting to what you’re allergic to. Sometimes there’s so much allergen (the triggering substance) out there that the medications just can’t keep up. Also, your reactions to the allergen might change, so you might have to add a new medication such as eye drops or nasal steroid spray. Although it’s unclear whether someone can develop resistance to an allergy medication they’ve used for a long time, sometimes switching to a different version of the same type of medication can help. For example, if you’ve been taking Claritin (loratadine) for a long time you might want to try Zyrtec (cetirizine). By the way, the generic versions of most nonprescription allergy medications work as well as the brand name medications. Finally, if your allergy medications don’t seem to be working as well as usual, consider doing more to avoid your triggers.

4)      You should only take your allergy medicine when you’re having symptoms - Fiction

If you know you have seasonal allergies or other allergies that are predictable as to when or where they might occur (like being exposed to a cat at a friend’s house), it’s better to start your medications before you start having symptoms. For seasonal allergies, take them every day as long as the triggers are in your environment. Prevention of the symptoms is more effective than treating them once they’ve started. This might mean taking allergy medicine every day for months at a time. The medicines commonly used for this are considered safe for both adults and children when used as directed.

5)      People with dog allergies can get “hypoallergenic dogs” so they won’t have any problems with their allergies – Fiction

There’s no such thing as a 100% hypoallergenic dog or cat, even one without fur or hair. It’s not the fur or hair that causes allergic reactions; it’s the dead skin cells and chemicals in the saliva and other secretions that cause trouble. Hypoallergenic dogs and cats may be somewhat less likely to cause allergic reactions, but there’s no guarantee that they’ll cause no reaction at all. Puppy kisses can be sweet and a lot of fun, but only until the allergy symptoms kick in.

6)      Having cats and dogs around very young children makes the children more likely to develop allergies – Fiction

Exposure to dogs and cats within the first 2 years of life actually helps prevent the development of allergies, not only to the animals, but also to other environmental triggers. The thought is they help the developing immune system recognize benign environmental triggers as “friend” instead of “enemy”. See the Hygiene Hypothesis above.

Dr. Lou Romig, Medial Director, After Hours Pediatrics Urgent Care

No BUTTS about it, every baby has diaper rash at some point in time. I will teach you how to recognize different types of rashes that affect that area and what to do for each of them.

The number one cause of diaper rashes is… diapers! Babies have always pooped and peed but how we’ve contained it has evolved from plant leaves, to animal skins, to thin cloths, to thick cloths, to disposable plastic and paper diapers. As we’ve made our modern diapers more leak-resistant, we’ve made them the perfect breeding ground for painful diaper rashes.

The area under a diaper is dark and damp, and lots of things can happen there, especially when it’s sealed tight for hours. Think of a Band-Aid on your finger. After you wash your hands throughout the day or even a couple of hours, and then take off the Band-Aid, the skin is moist and pale, wrinkly, and sometimes mushy. Now imagine what your finger would look like if there had also been poop and pee under there. That is exactly what you get under diapers. Most diaper rashes results from the irritation of stool on moist skin.

Cloths diapers hugged the baby’s bottom, but air could get through the cotton fibers. Today’s disposable diapers don’t let anything in or out--not liquid, not solid, not even air. Add those ruffled gathers that squeeze the legs, and the fact that moms use baby wipes instead of soap and water, and you have wet skin that can’t breathe, a nasty rash that gets rubbed by the diaper all day long, and one unhappy baby--and rightfully so!

So what can you do? If your baby has a diaper rash, treat it with four important things: soap, water, cream and air! With each diaper change, place the baby in the sink and wash their bottom carefully with your hand using only soap and water. Don’t use a washcloth because it can be rough and irritating. Then apply ointment or cream to make a barrier on the skin so it can heal without being rubbed raw. Plain Vaseline will do (no baby powder)! Then leave the baby’s diaper off for a good 30 minutes after changing so it can “air out.”

A specific kind of diaper rash that can occur during or after the use of antibiotics is a fungal or yeast diaper rash. The baby’s bottom will be red, but there will also be isolated spots that extend beyond the edges of the main rash. These are called satellite lesions and are specific for yeast infections. Also, the rash will extend into the groin creases. For this type of rash, an antifungal cream like Lotrimin is necessary.

