The safety issue relates to the way that the safety belts themselves restrain the child.  In order for the belt to restrain the child without causing injury, the belt must nestle against the child’s bones, rather than soft tissue.

Delaware law (click here for interesting info) requires kids to be in their car seats while travelling until the 8th birthday, or 65 pounds, whichever comes first.  But following this rule does not guarantee safety, especially for smaller kids, because of the geometry of safety belts.

To convince yourself (and your child, if she is agitating to get rid of the booster seat), you can try this test:

Let your child (over 8 years old and 65 pounds) sit in the back seat of your car, with just a seat belt on.  Drive around the block once or twice, then park in your driveway.  BEFORE the kids get out of the car, go to the back seat and check the position of the seat belts on the child’s body.

The lap belt should strike the child’s lower hip bones.  And the shoulder belt should be laying across the hard clavicle (collar bone).  If the lap belt has slipped up across the soft tissues of the belly, or if the shoulder belt lays across the soft tissues of the neck, then it is not safe for the child to be transported this way: in an accident, the safety belts themselves could cause soft tissue damage.  The purpose of the booster seat is to raise the child, so that the safety restraints are in the proper position.

Frankly, I think the only reason that a child would want to get rid of a booster seat is to think of themselves as more “adult”.   But the booster seats let the kids see out the car window better!  My daughter, who was rather petite, needed to use a car booster seat until she was almost 10.  When she complained, I performed the demonstration above, and she quickly understood the need.

(For information about car seats for younger kids, click here.)

–  David Epstein, MD

But medications can be expensive!  Your insurance plan’s drug benefit should help cover the cost, but sometimes there’s a problem.

If you arrive at your pharmacy and discover that your prescription is much more expensive that you expected, please have the pharmacy call us right away.  Perhaps we’ve prescribed a brand that your insurance company doesn’t cover.  Or perhaps there’s an equivalent medicine that works the same but costs less.   Or maybe the drug manufacturer has a “trial program” that would get you started at minimal cost.

We are quite happy to make a switch if we think it will work as well.  But we don’t know about the cost problem unless you tell us.   Don’t be shy!  Unfortunately, we can’t keep track of all the insurance formularies, because they’re all different.   And we don’t keep drug samples in our office.  But with the help of your pharmacist, we can find out which effective treatment will result in the lowest out-of-pocket expense for your family.

I’m always sad to hear that a family has decided not to purchase medication that I’ve prescribed because they can’t afford the cost, or that the family spent more than necessary.

Whether the medication is for eczema, asthma, ADHD or an infection, there’s almost always a way to make sure that you can afford your medication.   PLEASE call us before deciding that you can’t afford a medication that we’ve prescribed!

–  David Epstein MD

The most important technique is to expose the base of the cord.  If the base is not exposed to air, then bacteria can thrive in the wet, low oxygen environment; this may lead to infection.

Hydrogen peroxide, wetted on a gauze or cotton ball, is perhaps the best choice for cleaning.  Rubbing alcohol was recommended in the past, but it tends to cause rashes.  A little mildly soapy water can also be used.

Grasp the cord with your fingers, and pull up gently.  At the same time, pull the skin away from the cord, all around the cord, to expose the yellow base.  Then you can clean, all around, with the gauze wetted with hydrogen peroxide.  If the cord smells bad or seems infected, you can smear a little antibiotic ointment (such as neosporin) around and on the base of the cord.

You can clean the cord as often as needed, perhaps 3 or 4 times a day.  You may be instructed not to bathe your baby in the tub until the cord falls off; but I don’t feel strongly about this.  If your baby seems dirty or sticky, you may give a quick (warm) tub bath, then dry the infant thoroughly; then open up the base of the cord (as above) to allow drying.

Textbooks say that the umbilical cord usually falls off by two weeks of age.  But my experience is that the cord may stay attached longer, sometimes as long as 4 weeks.  I suspect the reason is that patients take such good care of the umbilical cord that it takes a while to deteriorate!

If you see the skin around the umbilical cord getting red, he should be examined to rule out infection.  But this is unusual.

–  David Epstein, MD

But most babies who cry a lot don’t have colic.  I haven’t made this diagnosis more than 2 or 3 times in my 20+ year career.  There is usually some other explanation for a baby’s fussiness.

For starters, true “colic” refers to a baby who cries all day and all night.  If your baby cries only at night, for example, and seems fine during the day, she probably doesn’t have colic, and may not have any medical problem at all.

A persistently crying baby with no other symptoms should be examined, to rule out an ear infection or other medical illness.  But most commonly, the medical exam is normal.

Here are some of the possible causes for fussiness in babies.

Overstimulation:  When my daughter was born, our friends and relatives were as excited as we were.  We had many visitors.  She slept all day, but then screamed all night.  Once we finally figured out that we needed to limit visitors during the day, she was more alert in the day, we all slept better at night.  TV is another important cause of overstimulation; I recommend that the TV be limited to an hour a day within the baby’s hearing.

