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By contactus@allchildrenpeds.com
August 01, 2018
Category: Uncategorized
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By Dr. Claire Cowley, FAAP, CLC

"Sleep with the fishes", "to sleep per chance to dream", "sleep like a baby", "sleep on it", "beauty sleep".  Sleep is monumental and essential as in this Irish Proverb:  "A good laugh, a long sleep are the best cures in a doctor's book".  Did you know animals would die of sleep deprivation before starvation?  So sleep is important for our looks, our health, both mental and physical; philosophers, writers and most everyone agree.  Thomas Edison wrongfully, we now know, disagreed "sleep is an absurd waste of time".  Americans now sleep about two hours less than they did a century ago with alarming consequences.  Underslept people are more moody, irritable, and irrational.  Sleep deprived suspects held by the police, it's been shown, will confess to anything in exchange for rest.  Lack of sleep in adults is associated with hypertension, obesity, type 2 diabetes, changes in cognitive function, increased heart disease and increased dementia risk.

In children sleep deprivation mimics ADHD (Attention Deficit Hyperactivity Disease) and is associated with depression, bedwetting, behavioral issues and growth disturbance.

How much sleep do children need?  Toddlers and preschoolers need about 11-13 hours, perhaps 11 at night and 2 hours of napping.  The napping may be no more than a quiet time; grade schoolers need 9-12 hours and teens through early adulthood need 8-10 hours.

Parents note sometimes that a child past their bedtime has a hard time settling down and may fight sleep and for those, an earlier bedtime may be appropriate.  Usually a bedtime between 7 and 8pm is appropriate with waking between 6:30 and 7:30am.  Kids that are more tired fight sleep and naps and exhibit some negative behaviors like defiant behavior, being accident prone and excessive talking.  Watch for the earliest signs of sleepiness; rubbing their eyes, lack of focus, yawning or crankiness.  Wait too long and you'll see a child who is wired, jumpy, frantic and a lot harder to get down.

Adolescents are a whole different set of issues:  so many activites and cell phones and other devices practically attached to their bodies.  Overscheduling, jobs, and homework make it difficult to get enough sleep.  During sleep we produce growth hormone which we need in youth to attain full growth and througout our lives to service all of our body systems.

One of the best things we can do as parents in this regard is model good sleep hygiene ourselves, by making good habits a family priority.  Look at the time a child needs to be up in the morning and plan backwards to get the proper amount of sleep.

A wise college student told me this past week that they noticed when they studied prior to a reasonable bedtime and got a good night's sleep they did better on testing than cramming all night. Our waking brain collects information and our sleeping brain consplidates, edits and stores it.  Think of our high achieving, fast track bright adolescents getting 5 and 6 hours of sleep on school nights; they risk depression, obesity, hypertension, ADHD like symptoms and more accidents due to loss of alertness.  In the United States on the Monday after Daylight Savings Time changes, there's a jump in fatal car crashes and heart attacks by 25%.

Melatonin is available over the counter and is suggested even by some physicians to promote good sleep.  Do we really need it?  Our levels surge at about 6 months of age and decline after age 50.  Circadian rhythm is the natural sleep wake cycle set up by light and dark to which the brain responds by releasing melatonin, signalling our brain to sleep.  Healthy humans without organic brain issues, circadian rhythm disturbances (like blindness or jet lag), ADHD or autism shouldn't  require extra melatonin.  Rather, a regular bedtime, a pre-bedtime routine which does not include stimulating activities like TV or rough play, a routine in which the parent is not in the room when the child falls asleep is best.  No caffeinated beverages for 6 hours prior to bedtime and no screen time 1 to 2 hours prior to bedtime.  The routine should be 20-45 minutes and might involve 3-4 soothing activities like bathing, changing to pajamas and reading stories.  The child goes to bed drowsy but awake.  A consistent bedtime helps to reinforce our natural circadian rhythm and fall asleep more easily, security at a very basic level.