And how can you prevent your baby from having diaper rashes in the first place? Customize your diaper! Start by pulling out the gathers around the legs. This opens up the leg of the diaper a bit, but then you must take scissors and cut the rest of the gathers in at least 8-10 spots to let the air flow thru. With the diaper on, you should be able to just see the child’s private parts. Then feed, poop, repeat!

Prevention is the best medicine for diaper rashes. Remember: too-tight diapers are BUTT BANDAIDS, but rather than making sores better, they can actually make them worse.

Pamela J. Beach-Reber, MD, MBA, FAAP, FACEP

After Hours Pediatrics Urgent Care/Nemours Children's Urgent Care

It’s that time of the year to commit to your New Year’s resolution.  One of the most common resolutions is a promise to exercise more and stay fit -- and it is often one we fail to keep!  Try these tips to help you and your family stay healthy in the New Year and all year long.

Choose an activity you can easily convert into exercise.  If you live close to your child’s school, don’t carpool.  Instead, walk or ride a bicycle.  With mom or dad walking or riding along, this simple activity can be turned into both a fun event as well as exercise.  Mix it up: walk one day, then ride a bike the next.  Save the car for rainy days.  Take different routes to make it interesting.  Stop off at a park on the way home.

Choose an activity that can easily be incorporated into your routine.  Walking or riding a bike to school with your children fits into your routine better than piling everyone into a car three times a week to go to a family gym!

Spice up the time when you perform routine activities.  If you set aside an hour every Saturday for the family to dust, vacuum, straighten the kids’ rooms, etc., make it fun.  Be silly.  Turn on music and dance while dusting.  The child with the best dance routine -- and who completes their chores -- gets a prize!

Get the family involved in a new activity.  Sign up the kids to learn martial arts: they will get a kick out of sparring with dad.  Have family swim meets at the pool with prizes for swimming across the pool the most times or for the first time a small child splashes into the water.  Get involved in ‘geocaching’ – finding hidden treasures and planting some as well.

Get a dog.  Walking the dog, running with the dog and throwing balls with the dog are all ways to get you and your family moving.

Find out which school activities you can participate in.  Many schools have walks and mini-races for special causes.  Get the family involved, and get into ‘training’ mode by practicing the activity in the weeks ahead.  Or, join in a club’s carwash to raise money for a trip. 

Plan ahead.  Everyone will be hungry after family exercise sessions.  Prepare healthy snacks, such as fruits and veggies -- not chips and cookies.  Drink water, not soda.

Health and family are two of the most important things in life: try combining them in the New Year and everyone will be better off!

Barbara L. Baldwin, DO, FACOP

Medical Director

After Hours Pediatrics Urgent Care

The threat of Zika has been dominating the headlines, and it’s important to know the facts so you can protect yourself and your family.

The Zika virus is most commonly transmitted to humans by the bite of an infected mosquito.  Zika is prevalent in Central and South Americas and the Caribbean; however, the identification of travel-related cases in the continental U.S. has recently progressed to more locally-transmitted cases.  

The best way to prevent contracting Zika is by protecting against mosquito bites: use an EPA-registered insect repellent; wear long sleeved-shirts and long pants; and eliminate standing water from around your home.

It’s important to recognize the symptoms of Zika in yourself or family members, which include: fever, rash, joint pain, red eyes, muscle pain and headache.  These symptoms typically last several days to a week.  There is no vaccine or medication to treat Zika.  In addition to mosquito bites, Zika can also be transmitted sexually, even before symptoms are present in the infected partner.  It is especially important for pregnant women to recognize Zika symptoms as the virus can cause serious birth defects and pregnancy complications. 

If you have questions or believe you may have contracted Zika, we encourage you to contact your primary care physician for appropriate testing.  Please be prepared to describe your symptoms and travel history.  CDC offers a resource to answer your Zika-related questions at www.cdc.gov/zika/. 

