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RIVERSIDE: NEW 'S GUIDE TO NEWBORNS “NEWBORN BASICS 101”

WELCOME TO OUR PRACTICES

SECAUCUS 714 10th street, Secaucus, NJ 07094 201-863-3346 Fax 201-863-5251

UNION CITY 4201 New York Ave, Union City, NJ 07087 201-601-9515 Fax 201-601-9516

JERSEY CITY 324 Palisades Ave, Jersey City, NJ 07306 Fax 201-418-7008

HACKENSACK 10 First Street, Hackensack, NJ 07601 201-342-8130 Fax 201-342-5275

HOBOKEN 232 Clinton Street, Hoboken NJ 07030 201-876-3216 Fax 201-876-3218

BAYONNE 506 Broadway, Bayonne, NJ 07002 Phone: 201-471-7012 Fax: 201-471-7014

RIDGEFIELD PARK 200 Main Street ,Ridgefield Park, NJ 07660 201-870-6100 Fax 201-870-6101

HOBOKEN NORTH 609 Washington Street, Hoboken, NJ 07010 201-706-8488 Fax 201-706-8489

JERSEY CITY (WATERFRONT) 46 Essex Street, Jersey City, NJ. 07302 201-360-2228 Fax 201-360-2258

Office Hours: Secaucus 8am – 10pm, 365 days a year! Union city 8am -8pm Mon. to Fri., Sat. 8-2pm, Sun. 8am-2pm Jersey City 8am - 7pm Mon. to Fri., Sat. 8-2pm Sun., Closed Sundays Hackensack 8am -7pm Mon. to Fri., Sat. 8-2, Closed Sundays Hoboken (Clinton St.) 8am-7pm Mon. to Fri., Sat. 8am-2pm, Sun 8am-2pm

Bayonne 8am-7pm Mon. to Fri., Sat. 8am-2pm, Closed Sundays Ridgefield Park 8am-7pm Mon. to Fri., Sat. 8am-2pm, Closed Sundays Hoboken North 8am-7pm Mon. to Fri., Sat. 8am-2pm, Closed Sundays Jersey City (Waterfront) 8am-7pm Mon. to Fri., Sat. 8am-2pm, Closed Sundays

Meet Our Doctors

□ AZZAM BAKER, M.D. □ ZEYAD BAKER, M.D. □ OMAR BAKER, M.D. □ IYAD BAKER, M.D. □ NAIMAT BOKHARI, M.D. □ SADRUL ANAM, M.D. □ NERMINE DOSS, M.D. □ CHAULA PARIKH, M.D. □ NOEL BANSIL, M.D. □ ANWAR AL-HADDAWI, M.D. □ SHEBA BEN, M.D. □ SEEMA TIKU, D.O. □ CLARA LEE, D.O. □ Jeani John, M.D. □ Michelle Valdivieso, M.D. □Rina Raju, M.D. □ CELIA THOMAS, D.O. □ CONCEPCION SANTOS-BORJA, M.D. □ WILSON DELGADO, M.D. □Wamiq Jadun, M.D. □Sandra Esteves, A.P.N. □ Jody Levy, M.D. □ Erin Zotti, APN □ Alicia Salas, M.D. □ Sunita Satwani, M.D. □ Michelle Valdivieso, M.D.

ALL ARE BOARD CERTIFIED/ELIGIBLE

Hospital Privileges Hackensack University Medical Center Palisades Medical Center Hoboken Medical Center Holy Name Medical Center Englewood Hospital and Medical Center Jersey City Medical Center

This information booklet is dedicated to the memory of Mrs. Izdihar A. Baker (1951—2007) for her vision and passion for all children!

Naimat Bokhari, MD

Contents

Appointments Fees and Insurance Referrals Emergency Care and After Office Hours

Prenatal Visit Newborn Essentials First Visit

Newborn Concerns Essential Equipments First Visit Newborn Jaundice Fever Feeding Bowel Movements Crying Colic Sleep Problems Sudden Death Syndrome (SIDS) Starting Solid Food

Toddlers Concerns Accidents Burns: Appetite - "Toddler's Slump Discipline/Tantrums Sleep Problems Toilet Training

Childhood Concerns Allergic Reaction and hives ADD/ADHD ASTHMA Bedwetting Concussion Constipation CPR Food Allergy Hearing Heart Murmur Lead Poisoning Nutrition Oral Health Delay Toilet Training

Childhood Illnesses Antibiotics Bronchiolitis Chickenpox Colds & Coughs

Croup Rash Earache Eczema Fever Flu Hand, Foot, Mouth Disease Pink Eye Rashes Roseola Sinusitis Sore Throat Stomach Pain Urinary Tract Infection Vomiting

Miscellaneous 1. Vaccine Preventable Diseases 2. current schedule 3. Post Partook Depression 4. Breast Feeding and Drugs Travel Medicine Sun Safety Indian

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APPOINTMENTS APPOINTMENT IS REQUIRED FOR WELL AS WELL AS SICK VISITS. WE TRY OUR BEST TO AVOID DELAY BUT IF EMERGENCY PATIENTS WILL BE SEEN FIRST AS WE ALMOST NEVER REFUSE A SICK CHILD. Fees And Insurances . We accept most of the private insurances and are providers for many HMO’s and Pop’s. Cash and credit cards are also accepted according to our fee plan. We charge co payments at the time of providing service unless otherwise arranged. We offer some services that are not covered by some insurance companies and in that cases you will be responsible for additional cost (travel vaccine, vision testing, hearing testing, finger prick blood testing instead of drawing blood from vein etc.) Emergency Care And After Office Hours One of the doctors from our group will be available during and after the office. Please DO NOT CALL after office hours for medication refills and non-emergency question like constipation. Almost all HMO’s and insurances require authorization from primary care physician except life threatening emergency. Still you are responsible to call your insurance and for any co pay charged.

NEWBORN CARE

ESSENTIAL EQUIPMENTS Car Seat

One of the most important jobs you have as a parent is keeping your child safe when riding in a vehicle. Each year thousands of young children are killed or injured in car crashes. Proper use of car safety seats helps keep children safe. But with so many different car safety seats on the market, it’s no wonder many find this overwhelming. The type of seat your child needs depends on several things, including your child’s size and the type of vehicle you have. and toddlers—rear-facing The AAP recommends that all infants should ride rear-facing starting with their first ride home from the hospital. All infants and toddlers should ride in a Rear-Facing Car Safety Seat until they are 2 years of age or until they reach the highest weight or height allowed by their car safety seat’s manufacturer Types of Car Safety Seats at a Glance Age Group Type of Seat General Guidelines All infants and toddlers should ride in a Rear-Facing Infant seats and Car Safety Seat until they are 2 years of age or until Infants/Toddlers rear-facing they reach the highest weight or height allowed by their convertible seats car safety seat’s manufacturer. All children 2 years or older, or those younger than 2 years Convertible seats who have outgrown the rear-facing weight or height limit and forward- for their car safety seat, should use a Forward-Facing Toddlers/Preschoolers facing seats Car Safety Seat with a harness for as long as possible, with harnesses up to the highest weight or height allowed by their car safety seat’s manufacturer. All children whose weight or height is above the forward- facing limit for their car safety seat should use a Belt- School-aged children Booster seats Positioning Booster Seat until the vehicle seat belt fits properly, typically when they have reached 4 feet 9 inches in height and are between 8 and 12 years of age. When children are old enough and large enough to use the vehicle seat belt alone, they should always use Lap and Shoulder Seat Belts for optimal Older children Seat belts protection. All children younger than 13 years should be restrained in the Rear Seats of vehicles for optimal protection.

Humidifier Humidifier are helpful in cold winters with dry heating systems. Cool-mist humidifiers and steam vaporizers are equally effective in humidifying the air and supplying the symptomatic relief humidified

air can give to the child who has significant nasal congestion. However, there are certain drawbacks to each of these methods. The ideal indoor humidity level is between 40% to 50% (Buy a hygrometer (humidity meter) and take some readings to find out if humidity level especially at night! Cool-Mist Humidifier These machines work by making water vapor through a rapidly turning disk within the water of the humidifier. Because the vapor from the machine is not heated, there is no risk of burning the child should the water spill or she places her face close to where the vapor escapes. The biggest drawback to cool-mist humidifiers is that the cool water can be an excellent breeding ground for mold and bacteria. Therefore, it is very important to follow the manufacturers instructions concerning cleaning, which usually includes cleansing the tank on a daily basis with, soap and water. In addition, these machines are quite efficient at dispersing the minerals within tap water, which can cause health problems themselves. So, distilled water should be used in cool-mist humidifiers. Also use if room temperature is un-usually high. Steam Vaporizer These devices are less likely to have a lot of mold and bacterial growth, but the risk of burn can be significant. Vapor is made in these machines by using a heating element to cause steam. This method does not cause minerals to be dispersed in the air. So, tap water can often be used with these devices making them much less expensive to operate. However, because of the very high temperature of the water, these should not be used for younger children. Also room temperature can be relatively lower.