Think of the homeless kids in our community trying to get an education while sleeping in cars, shelters and unstable situations.  Think of the attributes of the sleep deprived child; it's no wonder they have issues in school.  In closing, I have included an excellent link with a table to summarize good sleep hygiene.  Sources: The American Academy of Pediatrics, National Geographic, UpToDate and the online resource "Sleep Lady". 



By contactus@allchildrenpeds.com
May 16, 2018
Category: Uncategorized
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 The prevalence of dental cavities has decreased over the past couple of decades, but continues to account for one of the most common chronic diseases. Many oral health concerns begin in childhood, but the risk of developing dental disease decreases with good preventative care.

Below are some of the most common questions addressed with pediatricians about the health of children’s teeth.

  • When should parents start brushing their child's teeth? 

It is never too early to start going through the motions of brushing your child's teeth. Before your child has teeth, you can simply massage his/her gums. Daily dental cleaning should begin when your child's first tooth appears, which usually happens between 4-15 months of age. If your child does not have his/her first tooth by 18 months, discuss with your pediatrician about a referral to the dentist.

  • How long should children brush their teeth?

It is recommended to brush for 2 minutes. Try to create fun activities to keep your child engaged while brushing his/her teeth such as singing a song, playing music, or setting a timer. 

  • What toothbrush should parents buy?

For infants, it is recommend using a small, soft bristled toothbrush. For younger children, parents should consider buying a toothbrush with a thicker handle so it is easier to hold. Be creative and purchase a toothbrush that has a character or color that your child likes.

  • What toothpaste should parents buy and how much to use?

Toothpaste with fluoride is recommended for children of all ages. For children under 3 years of age, it is recommend using a small smear of toothpaste, about the size of a grain of rice. For children 3-6 years of age, it is recommend using a pea-size amount of toothpaste.

  • When should children have their first dental visit?

The American Academy of Pediatrics (AAP) and American Dental Association (AAPD) recommends to schedule the first dental visit at or near one year of age. Early dental visits and teeth brushing reinforces the importance of oral health. If oral diseases are diagnosed early, the problems can be eliminated or kept from getting worse. If your family does not have a dentist, talk with your pediatrician at the next visit about a pediatric dentist in your area. 

  • In addition to teeth brushing, how can parents help prevent tooth decay?

There are additional steps that parents can take to help prevent tooth decay in their children. Never put your child to bed with a bottle or sippy cup containing formula, milk, or juices. These drinks contain sugar which can cause tooth decay. Also, try to transition from a bottle to a cup at or near 1 year of age.

Limit sugary drinks provided to your child. The AAP recommends no more than 4 ounces of diluted juice daily for children 6-12 months, and no more than 4-6 ounces for children 1-6 years of age. No sugary drinks are recommended for children younger than 6 months. Additionally, limit sweet and sticky foods such as hard candy, gummies, and fruit roll-ups.

By contactus@allchildrenpeds.com
April 18, 2018
Category: Uncategorized
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Compiled by Jeffrey L. Wampler, MD, FAAP (not one original thought)

One of the most common complaints we get called about is a cough.  Many things can cause a cough.  Children get many illnesses in the winter that cause a cough.  Parents often worry that the cough is a sign of something ominous.  Furthermore, coughs that last for a long time are often distressing to both the child and the parent.

What is a cough?  Coughing occurs when something gets into the airway below the vocal cords.  The upper airway starts at the back of the nose and moves down to the vocal cords.  The lower airway include the trachea, the right and left bronchus which leads to each lung, the small tubes of the lungs called bronchioles, and the air sack.  On youtube there is a video...(https://wwwyoutube.com/watch?v-usAgJoVYVSc&feature-youtu.be) showing how a cough occurs in the body.