Joseph L. Chow, MD, MBA

President and Chief Medical Officer

TeamHealth Ambulatory Care

After a severe storm or hurricane, there are common pediatric complaints seen in emergency departments as a result of the weather experienced.  Children with seasonal and environmental allergies may have acute allergy symptoms, sometimes severe, and children with asthma/reactive airway disease can have attacks of wheezing and trouble breathing.  This is due to high winds that can cause unusual types and amounts of pollen and other allergens to be in the air and deposited on surfaces. In addition, flooding can cause the proliferation of mold, which can be highly allergenic (causing allergy symptoms). Children with allergies and asthma who are on daily medications to prevent allergy symptoms (such as loratidine, cetirazine, montelukast or inhaled oral/nasal steroids) should continue those medications and those who are not taking them might benefit from starting them after a storm.

Children assisting with post-storm clean-up around the home can be exposed to allergens through contact with plant/tree debris and contaminated surfaces. Children with severe allergies or asthma should not participate in these activities or should wear masks while assisting other family members.

Some children are dependent upon powered nebulizer machines to treat their asthma/reactive airway disease. Unfortunately, loss of power is a common problem during and after storms. Albuterol, the medication used for acute wheezing and wheezy cough can be given quite effectively to even very young children using a metered dose inhaler and spacer chamber with a mask or mouthpiece. This equipment does not need power, is very portable and very easy to use. Ask your primary care provider about obtaining an albuterol inhaler and spacer chamber if your child uses albuterol via nebulizer.  

In communities severely affected by a storm, pharmacies may not be open or easily accessible for days to weeks. Part of a family's hurricane preparations, both before the season starts and when a storm is forecasted to possibly affect their area, should include ensuring all family members have a sufficient supply of their prescriptions and over-the-counter medications to last for two weeks after a storm. In the state of Florida, the law requires that insurance companies approve and pay for early refills on prescription medications when the patient's county of residence is under a hurricane warning and the Governor has designated the county/state is in a state of emergency.  This applies only when the prescription has refills available. It is best NOT to wait until your area is under a hurricane warning to get additional medications but the law can help if necessary. 

Post-storm pediatric illness and injury is predictable, and by being prepared, we can enhance the level of medical care available to children after a storm. 

Lou Romig, MD, FAAP, FACEP

Medical Director

After Hours Pediatrics Urgent Care

When our children have fever or pain, we naturally want to make them feel better. Tender loving care can go a long way, but sometimes we need a little help from medications. When considering when to give medications for fever or pain and also what to give, the first thing to do is realize why we’re using the medication.

Pain is pretty self-explanatory – nobody wants their child to be in pain. Pain is not only upsetting, but it also can increase the heart rate, breathing and blood pressure (although not usually to dangerous levels) and make a child cranky or withdrawn. One of our key jobs as parents and caregivers is to reduce suffering by trying to minimize or prevent pain. Acetaminophen (such as the Tylenol™ brand) and ibuprofen (such as Motrin™ or Advil™) are our main tools to do that. Both are great medications for fever and pain, but ibuprofen has an added benefit of fighting inflammation, which acetaminophen does not. For this reason, ibuprofen is sometimes preferred for pain from injuries or illnesses involving inflammation.

Fever is one of the most common reasons caregivers seek medical evaluation for their children. There is much apprehension about fever: some people are afraid for their children when they have fever, having heard stories about fever causing brain damage and convulsions or even death. Couple that with the fact that children often look and act much sicker when they have fever, and it adds up to a lot of anxiety. Caregivers often turn to acetaminophen or ibuprofen, and sometimes both, in an effort to make the fever go away. There’s a lot of confusion about which medicine to give, how much to give and when to give it.

The good news is most stories about the dangers of fever are absolutely false! Fever from infection rarely goes above 106 F. The body temperature has to go above about 107 F before there is any damage to the brain or body. There is such a thing as febrile seizures, but they are limited to children between the ages of 6 months and 5 years. When they occur, they are usually very brief and do not cause complications. They are completely unpredictable and do not occur because the temperature goes above a certain level. They’re far scarier than they are dangerous. A fever that doesn’t go down all the way with proper doses of fever medication or one that comes back before the next dose is due is neither an indicator of the kind of infection (viral vs. bacterial) nor of the seriousness of the illness. The fact that you can’t completely control the fever is not something to worry about, as it means nothing about the infection that’s causing the fever. The fever will go away when the worst of the infection goes away.

The real reason to treat fever is to make your child feel better. Fever itself, regardless of the source of the infection, will increase the heart rate and breathing rate; make your child sleepy, cranky or clingy; and decrease their appetite. If you can get the fever down even a degree or two, your child will likely feel better, start eating and drinking better, and look much more like themselves. Then you’ll feel better too!