Ultrasonic Humidifiers These machines cause vapor by creating ultrasonic vibrations within the water. These were originally thought to be better because it was felt the risk of dispersing bacteria, molds, and minerals were minimal. However, this has not always been found to be the case. The safety of these devices is certainly better than the steam vaporizers, and they do tend to disperse much less bacteria and mold than the cool-mist humidifiers. However, they are quite efficient at sending minerals into the air, so distilled water must be used with these as well. With the burn risk to your younger child, I would steer clear of the steam humidifiers unless you can secure a nice place for them. And your decision about whether to purchase an ultrasonic or regular cool-mist humidifier ought to be based on cost and how difficult cleaning is going to be since they will need this maintenance daily. Finally, a word of caution about humidifiers in general. While these appliances can often give nice relief to a child who is stopped up from a cold, the humidity in the air can allow for mold growth within the carpeting or other areas of the house. For children with asthma, this increased exposure to mold can often actually make matters worse. .

Nasal Suction Bulb & SALINE DROPS - It's essential for helping young babies with breathing difficulties caused by sticky or dried nasal secretions along with saline drops. Use 2 drops each nostril morning and night if needed for excessive sneezing /noisy breathing and you bulb suction only if you see secretion after few minutes. Common brands are AYR and Little noses.

Thermometer - A rectal thermometer is more accurate in a newborn. The digital form reads in about 30 seconds and is worth the extra few dollars. Do not use ear or temporal scanner for newborn —6 months if you think baby really has fever (may use as initial screening).

AT HOME - VISITORS AND OUTINGS

When you first go home from the hospital, visitors should be limited to immediate family members and a few close friends (as long as they have no infectious illnesses. Prolonged visits should be discouraged. Your primary concern should be your baby and recuperation. The baby can be taken out for fresh air (depending on the weather), but you must avoid crowds for a minimum of 3 months, particularly during the winter. Dress baby in one more layer than yourself.

FIRST VISIT TO THE DOCTOR'S OFFICE

The 2days—1 week check-up is one of the most important visits during your baby's first year of life. By this time your baby will usually have developed symptoms of any physical condition that was not detectable during the hospital stay. We will also be assessing growth and development. We talk about Nutrition, bowel and sleep habits, infection prevention and travel issues! Keep your baby out of direct sunlight! Temperature Room temperature should be comfortable and baby usually requires one more layer than parents. Room temperature in summer should be around 74-75 F and in winter around 70-72 degrees. Fever is more than 99.6 under armpit or rectally more than 100.3. You don’t need to check it routinely but only if baby is feeling worm or refusing to eat or if does not look fine to you. We don’t want babies to have fever for first 3 months of life so please call us if baby is febrile Call us immediately if your newborn has any of the following! Fever of 100.4For38C or higher rectal temperature Seizure Purplish rash or skin rash Unusual irritability, lethargy Failure to eat Vomiting Diarrhea Dehydration Jaundice Any change in activity or behavior that makes you uncomfortable

Newborn jaundice Newborn jaundice is when a baby has high levels of bilirubin in the blood. Bilirubin is a yellow substance that the body creates when it replaces old red blood cells. The liver helps break down the substance so it can be removed from the body in the stool. High levels of bilirubin make your baby's skin and whites of the eyes look yellow. This is called jaundice. Causes and risk factors It is normal for a baby's bilirubin level to be a bit higher after birth. Most newborns have some yellowing of the skin, or jaundice. This is called "physiological jaundice." It is harmless, and usually is worst when the baby is 2 - 4 days old. It goes away within 2 weeks and doesn't usually cause a problem. Two types of jaundice may occur in newborns that are breast-fed. Both types are usually harmless. jaundice is seen in breastfed babies during the first week of life, especially in babies who do not nurse well or if the 's milk is slow to come in. jaundice may appear in some healthy, breastfed babies after day 7 of life. It usually peaks during weeks 2 and 3. It may last at low levels for a month or more. It may be due to how substances in the breast milk affect how bilirubin breaks down in the liver. Breast milk jaundice is different than breastfeeding jaundice. Severe newborn jaundice may occur if your baby has a condition that increases the number of red blood cells that need to be replaced in the body, such as: Abnormal blood cell shapes Blood type mismatch between the mother and the baby Bleeding underneath the scalp (cephalohematoma) caused by a difficult delivery Higher levels of red blood cells, which is more common in small-for-gestational-age babies and some twins

Infection Lack (deficiency) of certain important proteins, called enzymes Things that make it harder for the baby's body to remove bilirubin may also lead to more severe jaundice, including: Certain medications Congenital infections, such as rubella, syphilis, and others Diseases that affect the liver or biliary tract, such as cystic fibrosis or hepatitis Low oxygen level (hypoxia) Infections (such as sepsis) Many different genetic or inherited disorders Babies who are born too early (premature) are more likely to develop jaundice than full-term babies. Symptoms Jaundice causes a yellow color of the skin. The color sometimes begins on the face and then moves down to the chest, belly area, legs, and soles of the feet. Sometimes, infants with significant jaundice have extreme tiredness and poor feeding. Signs and tests Doctors, nurses, and family members will watch for signs of jaundice at the hospital, and after the newborn goes home. Any infant who appears jaundiced should have bilirubin levels measured right away. This can be done with a blood test. Many hospitals check total bilirubin levels on all babies at about 24 hours of age. Hospitals use probes that can estimate the bilirubin level just by touching the skin. High readings need to be confirmed with blood tests. Further testing may be needed for babies who need treatment or whose total bilirubin levels are rising more quickly than expected. Treatment Treatment is usually not needed. When determining treatment, the doctor must consider The baby's bilirubin level How fast the level has been rising Whether the baby was born early (babies born early are more likely to be treated at lower bilirubin levels) How old the baby is now Your child will need treatment if the bilirubin level is too high or is rising too quickly. Keep the baby well hydrated with breast milk or formula. Frequent feedings (up to 12 times a day) encourage frequent bowel movements, which help remove bilirubin through the stools. Ask your doctor before giving your newborn extra formula. Some newborns need to be treated before they leave the hospital. Others may need to go back to the hospital when they are a few days old. Treatment in the hospital usually lasts 1 to 2 days. Sometimes special blue lights are used on infants whose levels are very high. This is called phototherapy. These lights work by helping to break down bilirubin in the skin. The infant is placed under artificial light in a warm, enclosed bed to maintain constant temperature. The baby will wear only a diaper and special eye shades to protect the eyes. The American Academy of recommends that breastfeeding be continued through phototherapy, if possible. Rarely, the baby may have an intravenous (IV) line to deliver fluids. Expectations (prognosis) Usually newborn jaundice is not harmful. For most babies, jaundice usually gets better without treatment within 1 to 2 weeks. Very high levels of bilirubin can damage the brain. This is called kernicterus. However, the condition is almost always diagnosed before levels become high enough to cause this damage. For babies who need treatment, the treatment is usually effective. Complications Rare, but serious, complications from high bilirubin levels include: Cerebral palsy, Deafness, Kernicterus -- brain damage from very high bilirubin levels Calling us All babies should be seen by a health care provider in the first 5 days of life to check for jaundice. Jaundice is an emergency if the baby has a fever, has become listless, or is not feeding well. Jaundice may be dangerous in high-risk newborns. Jaundice is generally NOT dangerous in term, otherwise healthy newborns. Call the infant's health care provider if:

Jaundice is severe (the skin is bright yellow) Jaundice continues to increase after the newborn visit, lasts longer than 2 weeks, or other symptoms develop The feet, especially the soles, are yellow Prevention In newborns, some degree of jaundice is normal and probably not preventable. The risk of significant jaundice can often be reduced by feeding babies at least 8 to 12 times a day for the first several days and by carefully identifying infants at highest risk. All pregnant women should be tested for blood type and unusual antibodies. If the mother is Rh negative, follow-up testing on the infant's cord is recommended. This may also be done if the mother's blood type is O+, but it is not needed if careful monitoring takes place. Careful monitoring of all babies during the first 5 days of life can prevent most complications of jaundice. Ideally, this includes: Considering a baby's risk for jaundice Checking bilirubin level in the first day or so Scheduling at least one follow-up visit the first week of life for babies sent home from the hospital in 72 hours

FEVER in less then 3 months Do not give Tylenol or any other medicines, unless prescribed by the physician, to a baby under 2 months. If your baby feels hot check the temperature immediately. If the baby is bundled up, unwrap him/her and check the temperature in half an hour. Report any temperature >100.4 F degrees. If fever is present and your infant is less than 2 months old, call our office immediately (emergency number if after hours). If your baby is over 2 months and just received shots, give Tylenol. Call if fever greater than 103 degrees

FEEDING YOUR NEWBORN Baby’s usually lose 8-10% of by the first week and then regain it by second week! So weight check is very important during FIRST visit .We will discuss breast vs. formula feeding differences, night sleeping pattern etc. A breast-feeding mother often wonders if her baby is getting enough calories. Your baby is doing fine if he or she demands to drink every 2 to 3 hours, sleeps well after meals, and wets 6 or more per day. If there are any Concerns, please call during regular office hours and schedule a weight check. Bottle fed babies vary on the amount per feeding, but they generally eat every 3-4 hours and roughly 24-oz./24 hrs is acceptable if you pump or use formula. I’m hungry Signs may be Cries or fusses! Flails arms and legs Smiles and looks at you or even coos at you while you’re feeding the baby! I’m full signs may be Releases nipple or stops sucking Moves head away from nipple Slows down speed of sucking—may even fall asleep For Bottle Feeding: Similac/Enfamil is a convenient and well-balanced formula that is very close to breast milk. It is simple and easy to prepare. 1. Wash the top of the can with soap and rinse well. 2. Open and empty the entire contents of the 13 oz. can of Similac® Concentrated Liquid into a pitcher. 3. Add an equivalent amount (13 ounces) of water to the pitcher. 4. Stir and then pour 3 ounces of this formula into clean nursing bottles. When 3 ounces is no longer enough for your baby, you can gradually increase the amount in each bottle. Rule of thumb; 1/2 ounce not to exceed 32 ounces. It is not necessary to sterilize bottles, washing them with soap and hot water is sufficient. However, sterilizing the nipples is recommended. 5. Store bottles of formula in the refrigerator. If you use disposable type bottles, Similac is very simple to prepare. Boil the nipples and bottle covers for 10 minutes. Then use 13 ounces of the water to one can of Similac. Put the nipples and

covers on the bottles and store them in the refrigerator. Just before feeding, remove a bottle from the refrigerator and warm it in a pan of hot water for a few minutes, or you may use a bottle warmer. Test the temperature of the formula by shaking a few drops onto the inside of your wrist. It should feel warm, but not hot. DO NOT USE A MICROWAVE TO HEAT BABY'S FORMULA.