Coughs in chldren are most commonly due to post nasal drip.  Mucous drains from the upper airway into the lower airway.  However, some coughs originate in the lower airway and it's important to differentiate.  Sometimes an xray may be needed.  It is very helpful for the parent to be able to describe the cough.   (https://pediatricpartners.blogspot.com/2013/12/my-childs-cough-and-breathing-sounds.html)

Common Cold:  Colds are viral illnesses that cause mucous production in the upper airway.  The cough occurs from post nasal drip of the mucous.  They last about 10 days but the cough may linger beyond that.  Viral Cough:  This is similar to a cold but the lower airway is infected by the virus.  This means patients will not have the typical runny nose or congestion that occurs with a cold.  Again, this cough can last for weeks.

Influenza:  The flu is a severe viral infection that causes fever, body aches, fatigue, headache, sore throat and cough.  There is usually less mucous production in the upper airway with the flu compared to a cold.  Also, the fever is usually higher compared to the common cold.

Pneumonia:  This a probably what parents worry about the most.  Pneumonia is not usually present at the start of a cough or cold as it is frequently a secondary infection to the cold virus.  This is because the sticky environment that the cold virus creates is a perfect home for bacteria.  The infection, and pus it creates, fills the air sacks, making it hard to breathe and causing a high fever.  If your child has any difficulty breathing, seek medical care right away.  Pneumonia is also caused by viruses so not all pneumonia infections require antibiotics.  Furthermore, older kids and teens can get walking pneumonia which is caused by the bacteria Mycoplasma.  Your child's doctor may want a chest x-ray to determine if your child has pneumonia and what type they may have.

Bronchiolitis:  Caused by RSV, bronchiolitis is an infection of the bronchioles, or small tubes in the lungs.  The extreme amount of mucous production plus the airway causing cough, distress with breathing and sometimes wheezing. RSV is more severe for young babies so please take your child to the doctor right away if you suspect it.

Croup:  Croup is a viral illness that causes swelling in the upper airway.  The cough is described as barky and some children will make a sound when breathing in known as stridor.  Placing the child in a steamy bathroom or going out into the cool night air can calm a croup cough.

Sinusitis:  The diagnosis of sinusitis is made after a cold and cough have been present for at least 10-14 days.  The diagnosis is not made for a child that has a dry lingering cough that is gradually getting better, which is the typcial pattern.  The diagnosis should be made in the setting of continued congestion, worsening symptoms after 2 weeks, headache or face pain, and possibly new onset of fever.  Even if your child has symptoms of sinusitis, it will often get better on its own, so there is not a rush to start antibiotics.  However, it is a good idea to discuss treatment options with your child's doctor.

Whooping cough:  Sadly we still diagnose this dangerous vaccine-preventable infection that is caused by the bacteria Bordatella pertussis.  The infection starts with mild cold symptoms but eventually progresses to a sever spasmodic cough.  Young babies and children will create the classic whoop sound when breathing in following a coughing fit but older children may not.  Furthermore, babies may stop breathing all together.  Older children will cough so hard that they will throw up following the coughing fit.  Unfortunately, whooping cough can be fatal at worst and cause 3 months of cough at best, so make sure your whole family is up to date on their whooping cough vaccines.

Bronchitis:  Bronchitis is inflammation in the bronchus, or large tubes, of the lower airway.  While it is a common diagnosis in adults, especially smokers, it is not common in young children.  The symptoms typically overlap with either a cold or asthma.  The most common cause of bronchitis is a viral infection so antibiotics are not indicated unless there is a secondary pneumonia that has developed.

Asthma:  While asthma is not an infection and is going to require its own post, the most common trigger for asthma is a cold.  Therefore, if you think your child is wheezing during their illness, it is best to see the doctor.  Some chronic coughs may actually be cough-variant asthma even in the absence of wheezing so this is something your doctor may consider if you child has a chronic cough lasting more than 4 weeks.

How should you treat a cough?  If your doctor has prescribed antibiotics for pneumonia, a sinus infection or whooping cough, give the whole course as prescribed.  Because most causes of coughs are viral, there isn't anything we can give to make it go away any faster and antibiotics are not appropriate.  But there are things you can do to comfort your child and ease their symptoms.