Both acetaminophen and ibuprofen are excellent medications for fever control. We tend to limit ibuprofen to children older than six months. Children with kidney disease, bleeding problems or a few other chronic illnesses may not be able to take ibuprofen. If your child has a chronic disease, check with your primary care provider to see if he or she can safely take ibuprofen. A few studies have suggested ibuprofen may be better than acetaminophen in helping to treat fevers over 102 – 103 F, while acetaminophen may be better for children who are also having stomach pain or upset, because ibuprofen can sometimes irritate the stomach.  Some children consistently seem to respond better to one medication than the other. Each individual illness may also respond better to a particular medication. If you get a feeling that one medication is working better than the other, use that medication.

Many medical providers recommend alternating acetaminophen and ibuprofen for better fever control. Studies suggest there may be a slight improvement in fever control when using both medications; however, there is also an increased chance the child will accidentally be given an overdose of one or both medicines, especially if more than one person is giving the child medication. With this possible safety concern about accidental overdose, there’s little benefit in using the medicines on an alternating schedule.  If you choose to alternate acetaminophen and ibuprofen, alternate them every 4 hours. For example, give acetaminophen at noon, ibuprofen at 4pm, acetaminophen at 8pm, and so on. If more than one person will be giving medications, keeping a written schedule may help reduce dosing errors. There is absolutely no evidence that giving acetaminophen and ibuprofen at the same time helps to control the fever. This practice can also lead to significant medication overdoses thus is not safe.

Oral dosing recommendations on the packages of medications are most often given in weight or age ranges. This can lead to under-dosing or slight over-dosing. It’s best to get a dosing chart or recommendations from your medical care provider so you can dose your child based on their current weight. We recommend ibuprofen to be given at 10mg per kilogram of weight (about 10mg for every 2 pounds) every 6-8 hours or acetaminophen at 15mg per kilogram of weight every 4-6 hours. Acetaminophen can also be given as a rectal suppository, but they are available in a limited selection of doses. Suppositories should not be split to modify the dose because the medication may not be suspended equally throughout the suppository, so one portion may have more medication than another. This limits the usefulness of the suppositories. It is not true that suppositories work better or faster than oral medication. Ibuprofen is not available in suppository form in the U.S.

To sum it all up, whether they have fever or pain, we use acetaminophen and ibuprofen to make our children feel better. With a few exceptions, both medications are safe to use when given in appropriate doses and with appropriate timing. Ibuprofen may be better than acetaminophen for injuries or illnesses that also involve pain and inflammation or for higher fevers. There is no need to alternate the two medications for fever. Keep it simple and use which ever medication seems to work better. Consult your primary care or urgent care provider to learn the safest and most effective doses to meet your child’s needs. 

Lou Romig, MD, FAAP, FACEP

Medical Director

After Hours Pediatrics Urgent Care

Parents: soon you will be rushing to buy clothes, school supplies and, oh yeah, get that health check-up completed.  Is it really all that important, you ask?  Your child has been running around all summer and judging by his appetite and outgrown clothes, seems very healthy.

The short answer is yes!  The annual school physical for children is quite important.  Most visits to the doctor during the school year are for focused problems, such as a sore throat or injury.  The annual pre-school check-up is a great opportunity to take a comprehensive look at your child’s health.

Perhaps the most important decision you make about the pre-school health examination is where it takes place.  Nowadays, there are many health care outlets that advertise and perform these evaluations quickly and cheaply.  While they may be able to fill out a piece of paper and perform a basic exam, is it really what your child needs?  Quite simply – no! 

Your child’s primary care physician provides continuity with records of growth, immunizations, medical history and ongoing care.  This is indispensable in providing a comprehensive assessment of your child and is impossible to duplicate. So, while there is certainly a time and benefit to taking advantage of urgent care center services, these centers simply cannot provide this level of care for back-to-school physicals.

For example, a child or adolescent’s growth is measured along a standardized growth curve and most follow a pattern that your doctor can immediately analyze based on prior measurements.  If there is a new trend to the growth that alerts your doctor to ask questions regarding nutrition, exercise and other symptoms, it might be related to an underlying medical condition.