Nursing ' Diet can cause "GAS" in the breast fed infant. Avoid: 1. Broccoli, 2. Cabbage, 3. Onions, 4. Legumes - Beans, Lentils, 5. Garlic, 6. Excess Spices, 7. Chocolate, 8. Caffeine (in coffee, tea, soda) In general, any food that causes "gas" or "heartburn" in Mom, will likely distress the baby as well ! Foods to avoid in Allergenic Child/Nursing Mothers with allergenic baby: I. Milk (and any products containing milk) 2. Eggs (and any products containing eggs) 3. Strawberries 4. Chocolate 5. Tomatoes 6. Orange Juice 7. Wheat (in breads, cereals, etc.) 8. Peanuts and Peanut Butter 9. Shell fish (example - shrimp, lobster) 10. Corn

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BOWEL MOVEMENTS Babies less than 6 months of age commonly grunt, push, strain, and draw up the legs, and become flushed in the face during passage of bowel movements (BMs). This is normal as long as it does not cause pain (not crying). The frequency of BMs varies widely from one baby to another. Many pass a stool soon after each feeding (especially breast fed babies). By 3-6 weeks of age, some breast-fed babies have only one bowel movement a week and still are normal. Breast milk leaves very little solid waste to be removed. Therefore infrequent stools should not be considered a sign of constipation as long as the stools are soft (no firmer than the consistency of peanut butter), and your infant is otherwise normal, gaining weight steadily, and nursing regularly. If your baby is formula-fed, he/she may have at least one BM a day, but occasionally they also skip days Because an infant's stools are normally soft and a little runny, it's not always easy to tell when a young baby has mild diarrhea. Signs include a sudden increase in frequency (more than I BM per feeding), and unusually high liquid content in the stool. Diarrhea may be a sign of infection, food intolerance, and change in baby's diet or Mom's diet if breast-fed. Whether breast- or bottle-fed, if your baby has hard or very dry stools, it may be a sign that he/she is not getting enough fluid, that he/she is losing too much fluid due to illness, fevers, or heat. Once solid foods have been started, it may indicate that he/she is eating too many constipating foods!

CRYING

Crying is your new baby's method of communication. It may mean several things including: hunger, uncomfortable, too hot, too cold, wet, tired, over stimulated. Occasionally babies have fussy periods during the day when nothing consoles him'/her, but seem more alert after these periods and may sleep more comfortably. This kind of fussy crying seems to help babies get rid of extra energy so that they can relax. Soon you’ll be able to tell what each particular cry means. For instance, a hungry cry is usually short and low-pitched, and it rises and falls (similar sound to the "leave-me-alone" cry). An angry cry tends to be more turbulent. A cry of pain or distress generally comes on suddenly and loudly with a long, high-pitched shriek followed by a long pause and a wail. There could also be a mixture.

What to do: 1. Rocking - in a glider or rocker, or by swaying side-to-side 2. Touch - gently stroking the head or patting the back/chest 3. - wrapping baby snugly in a receiving blanket 4. Communication - singing or talking, playing soft music 5. Movement - walking with baby in your arms, a stroller, or car 6. Burping - relieve any trapped gas bubbles 7. Warm baths - if cord has fallen off (not all babies like this) Remember to call immediately if: It becomes a painful cry rather than a fussy one 2. Your baby cries constantly for more than 3 hours 3. You are afraid you may hurt your baby 4. You have shaken your baby 5. You can't find a way to soothe your baby (inconsolable)

Pacifiers The pacifier has to be introduced during the first month or two of life for it to substitute for the thumb. Although the orthodontic type of pacifier is preferred because it prevents tongue thrusting during sucking, the regular type usually causes no problems. Use a one-piece commercial pacifier. Don't put the pacifier on a string around your baby's neck; it could lead to strangulation. Rinse with water not your mouth. Advantages of pacifier over thumb sucking: It is more difficult to wean thumb sucking. Thumb sucking can cause a severe overbite if it is continued after the permanent teeth come in. When to wean the pacifier: A good age to make it less available is when your child starts to crawl. Give it only at night or naptime. A pacifier can interfere with normal and speech development. This is especially important after 12 months of age when speech should take off. Also there is a new study (10/2005) indicating pacifier use to prevent SIDS at birth for bottle- fed and after 1month for breast-fed babies.

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COLIC

Definition - unexplained crying; intermittent crying -2 times per day; healthy child (not sick or in pain); well-fed child (not hungry); bouts of crying usually last 1-2 hours; child fine between bouts of crying; onset under 4 weeks of age; and resolution by 3 months of age. Cause - When babies cry without being hungry, overheated, too cold, in pain, or sick, we call it "colic". About 10% of babies have colic. No one is certain what causes colic, but it tends to occur in high-needs babies with a sensitive temperament. Colic is not the result of bad , so don't blame yourself. Colic is also not due to excessive gas. Allergies to certain types of formula can cause crying but is not considered colic; usually is associated with diarrhea or vomiting. Colic is not caused by abdominal pain. When babies cry they assume a flexed position and their stomach

muscles feel hard because it's part of the crying mechanism. However, always remember, colic is a diagnosis of exclusion (in other words, the baby is totally healthy). Expected Course - This fussy crying is harmless. It starts within 3 weeks of birth and spontaneously improves at 2 months and is gone by 3-4 months. Although the crying can't be eliminated, the minutes of crying per day can be dramatically reduced with treatment. In the long run, these children tend to remain more sensitive and alert to their surroundings.

SLEEP PROBLEMS Newborns: * A newborn should sleep on their back. * Place your baby in the crib when he is drowsy but awake. This is the most important step. Without it, the others will fail. * Hold your baby for all fussy crying during the first 3 months. Babies can't be spoiled during the first 3 or 4 months of age * Carry your baby for at least 3 hours each day when he/she isn't crying. * Do not let your baby sleep for more than 3 consecutive hours during the day. * Keep daytime feeding intervals to no less than 2 hours for newborns. Don't let feeding become a pacifier. * Make middle-of-the-night feedings brief and boring. * Don't awaken your infant to change diapers during the night, unless they have a bad diaper rash. * Place your baby in its own bed. You won't sleep restfully and it is very difficult to wean.

Two-Month-Old Babies: * Move your baby's crib to a separate room. * Try to delay middle-of-the-night feedings.

Four-Month-Old Babies: Try to discontinue the 2:00 AM feeding before it becomes a habit. Breast-fed babies do not need more than 5 nursing sessions per day.

Spitting UP Most babies under the age of 1 year spit up to a small degree. The "valve" between the stomach and the esophagus doesn't close as tightly in this age group, especially premature infants. This can lead to Gastro esophageal Re-flux (GE reflux). It improves with age, usually beginning 6-9 months. Home Care: (1) Feed smaller amounts. Over feeding makes spitting up worse. It takes at least 2 hours to empty the stomach. (2) Burp your child frequently to prevent excess gas. (3) Positioning - Keep upright for at least 15-30 minutes after a meal. Don't bounce around. Place towel or wedge under the mattress to elevate head during sleep. Do not use pillows. (4) Avoid direct pressure on the abdomen. (5) If instructed by a healthcare provider, add 1/2 tablespoon of rice cereal per ounce of formula (equal to 2-tbsp./4 oz.). Or may use Enfamil AR formula made especially for babies with reflux. It becomes a medical concern that should be discussed during office hours if: (1) does not improve with the home care advice given above, (2) becomes cranky, (3) your baby does not gain weight properly, and (4) any other concerns or questions. If you think he/she is vomiting large amounts, see pg. 35 for recommendations. It becomes a medical emergency if it causes your child to choke/cough/ turn bluish around the lips. Call for assistance regardless of the time.