  1. Clear the airway by using saline in the nose
  2. Keep secretions looser by maintaining good hydration
  3. Soothe the throat with warm fluids and honey (only over 1 year of age)
  4. Use cough drops for children over 4 years old
  5. Use steam or a humidifier to keep the nasal passages from clogging up
  6. Avoid smoke exposure
  7. Only give decongestants or cough suppresant medications to children over age 6 and only give if it seems to temporarily help the symptoms

When is it time to worry?  As already mentioned above, if your child is coughing longer than 10 days, has any distress with breathing or chest pain, seek medical care.  Watch for rapid breathing, retractions (when the muscles sink between the ribs) and extra labor with breathing.  LIsten for sounds with breathing like stridor (whistle sound with inspiration) or wheezing (whistle sound with expiration).  Sometimes parents hear a whistling sound that they think is wheezing but is actually from breathing through a blocked nose.  Also, parents often worry in a small child that they can feel a rattle in the chest.  This is the child breathing through musous that is most likely in the upper airway.  When in doubt, take your child to see the doctor and if your child is getting tired from breathing, can't seem to catch their breath or looks blue around the lips, call 911.

Overall, if your child is coughing but is not having any difficulty breathing and has had a normal exam by the doctor, don't worry.  It is likely to pass.  However, if things get worse or the breathing looks labored, seek medical care.



  • AAP.org
  • Jaime Friedman, MD, FAAP
  • Web MD
  • UptoDate.com


By contactus@allchildrenpeds.com
February 28, 2018
Category: Well Care
Tags: ADHD  

So you have an explanation for your child's school and perhaps exasperating home life difficulties and perhaps it makes you look in a new way at yourself, a spouse or other relative who also likely has ADHD.  You may make an appointment to discuss medication with your pediatrician.  What other, non pharmacologic, treatment options might you look at?

Sleep:  A classic study in a landmark sleep text talks about a group of children with obstructive sleep apnea who had snoring, their tonsils and adenoids out.  Amazingly there were some in the group with ADHD and some with bedwetting who stopped having those problems.  What's going on?  Poor or inadequate sleep can cause those and other significant difficulties.  Sleep hygiene is the term for good sleep habits: No caffeine for 6 hours prior to sleep, no screen time for one or two hours prior to bed time, reasonable and similar bed and wake times between school and off school days, good bed time routines like brushing your teeth, shower, read or be read to.  Exercising daily for 30-40 minutes helps to relax us for sleep.  Especially in a child with ADHD, the structure of a good bed time routine is comforting, relaxing and promotes a good night's sleep.

Diet:  Another old study, the Feingold, said dyes and additives caused ADHD and that a diet free of them worked for a high percentage, there is a lot of controversy around this.  There are a small number of individuals in whom red dye causes a marked behavioral disturbance just as some people instead of being made sleepy by Benedryl become wired.  These are inherited genetic variations.  With the Feingold diet, parents had to carefully plan, structure and monitor what their children ate and when they at it.  I never cease to be amazed at how poorly many people eat.  Children with ADHD respond to sturcture and quality in their diet or the lack thereof.  Some newer thinking on diet, research proven, is around essential fatty acids.  A study of the Mediterranean diet in a group of children with ADHD showed that those who followed the diet more closely had fewer ADHD symptoms.  Was it the more fruits and vegetables, more complex carbohydrates, fewer simple sugar?  No, it was felt to be from the Omega 3's found in the fish emphasized in that diet.  That is the basis for one of the medical foods currently being given for ADHD and some other brain issues, like age related cognitive decline.  Diet is important; the Mediterranean diet has been shown to help ADHD and many chronic illnesses.  Feed your children and yourself breakfast.  Find something with adequate protein and calories to sustain them until lunch and if possible make fatty fish like tuna, salmon and other Omega 3:'s a part of your diet.  If you're vegetarian, seek out the plant sources like Flaxseed, chia seeds, brussel sprouts, hemp seeds and walnuts.