Another important area is the determination of sports preparedness.  Your child’s doctor will assess the physical and sexual maturity and help guide you on which types of activities are suitable.  In recent years, there has been a large increase in sports-related injuries in children.  They usually occur because there is a mismatch between the physical maturity of the child and the type of sporting activity.  Many children want to ‘do it all’ and participate in multiple sports, but they might actually not be physically mature enough to do so.  As a result, ‘overuse’ injuries are now common and can be debilitating if not handled properly.

The assessment of emotional and behavioral health is as important as the physical elements of the pre-school evaluation.  Paralleling their physical growth, children, especially adolescents, undergo changes in how they interact with the world around them.  By assessing the emotional health and coping skills in conversations with the child as well as the parent, issues can be addressed quickly.  Your child’s primary care doctor will have lots of resources available to help address these issues.

So, the bottom line is to schedule NOW for your child’s pre-school health evaluation with your trusted doctor.  Don’t wait until the last minute and settle for getting a paper filled out by a stranger.

Charles A. Welborn, MD, MPH, FAAP, FACEP

After Hours Pediatrics Urgent Care

When shopping for your child’s school backpack, there are important factors to consider. Carrying too much weight in a backpack or wearing it the wrong way can lead to unnecessary pain and strain for your child. Parents can take these steps to help children load and wear backpacks the correct way to avoid potential health problems.

Loading a backpack

A child’s backpack should weigh no more than about 10% of his or her body weight. This means a student weighing 100 pounds shouldn’t wear a loaded school backpack heavier than about 10 pounds.

Load heaviest items closest to the center of the child’s back (the back of the pack).

Arrange books and materials so they won’t slide around in the backpack.

Check what your child carries to school and brings home. Make sure the items are necessary for the day’s activities.

If the backpack is too heavy or tightly packed, your child can hand carry a book or other item outside the pack.

If the backpack is too heavy on a regular basis, consider using a book bag on wheels if your child’s school allows it.

Wearing a backpack

Choose a backpack with wide, padded shoulder straps and a padded back.

Distribute weight evenly by using both straps. Wearing a pack slung over one shoulder can cause a child to lean to one side, curving the spine and causing pain or discomfort.

Select a pack with well-padded shoulder straps. Shoulders and necks have many blood vessels and nerves that can cause pain and tingling in the neck, arms, and hands when too much pressure is applied.

Adjust the shoulder straps so that the pack fits snugly on the child’s back. A pack that hangs loosely from the back can pull the child backwards and strain muscles.

Wear the waist belt if the backpack has one. This helps distribute the pack’s weight more evenly.

The bottom of the pack should rest in the curve of the lower back. It should never rest more than four inches below the child’s waistline.

School backpacks come in different sizes for different ages. Choose the right size pack for your child as well as one with enough room for necessary school items.

Information cited from American Academy of Pediatrics and The American Occupational Therapy Association, Inc. 

Lou Romig, MD, FAAP, FACEP

Medical Director

After Hours Pediatrics Urgent Care

According to the American Academy of Pediatrics, the summer camp experience “has proven to have a lasting effect on psychological development, including significant effects on self esteem, peer relationships, independence, leadership, values and willingness to try new things.” 

With that, children generally like to participate in group activities and share among themselves while at summer camp; therefore, it is not uncommon for ‘little’ epidemics of minor illness to sweep through camps.  These may include conjunctivitis (pink eye), strep throat, stomach viruses, etc.  While some of this is inevitable, the occurrences can be lessened in two ways.  First, if your child is obviously ill, do not send him to camp.  You will only help spread his illness to the other campers. Second, it is the camp’s responsibility to send home any child that is sick in order to limit the spread of the illness.

What other health issues should you prepare for when sending your child to summer camp?  Camps offer a wide range of activities and almost all programs have some level of physical exercise.  Combine this with the general enthusiasm of children and there are bound to be bruises, minor cuts, falls, and occasionally more serious injuries such as broken bones.  The best medicine here is prevention: camps that stress proper supervision of play time and physical activities have lower rates of injury.  In addition to these injuries, also consider the fact that your child may be susceptible to heat-related illness, especially in the high heat and humidity of the summer months.  Make sure your camper has adequate hydration while at camp.  If the camp involves lots of outdoor activity, make sure there is a plan in place to prevent but also recognize symptoms of heat-related illness, such as heat exhaustion and heat stroke, which are dangerous conditions.

