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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". 



 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.

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.

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. 

December 18, 2017
Category: Uncategorized
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by Dr. Kathleen Maurer

Not too many years ago, children got most of their shots before they started kindergarten, and older children only needed an occasional tetanus booster .  Things have changed over the past decade, and several important vaccines are now recommended  for 11-18 year olds. Your pre-teen or teen-ager may be less than enthusiastic about getting vaccines when they come if for a sports physical or yearly exam, but it may help if they are prepared and understand the benefits of being protected from some very serious diseases. 

    1. Hepatitis A - This vaccine protects against a virus that affects the liver and can easily be transmitted person to person. There have also been a number of outbreaks through contaminated food or food handlers. International travel is also a risk factor, but with a more global society, community outbreaks have become more common. About 10-11 years ago, we began routinely giving Hepatitis A vaccine at 15 months and 2 years of age, so most of our younger patients have already had this vaccine, but many over 12 have not had this. Beginning in 2018, Kentucky Schools are requiring this vaccine for all students, so those who have not had it will need to get it. Students will need to have 2 doses of Hepatitis A vaccine at least 6 months apart.  If your child has not had both doses of Hepatitis A vaccine, please call our office to schedule an appointment.

     2. Pertussis (whooping cough) - Although this vaccine is included in the routine baby shots and preschool boosters, immunity tends to wane over time, and community outbreaks have become common. Older children and adults with pertussis may only have a very persistent and annoying cough, but this disease can be very dangerous and even fatal for vulnerable newborns and babies who are too young to be fully vaccinated. Beginning about 6 years ago, the Center for

Disease Control (CDC) and American Academy of Pediatrics (AAP) recommend all 11 year olds receive a dose of pertussis vaccine which is combined with tetanus vaccine (Tdap). This is now required for all Kentucky School children. (also recommended for all women during pregnancy, close contacts of all newborns and infants, childcare workers, and healthcare providers)

     3. Meningitis A vaccine (meningitis A, C, W, Y) -This vaccine protects against several strains of bacteria that can infect the blood, brain and spinal cord and cause serious and life threatening illness. It is most common in teens and young adults, and can spread quickly. The scary thing about this devastating and potentially deadly infection is that it can infect otherwise healthy young people, and its onset tends to be very rapid. A dose of Meningitis A vaccine is required at age 11, with a booster dose at age 16. (Certain high-risk patients may need to get this vaccine before age 11) 

     4. Meningitis B vaccine - This vaccine protects against a serogroup of the meningitis bacteria that is not included in the required Meningitis A vaccine. Within the past 5 years, multiple college campuses have experienced outbreaks of Meningitis B. The symptoms are identical to the other strains of meningitis, causing serious illness or deaths. Two doses of this vaccine are recommended for 16-18 year olds, and especially encouraged for those who will be heading to college. 

      5. HPV - Human Papilloma Virus is very prevalent in the population in general and is the cause of almost all cases of cervical cancer in women and some genital and head and neck cancers in men, as well as genital warts. Although its primary means of transmission is through sexual contact, it is not only careless people who contract this infection. Most people have no symptoms at all from this virus and it eventually clears on its own, but some cases will persist and lead to cancers. The first HPV vaccine, which covered for the most common cancer-causing strains, was approved in 2006.  The current Gardasil 9,  which has expanded protection against more strains of the virus, was approved in 2014. HPV vaccine is recommended for both boys and girls, ages 11 and up (approved down to age 9) Those who receive the first dose of vaccine prior to their 15th birthday only need 2 doses, 6 months apart, while those 15 and older will need 3 doses. 

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