Exercise is so remarkble in it's ability to calm us, to help us sleep, to relieve anxiety, to impose our sense of well being, to give us confidence.  And it has been shown to improve school performance.  It is essential for all of us if physically possible and is certainly not limited benefitting ADHD but all of us, find something you and they like to do and do it.

Cognitive Behavior Therapy (CBT) can improve ADHD behaviors by teaching skills for handling life challenges or overcoming negative thoughts.  CBT for children with ADHD seeks to improve their behaviour and functioning via praise and rewards for acceptable outcomes like staying in your seat, being attentive, not interrupting and handing in homework.  Such therapy should come before medication in ADHD children especially the very young.

School can implement IEP's for children with ADHD, individualized educational programs tailored to the result obtained by testing.  In the home, we can implement similar plans like how, where and when homework gets done, rooms tidied, chores done.

So, outside of medication, leading a sturctured, secure life with a good diet, exercise and enough sleep and healthy expectations about behaviors can optomize life outcomes with those special people among us with ADHD.

By contactus@allchildrenpeds.com
December 27, 2017
Category: Well Care
Tags: Sleep  

Good quality, restorative sleep is essential for optimal health and well-being. Insufficient sleep can cause problems with irritability, decreased daytime alertness and poor academic performance, and can contribute to depression, anxiety, ADHD and other mental health issues. Most parents know that sleep is important at all ages, yet in recent years I hear more patients tell me that they often do not sleep well. 

Our society has become increasingly dependent on electronics to function in our daily lives. Most parents and children use computers at work and school, and at home we are texting on our smart phones or keeping up with friends on social media. Our children often study and complete assignments online, but recently, more evidence indicates that an increase in sleep problems may be related to these electronic devices. Light receptors in the retina transmit messages to the brain, and the brain responds with an increase in alertness. The particular type of light associated with i-pads, computers, smart phones, video games, e-readers, and other electronic devices with a lighted screen, seems to be particularly stimulating to the "awake" centers in our brains. Some people are more susceptible to this than others. 

Making it a habit to turn off electronic devices at least an hour before bedtime can be of great benefit in improving sleep. Some children who are very sensitive may require longer than this, even several hours. Encourage your child to complete their online schoolwork first, so they can read (actual books, not e-readers) and do other non-computer based assignments later in the evenings. Parents should always make sure that their children's access to social media is adequately monitored and developmentally appropriate, but it is also important that electronics not be routinely used late in the evenings and into the night-time hours. Several families have told me that they have instituted a "turn-off, turn-in" policy and at an agreed upon time, their children are to turn their devices off and leave them in a specific location (not in their bedroom, where they may be tempted) 

For children that struggle with sleep issues, having a regular bedtime routine can help them "wind down." Depending on the age of the child, bath or shower, getting schoolwork and lunches ready, story-time or reading a book, listening to soothing music or guided relaxation/meditation may be calming and beneficial. Avoid caffeinated beverages and concentrated sweets, especially late in the day. Most of my patients will tell me that they sleep better and feel better when they are involved in sports or other regular exercise. Over-the-counter and prescription sleep aids are not recommended for most children, and should be used only after consulting with your childs' pediatrician.

Some older children and teens tend to fall into bad sleep habits over the summer, staying up late and sleeping in. They then struggle with getting up early for school. Although it can be difficult, try to maintain a consistent bedtime and avoid napping after school, then staying up late again at night. It may take some time to get back into a good routine. If you suspect that a medical issue such as asthma or sleep apnea might be the cause of your child's sleep problem, please call our office to set up a consult appointment to discuss this with us. If you are concerned that your child is suffering from a mental health issue such as depression or a significant anxiety disorder, or if you suspect a substance abuse issue please call for a referral to a qualified mental health provider. 

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