If you are considering what camp may be best for your child, here are a few items to think about.  Ensure the camp activities are appropriately matched to your child’s medical needs.  For many children, this may be as simple as having a camp physical performed with your primary care provider to validate their good health.  For those children with ongoing medical concerns, such as asthma, anaphylactic allergies, seizures or diabetes, for example, the routine activities of the camp should not place the child as risk for exacerbating any of these conditions.

Next, if the camp is a sleep-away camp, it should be able to provide basic medical care for a child with ongoing medical needs.  Staff should be trained in basic medical first aid and CPR, and should be qualified to store and administer any medications your child will need while away from home.  If your child attends a day camp, staff should have basic first aid training, CPR, and depending on your child’s needs, be able to administer necessary medications.  Whatever the type of camp, it is very important that the camp staff is aware of your child’s medical needs so they can be proactive in anticipating those needs.

The AAP guidelines offer specific and detailed information for camp administrators on preparing for the best and healthiest camping experience for both children and staff.  Camp health officials need to prepare and maintain health care and vaccination records, emergency plans; and need to anticipate emergency scenarios and how they will be handled. The AAP says all camps should have written health policies that have been reviewed by a physician who specializes in children’s health, and all camp health care providers should be trained and understand the health guidelines, including plans for treating both major and minor illnesses and injuries. Local emergency providers should be contacted before the start of camp to discuss emergency response times and plans of action.

Parents should ensure the camp meets the needs of their child’s interests and skills, so it is important to match the interests of the child to the camp offerings.  Keep in mind that homesickness is one of the most common things experienced by new campers, and parents can play a role in helping their camper to feel less anxious about being away from home and loved ones. Parents are encouraged to discuss homesickness openly with their child, demonstrating positivity about the upcoming camp experience. Involve your future camper in the process of choosing their camp and in preparing for camp. Parents are encouraged to have “practice” excursions for their young campers, where they will be away from home with friends or relatives. Frame the upcoming camping experience as being an exciting adventure that will help build positive feelings in the camper, rather than anxiety.

To select the proper camp for your child, be sure to look at the mission and goals of the camp, speak with the camp directors, and discuss the possibilities with your child in order to find the best placement. 

Elizabeth Brennan, MD, FACEP

Charles A. Welborn, MD, MPH, FAAP, FACEP

After Hours Pediatrics Urgent Care 

A major advantage of living in Florida is being able to enjoy the summer-like weather all year around. While we’re used to kids playing outdoors, we shouldn’t take for granted important safety precautions to protect our little ones.

How do we protect children’s skin while they have fun in the sun?

The two main recommendations from the American Academy of Pediatrics to prevent sunburn are to avoid sun exposure and cover up using lightweight cotton clothing, hats with wide brims, and sunglasses.

Children should avoid playing outside during peak sun exposure, between the hours of 10am and 4pm, and stay in the shade whenever possible.  Be sure to apply sunscreen that provides high SPF with both UVA and UVB protection on both sunny and cloudy days, and reapply at least every two hours or after swimming.

How do we keep children protected from the heat?

Heat and humidity can affect children more than you might think.  Children should stay well hydrated: if they are engaging in sports activities, make sure they are well hydrated BEFOREHAND and have easy access to water or a sports drink during activity.  They should be hydrating every 20 minutes and after one hour of sports activity with a sports drink or other available carbohydrate sources to replenish energy stores.  When heat and humidity reach critical levels, outdoor activities should be limited to no more than 15 minutes.

What should we do to keep children safe in the pool?

Enough can never be said about the topic of pool and water safety.   NEVER leave children alone near a pool, spa or other body of water, not even for a moment.  And, keep in mind when there are multiple adults around, everyone assumes someone else is watching the kids. Many drowning and near drowning incidents involve large parties with many children and adults present.  It is very easy for a child to fall into the pool without someone noticing with so many distractions present.

Whenever infants and toddlers are in or around water, an adult should be within an arm’s length, using ‘touch supervision’.  If your children are using inflatable swimming aids, do not be lulled into a false sense of security.  They are NOT intended to be substitutes for approved life vests.