Sudden Infant Death Syndrome (SIDS)

Back to sleep for every sleep Use a firm sleep surface Room sharing without bed sharing is recommended Keep soft objects and loose bedding out of the crib Pregnant women should receive regular prenatal care Avoid smoke exposure during pregnancy and after birth Avoid alcohol and illicit drug use during pregnancy and after birth Breastfeeding is recommended Consider offering a pacifier at nap time and bedtime Avoid overheating Do not use home cardiorespiratory monitors as a strategy for reducing the risk of SIDS

Infants should be immunized in accordance with recommendations of the AAP and CDC Avoid commercial devices marketed to reduce the risk of SIDS Supervised, awake tummy time is recommended to facilitate development and to minimize development of positional plagiocephaly

Starting Solid Foods: . Breast fed babies should be exclusively on breast-feeding until 6 months but around 4 months of age, most babies are developmentally ready to eat solid foods off the spoon. If your child doubles the birth weight and is 13 pounds+ and is hungry after 32 ounces of formula/8 breast-feeding and with good control of neck and body, he/she may begin solid food also hunger has to be another factor judge by how nicely baby is sleeping at night! Will discuss when to start foods during the 4—6 month physical if your child has had food allergies with the formula or breast milk. There is old study about increased risk food allergy but a 2010 American academy of Allergy and immunology disputes and suggested the following about Prevention of Food Allergy (http://www.niaid.nih.gov/topics/foodAllergy/clinical/Documents/FAGuidelinesExecSummary. pdf)

Start with Stage 1 foods: Cereals (rice -> oatmeal -> barley). Mix I tbsp. of cereal with breast milk or formula. In the beginning, make the cereal fairly thin and increase the consistency as your baby gets used to thicker food. Initially, you are going to give solid food once a day. Then increase the Serving size gradually as your baby learns how to eat. Remember, it takes awhile for your baby to learn to bring the food from the front of the mouth to the back to swallow. Observe for any adverse reactions, such as vomiting, loose stools, cramps or skin rash. If you suspect a food reaction, stop the suspected food item and if symptoms persist, call the office. Next, start Stage 1 vegetables (yellow -> green), then fruits. Start only one new food item every 3 to 5 days. Remember to alternate between the yellow and green vegetables. If your child's skin gets a yellow-orange tint, you're probably feeding too many yellow vegetables. By 5 months of age an average baby can take up to: 4 oz. of fruits 4 oz. of vegetables Divided into 2 servings/day 4 tbsp. of cereal In addition to 24-32 oz., of formula or breast milk. . By 6 months of age you can double the amount of solid food and divide into 3 servings/day. Example: Breakfast - 2 tbsp. of cereal + 4 oz. of fruits Lunch - 4 oz. of vegetables

Dinner - 2 tbsp. of cereal + 4 oz. of vegetables

After 7 months of age, you can start meats, white (i.e. chicken, turkey, veal and lamb) then beef. Start with 1 tbsp./day, and then you can increase to a maximum of 2 oz./day. If your baby does not like jar meat, try homemade (example - overcook a piece of chicken then blend with broth). If your baby is not accepting of meat, mix it with favorite food. After trying all the meats individually, you can start Stage 2 foods in all categories. Table foods - Can be introduced gradually after 6 months of age. It must be age-appropriate. Initially mashed or pureed, then chopped finely by 9 months. After 1 year of age, your child should be mostly on table foods. Exceptions!! - Things that are choking hazards (examples: whole grapes, raisins, nuts, popcorn, hard candy, peanut butter sandwiches). Peanuts, shrimp and strawberries are common allergy causing food so if given watch for rash, vomiting or difficulty breathing for the first 3 times when you give that food! Introduce the cup between 6-8 months of age. Most babies will accept water from the cup and eventually milk. Wean the bottle by 18 months of age (maximum 24 months). This will help to avoid delays in development, ear infections and tooth decay. In addition, never put the baby to bed with a bottle for the same reasons. Safety Tips: A. Do not feed directly from baby food jar (unless discarded after that feeding). B .Do not microwave bottles or foods in the jar. C. Place serving on dish and store jar with unused portion in the refrigerator. D. Store baby food in refrigerator only 2 DAYS. E. Stir microwaved foods well because they heat unevenly. F. Do not save any uneaten foods from baby's dish.

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TODDLER CONCERNS

ACCIDENTS - HOW TO KEEP YOUR CHILD SAFE? Most childhood injuries are unintentional, but almost all of them are preventable in one way or the other. Injuries can be a major cause of grief and sadness in a family, so learn how to protect your child. Here are some guidelines to help you childproof your home. During infancy 0-4 months * Secure the baby in a car seat; never place the infant seat on anything but the floor. * Don't leave the baby unattended on a changing table, bed, chair, or Couch. * Never leave young children or pets alone with the baby. * Place powder, baby cleaners and small objects out of the reach of the baby. * Make sure there is a non-skid matt on the bathroom and the bathtub. * Use small cords to attach , toys or religious objects to the baby's clothes * Install smoke and carbon monoxide detectors in the house. * Place the infant down when holding hot drinks. * Toys should be unbreakable, with no small parts or sharp edges. 6-12 months * The child becomes more mobile; use a as an island of safety. * Place safety latches on all cabinets containing potentially harmful substances: (medicines, vitamins, mouthwash, cosmetics and cleaning supplies) * Use gates on stairs, lock doors to the basement, use a fence barrier around pool. * Cover electrical outlets, insulate extension cords, and avoid dangling electrical cords. * Set the hot water temperature at no more than 120 F. * Don't give foods that can be easily aspirated (peanuts, hot dog, grapes, raisins etc.). * Make sure there are no plastic bags or balloons within the reach of the baby.

1-5 years * Running, climbing and jumping allow the child to reach and speed. * Make sure window screens and guards are in place. * Keep stools and chairs away from counters and stove. * Sharp objects like knives should be out of reach of children. * Avoid placing coffee table in the center of family room, cover edges and corners. * Provide a barrier between fireplace and other heat sources. * Advise the child to be careful around strange animals. * Talk about not following strangers, nor accepting touching they don't like. 5 years-adolescence * importance of wearing helmet and protective gear when riding bikes, and seat belts in the car. * Also talk about wearing protection when skating or practicing sports.

Burns: For an active flame the child should “drop and roll". Don't run. Apply plenty of cool water immediately, nothing else please, for electrocution remove the child from contact with non- conductive material, call us/91 I immediately.

Choking or foreign body: do not intervene if the child can cough, breathe or speak, a natural cough is better than an artificial one. Do not put your linger in the mouth unless you can see the object, you may use Heimlich maneuver in children over 1 year or gentle back blows for children under 1 year (these procedures are part of CPR classes which every parent should know, they are given in your local fire department or ambulance corp.) First aid measures: for trauma remember “'RICE." Rest - immobilize do not use or move the injured area, Ice area 10-15 minutes each hour for 2 hours, Compress, apply pressure to stop bleeding, or decrease swelling and Elevate the injured area to stop swelling or bleeding. For wounds or cuts, stitches are only needed when (1) edges are gaping, (2) in the mouth when they cross the lip line and (3) in the tongue if they are over 1 inch or go completely through. For head trauma please refer to head injury precautions in this booklet.

APPETITE - "Toddler's Slump" The first year of life a baby will triple his/her birth weight. After the first year, they normally gain 1/2 lb. per month. Because they are not growing as fast, they need fewer calories. It is normal for your toddler to eat only one good meal a day, approximately 1/3rd of an adult portion. You should limit milk and dairy products to 20 oz. per day. Otherwise, the appetite may drop even further and your child can become anemic. In addition, do not allow your child to fill up on junk food, juices or punch. Now is the time to establish good eating habits.

High Calorie Ideas for Toddlers Recipes: Fortified Milk Add 2-4 Tbsp of powdered skim milk to 1-cup whole milk.

Super Shake 1-cup ice cream 1 cup fortified milk I package Carnation Instant Breakfast

Super Pudding 1 cup fortified milk I cup heavy cream 1 package (4 ½ oz) instant pudding Make into ½ cup servings

Super Grilled Cheese Dip cheese sandwich into egg and fortified milk mixture before grilling with lots of butter or margarine. This will be like French toast with cheese in the middle.

Discipline/Tantrums Begin discipline after 6 months of age. The main cause of spoiled children is a lenient, permissive parent who doesn't set limits and gives in to tantrums and whining. Children tend to do better in a structured environment that allows room for growth and constructive creativity.

Guidelines for Setting Rules: Use rules that are fair and attainable depending on age and stage of development. Be clear, concrete and consistent. State the appropriate and acceptable behaviors. Be strict- mean what you say and follow through! Ignore unimportant or irrelevant misbehavior. Praise good behaviors. Concentrate on 2-3 rules initially. All caretakers must be consistent for it to work (verbal and nonverbal)! Discipline Techniques and Consequences: Initially, structure, distraction, verbal and nonverbal disapproval and temporary time-out (1 minute/ year with a maximum of 5 minutes). After 3-5 years, add natural or logical consequences (immediately after the incident by the adult who witnessed the misdeed). Direct the punishment against the behavior, not the person. Make a one-sentence comment about the rule when you punish your child. Also restate the preferred behavior, but avoid a long speech. Ignore your child's arguments while you're correcting him/her. These are delay tactics. Have a discussion with your child at a later more pleasant time. Make the punishment brief. Follow the consequence with love and trust. After 5 years of age, add delay of privileges after desired task is completed. Temper Tantrums are an immature way of expressing anger. Try to teach your child that tantrums don't work and that you don't change your mind because of them. By 3 years of age, you can begin to teach your child to verbalize their feelings. We need to teach children that anger is normal but that it must be channeled appropriately. Responses to Tantrums: (1) Support and help children having frustration-or fatigue-related tantrum. (2) Ignore attention seeking or demanding-type tantrums. (3) Physically move children having refusal-type tantrum to desired location. (4) Use time-outs for disruptive-type tantrum. (5) Hold children having harmful or rage-type tantrums (only if it helps).