The “fussy period”:  At a few weeks of age, many infants will start crying every evening.  The infant may start to get wound up just after supper, then wail on and off until he exhausts himself before midnight.  These infants sleep fine the rest of the night, and they seem fine in the daytime.  This “Fussy Period” is well known.  It is frustrating but not serious, and most babies grow out of it by about 6 weeks of age.  This is another manifestation of overstimulation.  During the day, do what you can to limit the noise, and handle the baby gently; when the baby is wailing, certainly offer feedings, holding, and other comforts; and get through it as best as you can.

Parental excitement: The noise that a screaming newborn makes is close to intolerable.  Exhausted, frightened parents can be desperate to calm the baby.  But please be assured that if the baby is gaining weight, is feeding well, and has no other sign of illness, then it is very unlikely that the screaming represents a medical emergency.  In fact, parents can inadvertently overstimulate a screaming baby.  Vigorous bouncing, loud “shh”‘ing, and patting the baby may inflame his mood, causing a vicious cycle.  Instead, the most effective action is to role-model the calm behavior that you would like the baby to perform.  You can hold the baby close, move slowly if at all, and speak quietly if at all.  The louder the infant becomes, the more quiet and soothing you can try to be.  It may take an hour, or much longer!  But, through your role modelling, your infant will learn self-soothing; he will learn to manage his own emotional state, which is a very useful skill for anyone to learn early.

Teething: probably not a cause of infant colic.  Infants may start chewing and drooling for months before the first tooth breaks through.  But infants under 2 months old are unlikely to have behavior changes due to teething.

Formula “allergy”:  Most infants can handle any commercially available formula.  But some will have a formula intolerance, manifested as persistent vomiting, diarrhea, or constipation.  Simple crying without other symptoms is rarely due to formula intolerance; but a change in formula might be worth a try.  Try switching to a soy formula, or Nutramigen (or their generic substitutes).  Don’t bother with low-iron formula; there is not enough iron in formula to cause intestinal problems, although the iron is needed to prevent anemia.  Don’t switch to another formula in less than 5-7 days; rapid formula changes will leave you unsure which one helped the most.

Gastroesophageal reflux:  In my experience, “silent reflux” is the most common medical cause of persistent crying in infants.  Stomach contents may not reflux all the way into the mouth, but the discomfort of having stomach acid refluxing into the esophagus can cause crying and arching.  Keeping the baby upright during and after feeds can help.  If not, a visit to the office might be useful; the baby should be examined, then we might try thickening the milk with cereal, or medication.  Sometimes XRays are needed.

A persistently crying newborn can be frustrating, or even frightening.  But there’s usually a treatable cause.  So don’t give up hope – and try to get some sleep!

–  David Epstein, MD

Until now!  Recently, I have seen a steady stream of recent research suggesting that vitamin supplements, especially with Vitamin D, might be useful.

People with low blood levels of Vitamin D have reported 40% more frequent respiratory infections.  The association is even stronger for those with asthma or other lung diseases. (Arch Intern Med. 2009; 169:384-390.)

Teenagers with low Vitamin D levels are twice as likely likely to have high blood pressure, obesity, and high blood sugar.  They were also more likely to have cholesterol problems.  The same finding has been previously reported in adults.  Low Vitamin D levels have direct effects on blood pressure metabolism and insulin levels, and might also be a marker for poor diet.  Vitamin D tends to be drawn into fat tissue, so people with obesity probably need higher Vitamin D intake.  (Click here for the article. 1)

And, of course, Vitamin D’s relationship to bone health is well known.  This has led to universal supplementation of milk with Vitamin D, to complement milk’s calcium supply.  Kids should be happy about this; they don’t need to swallow cod liver oil any more!

Vitamin D deficiency turns out to be surprisingly common.  61% of American children have low serum Vitamin D levels, and almost 10% are frankly deficient.  Only 4% of kids take regular children’s vitamin supplements.  (Click here to see the data. 2)

As a result, the AAP now recommends Vitamin D supplements for all children, 400 IU (”International Units”) per day.  (Click here for the AAP report. 3) (Most children’s vitamin supplements provide this amount, but check the label to be certain.)  But even this may turn out to be insufficient for some kids.  Obese children, and kids taking seizure medications, might need more.

What do I recommend?

• Infants fed with breastmilk should be given a daily vitamin supplement, starting at 1 month of age (such as Tri-Vi-Sol).  (Formula already contains vitamin supplements, so infants taking more than 16 ounces of formula per day don’t need Tri-Vi-Sol.)
• For kids over 1 year, and actually into adulthood, a regular vitamin supplement (any brand) should be given daily.  Any brand should be fine; I suggest you find a brand that also provides mineral supplementation, such as iron, zinc, and even selenium.
• Unfortunately, blood testing for Vitamin D is problematic.  Some doctors recommend keeping levels above 20 ng/ml; but others recommend levels above 20 ng/ml.  Lab testing and reporting of Vitamin D levels are not yet standardized.  And Vitamin D levels vary normally with the seasons.  So I don’t recommend blood tests except under specific circumstances.