 What about children and boating safety?

Children should wear life jackets at all times while on boats or around a body of water.  Make sure the life jacket is the right size for your child, i.e. not too loose, and worn as instructed with all straps belted. As the adult, wear a life jacket for your own protection and to set a good example.   Blow-up water wings, toys and rafts should not be used as a substitute for life jackets or personal flotation devices.  Adolescents and adults should be warned of the dangers of boating under the influence of alcohol and drugs, even some prescription medications.

Elizabeth Brennan, MD, FACEP 

Many children will have an occasional wheezing episode in their early childhood.  Rather than call it asthma, which is a chronic, recurrent illness, pediatricians initially call this wheezing: ‘reactive airways’.  The typical child develops a runny and stuffy nose or viral cold symptoms; then within 1-3 days, a tight, dry cough develops.  Most parents do not hear wheezing until after the cough develops.  If the wheezing becomes chronic and matches certain criteria, your child may be given a diagnosis of asthma.

The wheezing in a child is the result of two different processes.  The first is an inflammation that causes a thickening of the walls of the breathing passages in the lungs and also produces extra mucous.  The second is a tightening of the muscles that surround these same breathing passages.  The medicines used to relieve wheezing will treat one of these two processes will differ depending on whether the child needs quick relief from the wheezing or needs a maintenance medication to prevent wheezing.

In the child who is wheezing and needs quick relief of respiratory symptoms, bronchodilators and steroids are typically used.  Rapid acting bronchodilators are medicines that relax the muscles surrounding the large breathing passages in the lungs.  These medications include beta agonists such as albuterol (Proventil) and levalbuterol (Xopenex), as well as anticholinergics such as ipratropium (Atrovent).  Oral steroids such as prednisone are used to quickly reduce the inflammation in the breathing passages.

Long-term controller medications are used for children who have frequent wheezing.  These medicines focus on the prevention of wheezing when the child is exposed to a trigger such as a viral illness or allergen.  Long-acting bronchodilators such as salmeterol (Serevent) help keep the muscles around the breathing passages relaxed.  Inhaled (not oral) steroids such as budesonide (Pulmicort), or leukotriene modifiers such as montelukast (Singulair) assist in reducing inflammation over time.  At times, different types of these controlling medications are combined in a single medication.  An example is the combination of salmeterol (a long-acting bronchodilator) and fluticasone (an inhaled steroid) in the medication Advair.

It is very important that if child is using the long-term controller medications and starts to wheeze, the quick relief or ‘rescue’ medications must be used to relieve the wheezing.  Simply giving more of the controller medications will not work, and your child will not improve.

Learning to use the right medications at the right time for your child can be confusing.  Be sure to discuss the types of medications your child is using with your doctor and write down the proper way to use them.

Paula Rooney, PA-C

After Hours Pediatrics Urgent Care

We have a dog/cat so my children are not afraid of animals.  Why should I be concerned about animal bites?

Most people are bitten by their own pet or one they know.  It is estimated that each year, more than 2 million people across the U.S. are bitten by animals, and about 800,000 require medical treatment.  Dog bites account for more than 90% of these injuries, and cat bites account for most of the remainder.  The number of recorded dog bite injuries is significantly higher in children than adults. In fact, about 50% of school age children have experienced a dog bite at some point in their lives.

Which is worse, dog bites or cat bites? 

Dogs have strong jaws and relatively dull teeth compared to cats, so the wounds caused by dogs are usually a crushing injury of the tissue that is bitten and/or lacerations or tearing of the skin rather than puncture wounds. Most dog bites do not penetrate deeply enough to get bacteria into bones, tendons or joints; but they often do a lot of damage from the trauma of the bite. Tissue that has been crushed, however, such as with a bite to the hand, is particularly susceptible to infection.

Cats’ teeth are thin and sharp, so the wounds they cause are more likely to be puncture wounds. These wounds can reach into joints and bones and introduce bacteria deeply into the tissue. Puncture wounds are very difficult to clean, so a lot of bacteria may be left in the wound. Also, most cat bites are to the hand, which makes infection more likely.

Dog bites often do more outright damage, but only 3-18% become infected. In contrast, cat bites may appear more trivial, but up to 80% of cat bites may become infected if proper care is not taken.

What should I do if my child is bitten?