SLEEP PROBLEMS*

Habitual night feeding. (Disrupts sleep after 4 months of age in the 10% of babies who haven't learned to sleep 8 hours or more without feeding.) · Gradually stretch daytime feeding intervals to 4 hours or more to eliminate the “grazing" habit. · Feed the baby in a room other than the bedroom. · Stop any naptime or bedtime feeding before the baby falls asleep. · Make nighttime feedings brief and boring. · Phase out nighttime feedings by gradually reducing the amount until the baby no longer craves food at night Habitual night crying. (Occurs after 4 months of age in babies who have been “trained" to rely on parents to get them to sleep.) · Put the baby in the crib when he's drowsy but still awake. · Leave him to cry it out, checking on him briefly every 15 minutes. He’ll cry 30-90 minutes the first night but should sleep though the night within 2 weeks. Bedtime refusal (Affects children older than 2 years.) · Start a pleasant bedtime ritual, then enforce the rule that the child follows the rule, but close it (barricading it if necessary) if he or

She screams or comes out. · Reopen the door every 15 minutes to briefly remind the child that it will stay open if he follows the rule. Nighttime wakening or early rising. (Affects children older than 2 years)

· Delay bedtime and reduce naps before the child needs less sleep. · Sternly order him back to his room if he crawls in bed with parents, escorting him if necessary. · Set a radio alarm for an appropriate time, and then enforce the rule that he cannot leave the room until the music comes on.

TOILET TRAINING Bowel and bladder control is a necessary social skill. Toilet training your child takes time, understanding, and patience. This discussion is intended to give you information that will help guide your child through this important stage of social development.

The first and most important rule is not to rush your child into using the toilet. A child must be ready. When is a child ready for toilet training? There is no set age at which toilet training should begin. The right time depends on your child's physical and psychological readiness. A child younger than 12 months has no control over bladder or bowel movements and little control for 6 months or so thereafter. Between 18 and 24 months, a child can start to show signs of being ready, but a child may not be ready until 30 months or older. A.A.P. recommends starting at 2 years of age. Your child must be able to control the muscles that regulate the bowel and bladder to be toilet trained. Knowing how to get to the potty or toilet and then undress quickly also is important. In addition, your child must be emotionally ready. He or she needs to be willing and cooperative, not fighting or showing signs of fear. If your child protests vigorously, it is best to wait for a while. Things that cause stress in the home may overwhelm the effort to learn this important new skill. Sometimes it is a good idea to delay toilet training in the following situations: · The family has just moved or will move in the near future. · A new baby is expected in the next several weeks or has recently been born. · There is a major illness, a recent death, or some other family crisis. However, if your child is progressing without problems, there is no need to stop toilet training. Try to avoid a power struggle over toilet training. Children at the toilet-training age are becoming aware of their individuality. They look for ways to assert independence. Some children may demonstrate their power by holding back bowel movements. Your best approach is to treat toilet training in a relaxed manner and to avoid becoming upset. Remember that no one can control when and where a child will urinate or have a bowel movement except the child. Your goal is to teach your child appropriate behavior that he or she can master as a part of growing up. Look for any of the following signs that your child is ready to begin training: · Your child remains dry at least 2 hours at a time during the day or is dry after naps. · Bowel movements become regular and predictable. · Facial expressions, posture, or words reveal that a bowel movement or urination is about to occur. · Your child can follow simple verbal instructions. · Your child can walk to and from the bathroom, undress, and then dress again. · Your child seems uncomfortable with soiled diapers and wants to be changed. · Your child asks to use the toilet or potty-chair. · Your child asks to wear grown-up underwear.

CHILDHOOD CONCERNS

ADD/ADHD

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. ADHD is also among the most prevalent chronic health conditions affecting school-aged children. The core symptoms of ADHD include inattention, hyperactivity, and impulsivity. Children with ADHD may experience significant functional problems, such as school difficulties,

academic underachievement, troublesome interpersonal relationships with family members and peers, and low self-esteem. Individuals with ADHD present in childhood and may continue to show symptoms as they enter adolescence and adult life Presentations of ADHD in clinical practice vary. In many cases, concerns derive from parents, teachers, other professionals, or nonparental caregivers. Common presentations include referral from school for academic underachievement and failure, disruptive Classroom behavior, inattentiveness, problems with social relationships, parental concerns regarding similar phenomena, poor self-esteem, or problems with establishing or maintaining social relationships. Teachers identify children with core ADHD symptoms of hyperactivity and impulsivity, because they often disrupt the classroom. Even mild distractibility and motor symptoms, such as fidgetiness, will be apparent to most teachers. In contrast, children with the inattentive subtype of ADHD, where hyperactive and impulsive symptoms are absent or minimal, may not come to the attention of teachers. These children may present with school underachievement.

ALLERGIES I HAY FEVER Symptoms *Clear nasal discharge with sneezing, sniffing, and nasal itching. *Occasionally associated with red/watery/itchy/swollen eyes, sinus and ear congestion, fatigue, cough secondary to a postnasal drip, constant throat clearing, mouth-breather, dark circles under eyes, etc. *Symptoms occur during the pollen season (spring or fall) for hay fever or year-round for dust, molds, pets, certain foods, etc. TREATMENT 1. Antihistamines. Benadryl. If this medication is not effective or too sedating, call the office during regular office hours. 2. Limit Exposure to: Pollen - keep windows closed in car and home, use air conditioner when possible. Dust - Remove stuffed animals, use damp cloth to dust, vacuum and clean sheets with hot water weekly, use HEPA filter if possible. Molds - Don't use carpeting in bathroom and kitchen. Avoid overuse of humidifiers (change water daily and clean weekly) Pets - occasionally have to be kept outside, definitely keep out of child's room. If eyes are affected, wash the face and eyelids to remove allergen. Then apply a cold compress to the eyelids. If 6 years or older, you can use Naphcon A or Visine AC (1-2 drops, up to 4 times per day). They are both over-the-counter but make sure child does not ingest it!

ASTHMA Asthma is a reactive airway disease (sensitive airways) that can be triggered by respiratory infections, cold air, exercise or by different allergens. Many parents have a phobia about the diagnosis of asthma and they only picture children who are gasping for air and having difficulty breathing. Many children with asthma will present only with chest pain or a constant hacking cough (cough variant asthma) that does not respond to cough medications. Children with recurrent croup or bronchitis may have underlying asthma. (Children with asthma should be able to lead a normal life and participate in any activities they want

AUTISM Autism is a complex and pervasive developmental disorder characterized by varying degrees of impairment in communication skills, social interactions and presence of restricted, repetitive and stereotyped behaviors, interests and activities! Most scientists consider autism a developmental disorder, likely influenced by genes. disorders range from mild Asperger's Syndrome to severe mental retardation and social disability, and there is no cure or good treatment.

Watch for the Red Flags of Autism

For a parent, these are the “red flags” that your child should be screened to ensure that he/she is on the right developmental path. If your baby shows any of these signs, please ask your pediatrician for an immediate evaluation: No big smiles or other warm, joyful expressions by six months or thereafter No back-and-forth sharing of sounds, smiles, or other facial expressions by nine months or thereafter No babbling by 12 months No back-and-forth gestures, such as pointing, showing, reaching, or waving by 12 months No words by 16 months No two-word meaningful phrases (without imitating or repeating) by 24 months Any loss of speech or babbling or social skills at any age

BED WETTING (ENURESIS) I Enuresis is the involuntary passage of urine during sleep. It is a very common problem affecting 40% of 3 year olds, 10% of 6 year olds, and 3% of 12 year olds. We consider it normal until at least 6 years of age. Most of these children have inherited small bladders, which can't hold all the urine produced in the night. In addition, they don't awaken to the signal of a full bladder.

Suggestions: · Encourage your child to get up to urinate during the night. · Encourage postponing urination during the daytime. · Encourage daytime liquids. · Discourage nighttime liquids. · Protect the bed from urine. · Establish a morning routine for wet pajamas and bedding, Respond positively to dry nights. · Respond gently to wet nights. Call during regular office hours if · Your child also has daytime wetting · your child used to be dry at night greater than 3 months; · your child is over 12 years old · Your child is over 6 years old and it doesn't improve with the suggestions listed above. If your child develops pain with urination,

CONCUSSION(HEAD INJURY) Concussion occurs when a person’s brain is violently rocked back and forth inside of the skull because of a blow to the head or neck. Concussion can disturb brain activity, and symptoms may include disorientation, confusion, dizziness, amnesia, uncoordinated hand-eye movements, and sometimes unconsciousness. The loss of consciousness results from the disturbance of the brain’s electrical activity. Severe concussion, although rare, can lead to brain swelling, cell and blood vessel damage, and even death. Symptoms of sports-related concussion are not always obvious and the decision to allow the player to return to the game is not always straightforward. Concussion does not always cause unconsciousness and its neuro-cognitive and even some physical effects may not show up on a CT scan or MRI. Allowing enough healing and recovery time following a concussion is crucial in preventing further damage. Research suggests that the effects of repeated concussion are cumulative. Most athletes who experience an initial concussion can recover completely as long as they are not returned to contact sports too soon. Following a concussion, there is a period of change in brain function that may last anywhere from 24 hours to 10 days. During this time, the brain may be vulnerable to more severe or permanent injury. If the athlete sustains a second concussion during this time period, the risk of permanent brain injury increases.