And don’t forget to check my handout on Calcium supplements (click here).

–  David Epstein, MD

1. [PEDIATRICS Vol. 124 No. 3 September 2009, pp. e371-e379]
2. [PEDIATRICS Vol. 124 No. 3 September 2009, pp. e362-e370]
3. [PEDIATRICS Vol. 122 No. 2 August 2008, pp. 398-417]

This is certainly not a “new” vaccine;  the H1N1 vaccines are just like the regular seasonal vaccine, made by the same manufacturers, who use the same egg-culture process.  There’s a different flu virus inside, but that’s little different than the “new” seasonal flu vaccine that comes out each autumn.

Side effects?  I’ve heard of no reactions from my patients so far, other than occasional 1-2 days of fever.  So there’s no reason to be more fearful of the Swine Flu vaccine than any other routine immunization.  (Click here to visit my post last month about the safety of flu vaccines.)

It’s unfortunate that there’s so much noise and misinformation about flu vaccines.  Much of it stems from recent political activity from groups who oppose universal vaccination.  (Click here to see my thoughts about that issue.)

But the facts are plain.  Thousands of people die each year from influenza.  The CDC reports that 324 Americans have died from Flu since April (as of 2/10/10), including 260 children.  (Click here to see the data.) Thousands more have been hospitalized.

But I’m not aware that anyone ever died from a flu shot.  The balance of safety is certainly convincing: we’re all better off getting vaccinated!

–  David Epstein, MD

We’ve only received 100 doses of the shot for infants and toddlers so far.  We hope to have further shipments soon, so that we can vaccinate everybody, but it’s possible we’ll run out temporarily.  Remember that you need 2 doses (at least 3 weeks apart) for the best immunity (estimated at 85%), but the first shot gives some useful protection (estimated at 75%).  So we’ll try to give everybody the first dose before we start giving boosters.  Once we have received enough vaccine, we’ll start administering the boosters.

We have also received a second shipment of the H1N1 shot for older kids (with preservative).  So now we have enough H1N1 vaccine to vaccinate all our high-risk patients for their first vaccine.  If your child has asthma (or other high risk illness), you should be on our schedule now to receive the first dose.  I’ll post a note here when we have enough for boosters.  We now have enough seasonal flu vaccine for all our patients as well; all kids should be given both.

To give you some perspective, Delaware Modern Pediatrics has received only 300 of the 2300 doses of H1N1 we ordered for our patients.  Obviously, supplies are still tight.  This is not the fault of the Division of Public Health; the manufacturing process for flu vaccine is antiquated and slow.  We have similar supply problems with the seasonal flu vaccine in most years (though not this year); but the shortages haven’t been as noticeable because demand for flu shots has never been this high.

Should you have your kids vaccinated through school?  Yes, absolutely, if you can!  The only exception is for kids with asthma (or other serious underlying disease) who are being offered only the nasal flu vaccine at school; those patients should be given the injection (available through our office for our current patients).

The vaccine we have received is a shot.  It’s the type “with preservative.”  If your child is able to receive the Swine Flu vaccine from another source, such as your school, I strongly encourage you to do so!  The only exception is if the school’s vaccine is the nasal “Flu-Mist” type, which is a live virus, which would be contra-indicated for kids with chronic conditions such as persistent asthma.

So, regrettably, we still can’t schedule flu shots for kids not on the high-risk list.  I still expect to receive further shipments of H1N1 vaccine – and I expect that we’ll be able to vaccinate all our patients by the end of the flu season!  I’ll post a note on the blog here, when we receive enough to vaccinate everybody.

–  David M. Epstein, MD

But pressure against these videos has continued to mount.  Disney, who bought Baby Einstein in 2001, calls the bad publicity a “smear campaign.”  But on September 4th, as reported this week on the New York Times front page, the Campaign for a Commercial-Free Childhood convinced Walt Disney Studios to offer a full refund.  The refund applies to any Baby Einstein DVD purchased after mid-2005.  Return your DVD, and get a check for $15.99 – no questions asked!  You don’t even need the original receipt, or even the box.  Just mail in your Baby Einstein DVD before March 4, 2010.

To download the refund form, click here. Or go to the Baby Einstein website, and search for “einstein moneyback;” the link for the refund form will be on the right-hand side of the page.

Remember that the American Academy of Pediatrics still recommends that there’s no reason to turn on the TV at all, for children under 2 years old; and for kids over 2, limit screen time to 10 hours a week.

–  David Epstein, MD

Should you sign your child up?  Yes!   If the school is ready to give your child a flu vaccine, I recommend that you participate.   We expect to have the vaccine in stock also, but I don’t know when it will be delivered.  If you’d prefer that we administer it instead of your school’s nurse, we’ll be happy to help.  (I’ll post a note on the blog when we get it in!)

The Swine Flu nasal vaccine probably will be delivered before the injections.  The live nasal flu vaccines are perfectly appropriate for any child over 2 years old, if they don’t have asthma (severe enough to have 4 attacks a year or more, or needing daily asthma medication.)

–  David Epstein, MD