First, you want to calm and reassure your child.  If the wound is not bleeding heavily, it is important to thoroughly cleanse it by washing and lightly scrubbing with mild soap and running water for 3-5 minutes.  Then, cover the bite with antibiotic ointment and a clean dressing and notify your pediatrician or go to the ER to have the wound evaluated.   If the wound is bleeding heavily, cover it with a dressing, apply pressure and take your child to the ER to be treated. 

Overall, animal bites should be evaluated by your primary doctor or by an Emergency Department physician because of the risks of infection, foreign material in the wound, and the possibility of nerve or blood vessel damage.  The doctor will evaluate the need for antibiotics (especially for bites on the hands and feet); the need for a tetanus booster; and whether rabies prophylaxis needs to be considered.

How can I tell if the bite is becoming infected?

Symptoms of infection at or around the bite site may include: redness, swelling, increasing pain, pus drainage, red streaking from the bite site and fever.

How can my family and I avoid being bitten?

PREVENTION IS KEY! First, NEVER leave a baby or small child alone with an animal.  In small children, bites to the face, neck or head are extremely hazardous. Because their small stature often puts their heads near dogs’ mouths, children are often bitten in these areas. Dog bites can cause fractures of the face and skull.

Teach children, including toddlers, to be careful around pets and other animals by not:

Contacting or interacting with unknown animals. Even animals that appear friendly can bite if provoked.

Feeding or trying to catch or play with wild animals, such as squirrels, raccoons or rats.

Disturbing an animal while it is feeding or taking care of its babies.

Aggressively playing with an animal. Even the family dog can bite its owner by accident while playing tug of war.

Sticking fingers into animals' cages, for example at the pet store or zoo.

Elizabeth Brennan, MD, FACEP

After Hours Pediatrics Urgent Care

Fever is an important defense mechanism to help the body battle infection. And since fever helps fight infection, we do not want to treat the fever, but rather we want to treat the child's discomfort.

The height of the fever does not show any direct correlation with how sick your child is. Simple infections like a cold virus or sore throat can cause high fever whereas some very serious infections can cause no fever at all.

So what numbers define a fever? A fever is considered to be present when a child has a temperature of 100.4 F (38 C) in the bottom, 99.5 F (37.5 C) in the mouth or 99 F (37.2 C) under the arm.

In the last half of the 20th century, we have come to believe that fever is bad. This is unfounded and has led to “fever phobia”. Fever does not harm, does not kill you and does not cause brain damage. But it can trigger febrile seizures, which are seen in 5% of children under the age of 5, and this is the main reason for our "fever phobia". Febrile seizures occur when the body temperature changes very rapidly, like boiling water in a microwave.

The body's thermostat is set to go no higher than 105 F, EXCEPT when a child is locked in a car on a hot day!

Treat the child, not the fever!

If the child is alert and smiling, playing at intervals, eating and drinking fair with good amounts of urine output, let the fever do its thing.  If the child is lethargic, won't drink and is very irritable, then treat the discomfort and seek help from your doctor.
Never wake a sleeping child to take their temperature or to give a fever reducing medicine.  In this case, the fever is not bothering them, only you!

So, how do we treat a fever? Acetaminophen (Tylenol) and ibuprofen (Motrin or Advil) are both effective in reducing discomfort. It has not been shown conclusively that one works better than the other, nor has alternating the two shown to be better than one or the other alone.  However, alternating two different medicines does contribute to parent errors since acetaminophen is given every 4-6 hours and ibuprofen is given every 6-8 hours, thus their concentrations and therefore dosing amounts are different.

Both of these medications have their own side effects: liver damage can be seen with prolonged use of acetaminophen and stomach pain with or without bleeding or kidney damage can occur with ibuprofen.  There has also been noted to be a possible association between acetaminophen and worsening of asthma.

Never give children aspirin because of the association between aspirin and a serious illness called Reye's syndrome. Also, do not give ibuprofen to infants younger than 6 months.
 Most of all, it is important to monitor the child's well-being, activity and hydration, rather than the height of the temperature.  The goal of fever reduction is to make the child more comfortable.

So treat the child, NOT the fever!

Pamela J. Beach-Reber, MD, MBA, FAAP, FACEP

After Hours Pediatrics Urgent Care