Because many mild concussions go undiagnosed and unreported, it is difficult to estimate the rate of concussion in any sport. Studies estimate that approximately 10 percent of all athletes involved in contact sports, such as football, have a concussion each season. In high school athletics, there are about 60,000 concussions each year; 63 percent of those occur in football. Other high school sports with a high risk of concussion are: girls and boys soccer (incidence in girls is higher than in boys); girls and boys basketball, lacrosse, and ice hockey. Even in contact sports, some concussions may be prevented by teaching and executing proper playing, tackling and defensive techniques; and by wearing properly fitted equipment, especially headgear. Concussion often results from accidents that involve: Motor vehicles ,Bicycles Skates, skateboards, and scooters Sports and recreation Falling down Firearms ,Physical violence ,Assault and battery Symptoms A concussion causes symptoms that may last for days, weeks, or even longer Symptoms that may appear in a child with a concussion include: Listlessness or tiring easily Irritability or crankiness Changes in: Eating or sleeping patterns Behavior School performance Lack of interest in favorite toys or activities Loss of new skills, such as toilet training Loss of balance, unsteady walking Symptoms in older child/teen include: Confusion Loss of memory about the accident Low-grade headaches or neck pain Nausea Having trouble: Remembering things Paying attention or concentrating Organizing daily tasks Making decisions and solving problems Slowness in thinking, acting, speaking, or reading Feeling fatigued or tired Change in sleeping pattern: Sleeping much longer than usual Trouble sleeping Loss of balance Feeling light-headed or dizzy Increased sensitivity to: Sounds Lights Distractions Blurred vision or eyes that tire easily Loss of sense of taste or smell Ringing in the ears Mood changes: Feeling sad, anxious, or listless Becoming easily irritated or angry for little or no reason

Lacking motivation Your child will need thorough examination after injury and before clearance to go back to school/gym or any sport resumption!!

CONSTIPATION (passage of hard stool) For infants less than 4 months old may need to switch formulas - speak to physician. If your child is eating solid foods you may need to add high fiber foods to his/her daily diet. These include apricots, prunes, peaches, pears, plums peas, beans, broccoli or spinach (raisins if older than 2 years) daily. Avoid carrots, squash, bananas, and apples. Do not give more than 20 oz. whole milk after 1 year of age. Some school age children develop constipation that might go on for weeks and months where the retained stool will stretch the large intestine to the point of losing the urge to defecate. The most common reason for relapses and failure of treatment is under-treatment and prematurely discontinuing therapy. If the child has been constipated for six months, you should continue treatment for six months. The first step is to clean out the entire hard stool by giving a pediatric Fleets enema every night for three successive nights. In the meantime start the child on 2 tablespoons of MINERAL OIL mixed with juice or soda once a day to help soften the stool. If the child skips having a bowel movement for two days you can give SENOKOT children's syrup as needed (please follow recommended doses). Remember you have to continue the mineral oil for a good amount of time. It is a natural fat and it does not cause dependency. Give it at a different time of day than you give your child his/her vitamins. If the stool gets too loose, cut down on the amount of mineral oil to one tablespoon a day

CPR

Steps for unresponsive infants (<1 year) and children (1 year to puberty): open airway; give 2 breaths if not breathing; begin compressions if no pulse; activate EMS system, use automated external defibrillator (AED) after 5 cycles of CPR in children; if rhythm shockable, give 1 shock and resume CPR for 5 cycles; if rhythm not shockable, resume CPR and check rhythm every 5 cycles until response or PALS providers intercede. For sudden collapse in child, activate EMS and get AED before CPR. Barrier devices do not reduce infection risk and might increase resistance to air flow. Bag-mask ventilation is as effective as endotracheal intubation for short periods; use 100% oxygen until more information known. If definite pulse, give 12 to 20 breaths/minute (1 breath every 3 - 5 seconds) and check pulse every 2 minutes; if no pulse or if pulse > 60 beats/minute with poor perfusion, begin chest compressions at 100 per minute. Cycle consists of 30 compressions (1 rescuer) or 15 compressions (2 rescuers) per 2 breaths. Ideal ratio unknown, but previously recommended 5:1 ratio resulted in less than 60 compressions/minute. If rescuer unable to ventilate patient, chest compressions alone are recommended versus no resuscitation. Changing rescuer every 2 minutes will maintain good compressions (forceful, fast, full chest recoil, minimal interruptions). For severe foreign body airway obstruction, perform sub diaphragmatic abdominal thrusts (child) or 5 back blows alternating with 5 chest thrusts (infant). For drowning victims, ventilation, but not compressions, can be started in the water if it does not prolong removal from water. In performing BLS for unresponsive infants and children, 5 cycles of CPR can be initiated before or concurrently with EMS system activation/911 and AED retrieval.

Food Allergy

Food allergy is a potentially serious immune response to eating specific foods or food additives. Eight types of food account for over 90% of allergic reactions in affected individuals: milk, eggs, peanuts, tree nuts, fish, shellfish, soy, and wheat. Reactions to these foods by an allergic person can range from a tingling sensation around the mouth and lips and hives to death, depending on the severity of the allergy. The mechanisms by which a person develops an allergy to specific foods are largely unknown. Food allergy is more prevalent in children than adults, and a majority of affected children will “outgrow” food allergies with age. However, food allergy can sometimes become a lifelong concern . Food allergies can greatly affect children and their families’ well-being. There are some indications that the prevalence of food allergy may be increasing in the United States and in other countries

· In 2007, approximately 3 million children under age 18 years (3.9%) were reported to have a food or digestive allergy in the previous 12months.

From 1997 to 2007, the prevalence of reported food allergy increased 18% among children under age 18 years. Children with food allergy are two to four times more likely to have other related conditions such as asthma and other allergies, compared with children without food allergies. Food allergies can be diagnosed via blood test or skin test and we offer both options to our patients!

Hearing Signs that indicate baby have normal hearing?

Birth to 3 or 4 months: Startles to sudden, loud sounds. Stops moving or crying in response to your voice.

3 months: Imitates gurgling or cooing sounds. Awakes to loud noises.

4 to 5 months: Turns eyes and head in direction of sounds.

7-9 months: Responds to his name. Babbles in multiple syllables.

9 months: Makes sounds.

9 to 12 months: Uses his/her voice to get attention. Says first word. Imitates sounds. Responds to music.

12 to 18 months: Imitates sounds and simple words. Uses 3 to 20 words.

HEART MURMUR A heart murmur is an extra or unusual sound heard during a heartbeat. Murmurs range from very faint to very loud. Sometimes they sound like a whooshing or swishing noise. The two types of heart murmurs are innocent (harmless) and abnormal. Innocent heart murmurs aren't caused by heart problems. These murmurs are common in healthy children. Many children will have heart murmurs heard by their doctors at some point in their lives. People who have abnormal heart murmurs may have signs or symptoms of heart problems. Most abnormal murmurs in children are caused by congenital heart disease. These defects are problems with the heart's structure that are present at birth. A heart murmur isn't a disease, and most murmurs are harmless. Innocent murmurs don't cause symptoms. Having one doesn't require you to limit your physical activity or do anything else special. Although you may have an innocent murmur throughout your life, you won't need treatment for it. When do heart murmurs become a concern? When they occur very early at birth or during the first six months of life. These murmurs are not functional or innocent, and most likely they will require the attention of a pediatric cardiologist immediately. They may be due to abnormal connections between the pumping chambers (septal defects) or the major blood vessels coming from the heart (e.g., transposition of vessels). Your infant will be observed for changes in skin color (turning blue), as well as breathing or feeding difficulties. He also may undergo additional tests, such as a chest X-ray, electrocardiogram (ECG), and an echocardiogram. This echocardiogram creates a picture of the inside of the heart by using sound waves. If all of these tests prove normal, then it is safe to conclude that the baby has an innocent murmur, but the cardiologist and pediatrician may want to see him again to be absolutely certain. .

Lead Poisoning Lead poisoning is caused most often by eating lead contained in dust, bits of old paint or dirt, by breathing lead in the air, or by drinking water from pipes lined or soldered with lead. There also may be lead in hobby materials such as stained glass, paints, solders, and fishing weights.” Lead also might be in food cooked or stored in some imported ceramic dishes. Do not serve acidic substances (e.g., orange juice) in these dishes, since the acids can leach lead from the dishes into the food. Although food cans with soldered seams could add lead to the food inside them, seamless aluminum containers in the United States generally have replaced these cans. Contrary to popular belief, lead poisoning is not caused by chewing on a pencil or being stabbed with its point. The so-called lead in a pencil actually is harmless graphite, and there is no lead in the paint coating the outside Lead was an allowable ingredient in house paint before 1978 and so may be on the walls, doorjambs, and window frames on many older homes. As the paint ages, it chips, peels, and comes off in the form of dust. Toddlers may be tempted by such bite-size pieces and will taste or eat them out of curiosity. Even if they don’t intentionally eat the material, the dust can get on their hands and into their food. Sometimes the lead containing finish has been covered with other layers of newer, safer paints. This can give you a false sense of reassurance, however, since the underlying paint still may chip or peel off with the newer layers and fall into the hands of toddlers. Although there has been a decline in high lead levels in children’s blood, somewhere between half a million and one million children in the United States still have unacceptably high levels. Living in a city, being poor, and being African American or Hispanic are all risk factors that increase the chances of having an elevated blood lead level. But even children living in rural areas or who are in well-to-do families still can be at risk. As a child continues consuming lead, it accumulates in the body. Although it may not be noticeable for some time, ultimately it can affect many areas of the body, including the brain. Lead poisoning can cause learning disabilities and behavioral problems. Very high levels will likely cause the most severe problems, but the extent of damage for any individual child cannot be predicted. Lead also can cause stomach and intestinal problems, loss of appetite, anemia, headaches, constipation, hearing loss, and even short stature. Iron deficiency increases the risk for lead poisoning in children, which is why these two disorders are often found together in children. Prevention

If your home is older, the likelihood of having dangerous amounts of lead there can be very high, especially for the oldest homes (those built before 1960). If you think your home may contain lead, clean up any paint dust or chips using water. During this cleanup, if you add a detergent to the water, it will help bind the lead into the water. Also, keeping surfaces (floors, window areas, porches, etc.) clean may lower your child’s chance of being exposed to lead-containing dust. Older windows are of particular concern since paint on wood frames frequently is damaged and the action of opening and closing windows can produce lead containing dust. Do not vacuum the chips or dust, as the vacuum will spread the dust out through its exhaust hole. It’s also a good idea to have your child wash his hands often, particularly before he eats. Incidentally, in a rented home, the landlord is responsible for all maintenance, and this includes necessary repainting and repairs. If you suspect unhealthy lead levels in the building, and your landlord is unresponsive or is not using lead-safe work practices when doing repairs, ask your community’s health department for help. Testing Only sure way to know if your child has been exposed to excessive lead is to have him/her tested. A blood test for lead at ages one and two years is recommended for children at high risk for lead exposure. In communities where high blood lead risk is low, a series of questions will determine whether a blood test is necessary. . The most common screening test for lead poisoning uses a drop of blood from a finger prick. If the results of this test indicate that a child has been exposed to excessive lead, a second test will be done using a larger sample of blood obtained from a vein in the arm. This test is more accurate and can measure the precise amount of lead in the blood. Children who have lead poisoning should immediately be moved from the home where they are being exposed to this toxic substance. In rare instances, they may require treatment with a drug that binds the lead in the blood and greatly increases the body’s ability to eliminate it. When treatment is necessary, usually oral medicines are used on an outpatient basis. Much less frequently, the treatment may involve hospitalization and a series of injections. Acceptable level is < 9 but ideal level as of 2013 is < 5

NUTRITION,

2006 guidelines are

Food 1,000 k cal/d 1,400 k cal/d 2,000 k cal/d 2—3 Years old 4—6 Years old Teenagers Fruit, cup 1 1.5 2 Vegetables, cup 1 1.5 2.5 Dark green vegetables, cup/wk 1 1.5 3 Orange vegetables, cup/wk 0.5 1 2 Legumes, cup/wk 0.5 1 3 Grains, oz 3 5 6 Whole grains 1.5 2.5 3 Meat/beans, oz 2 4 5.5 Milk, cup 2 2 3 Oils, tsp 3 3.5 5

Also

Children and adolescents should engage in at least 60 minutes of physical activity at least 5 days a week, and pregnant women 30 minutes or more. In children from 2 to 3 years of age, total fat should be between 30%-35% of kcals; in children from 4 to 18 years, total fat should be between 25%-35% of kcals. Children and adolescents should meet recommendations for fiber and avoid excessive calories from added sugars.

CHOLESTEROL -

If your child's cholesterol is high or borderline the following suggestions should be started to reduce the risk of coronary heart disease. Even if no one else has high cholesterol, the entire family should follow the same regimen (exception - children under 2 years). Living a long and healthy life requires healthy eating and exercise patterns.

LOW- FAT DIET · Serve more fish, turkey, and chicken since they have less fat than red meats. Buy lean ground beef. Use lean ham or turkey for sandwiches. · Trim the fat from meats and remove the skin from poultry before eating. · Avoid the meats with the highest fat content, such as bacon, sausages, salami, pepperoni, and hot dogs. · Limit the number of eggs eaten to 2-3 per week. · Limit the amount of all meats to portions of moderate size. · Use 1% or skim milk instead of whole milk. · Use a margarine product instead of butter. · Avoid deep fat fried food or food fried in butter or fat. · Increase your child's fiber intake. Fiber is found in most grains, vegetables, and fruit. · Olive oil is recommended over the other types of oil because it increases the HDL ('~good- type" of) cholesterol. FAMILY EXERCISE PROGRAM Your goal should be 20-30 minutes of vigorous exercise 2-3 times per ~week. The exercise must involve the large muscles of the legs and cause your heart to beat faster. Examples - biking; walking; using stairs instead of ~elevator; jump rope; exercise to a video; join a team; swimming; jogging; limit TV/video and computer games to 2 hours.

ORAL HEALTH Early childhood caries (cavities) is the number 1 chronic disease affecting young children. Early childhood caries is 5 times more common than asthma and 7 times more common than hay fever. Tooth pain keeps many children home from school or distracted from learning. Children are recommended to have their first dental visit by age 1 and definitely after 2nd birthday! "Increased biting, drooling, gum rubbing, sucking, irritability, wakefulness, ear rubbing, facial rash, decreased appetite for solid foods, and mild temperature elevation were all statistically associated with teething.” Symptoms not associated with teething included congestion, cough, and sleep disturbance, decreased appetite for liquids, vomiting, and loose or increased stools. Furthermore, no single symptom occurred in more than 35% of infants The safest recommended intervention for teething is the use of cold items because the cold acts as an anesthetic for the gums. Refrigerated teething rings, pacifiers, spoons, clean wet washcloths, and frozen bagels or bananas are all good choices. However, teething rings should be placed in the refrigerator only (not the freezer) to prevent infants from developing fat necrosis. Topical teething

gels sold over-the-counter (OTC) are often used for teething; however, these gels can carry serious risks, including local reactions, seizures (with overdose), and methemoglobinemia . If necessary, parents should be instructed on proper dosing of OTC analgesic medications, such as acetaminophen or ibuprofen. Anticipatory guidance: Stop night feedings once the teeth erupt. The majority of children are physiologically able to tolerate a prolonged fast around 6 months of age, which is when the teeth typically begin to erupt. Parents should try to use methods other than feeding to calm a crying child, including providing a transitional object such as a small blanket or stuffed toy, offering a pacifier, rocking, or singing. If a child needs a bottle to fall asleep, it should contain only plain water. Parents who elect to continue to feed on demand at night should be instructed to wipe the infant’s teeth clean after feedings. Never prop a bottle and always remove it promptly once the infant is done feeding. Discourage prolonged and frequent use (especially ad lib) of a bottle or sippy cup during the day, unless the cup contains plain water. Parents should be encouraged to limit the drinking of sugary fluids to meals and snack times. Introduce a cup as soon as the child can sit unsupported (around 6 months of age) and try to eliminate the bottle by 1 year of age And start using toothpaste without fluoride after 1st birthday.

POISONING Each year, approximately 2.4 million people – more than half under age 6 – swallow or have contact with a poisonous substance. The American Academy of Pediatrics (AAP) has some important tips to prevent and to treat exposures to poison. Please feel free to excerpt these tips or use them in their entirety for any print or broadcast story, with acknowledgement of source. To poison proof your home: Most poisonings occur when parents or caregivers are home but not paying attention. The most dangerous potential poisons are medicines, cleaning products, antifreeze, windshield wiper fluid, pesticides, furniture polish, gasoline, kerosene and lamp oil. Be especially vigilant when there is a change in routine. Holidays, visits to and from grandparents’ homes, and other special events may bring greater risk of poisoning if the usual safeguards are defeated or not in place. Store medicine, cleaners, paints/varnishes and pesticides in their original packaging in locked cabinets or containers, out of sight and reach of children. Install a safety – that locks when you close the door – on child-accessible cabinets containing harmful products. Purchase and keep all medicines in containers with safety caps. Discard unused medication. Never refer to medicine as “candy” or another appealing name. Check the label each time you give a child medicine to ensure proper dosage. Never place poisonous products in food or drink containers. Keep coal, wood or kerosene stoves in safe working order. Maintain working smoke and carbon monoxide detectors. Treatment If your child is unconscious, not breathing, or having convulsions or seizures due to poison contact or ingestion, call 911 or your local emergency number immediately. If your child has come in contact with poison, and has mild or no symptoms, call your poison control center at 1-800-222-1222 Different types and methods of poisoning require different, immediate treatment: Swallowed poison – Remove the item from the child, and have the child spit out any remaining substance. Do not make your child vomit. Do not use syrup of ipecac.

Skin poison -- Remove the child’s clothes and rinse the skin with lukewarm water for at least 15 minutes. Eye poison -- Flush the child’s eye by holding the eyelid open and pouring a steady stream of room temperature water into the inner corner for 15 minutes. Poisonous fumes – Take the child outside or into fresh air immediately. If the child has stopped breathing, start cardiopulmonary resuscitation (CPR) and do not stop until the child breathes on his or her own, or until someone can take over.

SCHOOL READINESS Each child is viewed as unique in his developmental style, but generally all children follow the same sequence of developmental milestones. At age 5 years children should have readiness skills to enter Kindergarten. The exact time of enrollment in KG depends on your Childs birth date and your school districts cut off date. The following are generally accepted guidelines to determine if your child is ready to enter Kindergarten. It is strongly recommended to enroll them in a pre-school at age 4 years. Gross Motor Skills: Beginning to skip and balance on one foot. Fine Motor Skills: Buttons clothes, uses scissors to cut in a straight line. Visual-Motor Skills: Copies a triangle, draws a person with a body. Speech and Language: Speaks in long sentences, able to describe events and pictures. Speech should be well understood by strangers. Able to follow three stage verbal instructions. General Fund of Knowledge: Days of the week, able to count to 10 with correct pointing. Personal-Social-Emotional Maturation: Is completely toilet trained. Have self-care skills to dress, undress and wash. Understands and follows routines, makes transitions easily, separates readily and for prolonged periods from parents. Able to participate in a group setting. If your child does not seem to have the expected skills, do not hold him back but discuss your cancers with your pediatrician and the school officials. WEIGHT - TOO MUCH? Your child is considered overweight if he/she weighs more than 20% over the ideal weight for height. Follow the percentiles during well child visits. The best time to establish eating patterns to minimize the possibility for obesity is in infancy (examples - do not overfeed, do not pacify~ with food or the breast, don't force them to finish, do not start solids before 4 months, etc.). Less than 1% of obesity has an underlying medical cause. Losing weight is very difficult. Keeping the weight off is also a chore. Stop it before it gets out of control! Minimize junk foods, sweets and excessive juice/soda/punch; don't have it in the house. The entire family should eat the same diet and get involved in a fun exercise program. It is very important to protect their self-esteem. Accept your child for who they are. Don't make the weight an issue. Never say you're fat. Don't deprive them of food if they're hungry, but supply healthy snacks. Set an attainable goal - maintain current weight or lose 1 lb./week. Decrease Calorie Consumption. Eat 3 well-balanced meals of' average-size portions every day (discourage seconds, if given wait 10 minutes.) Offer no more than 2 healthy snacks per day. Drink no more than I 6 oz. of skim or low-fat milk per day. Keep juice consumption to 8 oz. or less per day. Drink a glass of water before meal and chew food slowly. Avoid rich desserts. Give 1 multivitamin per day. Increase Calorie Expenditure. Establish an exercise routine.

Speech Delay Delays in language are the most common types of developmental delay. One out of 5 children will learn to talk or use words later than other children their age. Some children will also show behavioral problems because they are frustrated when they can't express what they need or want. Simple speech delays are sometimes temporary. They may resolve on their own or with a little extra help from family. It's important to encourage your child to "talk" to you with gestures or sounds and for you to spend lots of time playing with, reading to, and talking with your infant or toddler.

Sometimes delays may be a warning sign of a more serious problem that could include hearing loss, developmental delay in other areas, or even an autism spectrum disorder (ASD). Language delays in early childhood also could be a sign of a learning problem that may not be diagnosed until the school years. It's important to have your child evaluated if you are concerned about your child's Your baby is able to communicate with you long before he or she speaks a single word! A baby's cry, smile, and responses to you help you to understand his or her needs. Learn how children communicate and what to do when there are concerns about delays in development.

Milestones during the first 2 years Children develop at different rates, but they usually are able to do certain things at certain ages. Following are general developmental milestones. Keep in mind that they are only guidelines. Even when there are delays, early intervention can make a significant difference. By 1 year most babies will Look for and be able to find where a sound is coming from. Respond to their name most of the time when you call it. Wave goodbye. Look where you point when you say, "Look at the ______." Babble with intonation (voice rises and falls as if they are speaking in sentences). Take turns "talking" with you—listen and pay attention to you when you speak and then resume babbling when you stop. Say "da-da" to dad and "ma-ma" to mom. Say at least 1 word. Point to items they want that are out of reach or make sounds while pointing. Between 1 and 2 years most toddlers will Follow simple commands, first when the adult speaks and gestures, and then later with words alone. Get objects from another room when asked. Point to a few body parts when asked. Point to interesting objects or events to get you to look at them too. Bring things to you to show you. Point to objects so you will name them. Name a few common objects and pictures when asked. Enjoy pretending (for example, pretend cooking). They will use gestures and words with you or with a favorite stuffed animal or doll. Learn about 1 new word per week between 11/2 and 2 years. By 2 years of age most toddlers will Point to many body parts and common objects. Point to some pictures in books. Follow 1-step commands without a gesture like "Put your cup on the table." Be able to say about 50 to 100 words. Say several 2-word phrases like "Daddy go," "Doll mine," and "All gone." Perhaps say a few 3-word sentences like "I want juice" or "You go bye-bye." Be understood by others (or by adults) about half of the time. When milestones are delayed If your child's development seems delayed or shows any of the behaviors in the following list, tell your child's doctor. Sometimes language delays occur along with these behaviors. Also, tell your child's doctor if your baby stops talking or doing things that he or she used to do. Doesn't cuddle like other babies Doesn't return a happy smile back to you Doesn't seem to notice if you are in the room Doesn't seem to notice certain noises (for example, seems to hear a car horn or a cat's meow but not when you call his or her name) Acts as if he or she is in his or her own world Prefers to play alone; seems to "tune others out" Doesn't seem interested in or play with toys but likes to play with objects in the house

Has intense interest in objects young children are not usually interested in (for example, would rather carry around a flashlight or ballpoint pen than a stuffed animal or favorite blanket) Can say the ABCs, numbers, or words to TV jingles but can't use words to ask for things he or she wants Doesn't seem to be afraid of anything Doesn't seem to feel pain in a typical fashion Uses words or phrases that are unusual for the situation or repeats scripts from TV .

CHILDHOOD ILLNESSES

Antibiotics UNNECESSARY ANTIBIOTICS CAN HARM YOUR CHILD Antibiotics should not be used to treat viral infections. More and more resistant bacteria developed as a result of antibiotic abuse. We are reaching a point when we will have no effective antibiotic for certain infections. When are antibiotics not needed?

Common colds, sore throat caused by viruses (positive strep throat requires antibiotics and this must be diagnosed by a laboratory test). Croup or bronchitis may be needed to be treated with antibiotics. Most children with thick or green mucus do not have sinus infections. Antibiotics are needed for more long lasting or severe cases. Approximately 30 percent of ear infections are caused by viruses and will not benefit from antibiotics.

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BRONCHIOLITIS Bronchiolitis is a viral infection of the lower respiratory tract in children under 2 years of age. It starts like a common cold with a runny nose and ~sneezing. After a few days the child develops a wheezy cough and trouble breathing. In some infants symptoms appear much more quickly. For mild cases you can use a cool mist humidifier and normal saline nose drops with. Suction. Give your child plenty of fluids. Bring the child during office hours for evaluation and treatment plans. If your child has difficulty breathing or breathing becomes faster than 60 breaths per minute when your child is not crying call immediately for further advice.

CHICKENPOX (Varicella) A safe and effective vaccine is available and recommended for all children age one year and older. If your child did not receive the vaccine, call the office for information on the vaccine or an appointment. If your child develops chickenpox he will have itchy red spots that start on the trunk (body) that will ~spread over the arms, legs and face in the next five days. It will change from red spots to blisters (fluid filled) that will start to crust. He might have fever for the first four days. The child is infectious one day before the rash appears until all the lesions are dry and crusted (in approximately one week). You can use Tylenol for the fever, Benadryl to relieve the itching and Avenue oatmeal bath. Your child cannot attend school for one week. Chickenpox is not an emergency and the child does not have to be seen in the office unless he develops complications (fever for longer than four days, vomiting, infected skin rash).

Colds /URI colds are viruses. You can help your child by giving medications that will relieve some of the symptoms. There is no cure. Antibiotics will not shorten the course. A cold typically lasts 7-10 days. Typical Course: Runny or stuffy~ nose usually associated with a cough and fever. The fever usually occurs in the first 2-3 days with clear mucous. Then the mucous becomes yellow/green for a couple of days (especially if infants aren't frequently suctioned or an older child can't blow their nose).

Subsequently, the mucous turns clear. The cough can continue for 2 weeks. Additional symptoms can occur including: sore throat, decreased appetite, swollen lymph nodes in the neck, and red eyes without discharge. Frequency: Children younger than 5 years get as many as 8-10 colds per year usually clustered in the fall and winter months. The frequency gets less, as they get older.

Call the office immediately if breathing becomes difficult and no better after clearing the nose. Call during regular office hours if: · Fever greater than 3 days. · Nasal discharge greater than 10 days. · Infant isn't drinking usual amount for the day. · Earache or sinus pain. · Sore throat is getting worse. · Your child is getting worse or any other concerns.

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CROUP Croup is a viral infection in and around the voice box. Your child may go to bed with a runny nose and mild cough but wake up during the night with a scary cough that sounds like a seal's bark. The child's breathing may become noisy and labored. He/she may or may not have fever. Most cases of croup can be handled at home. Turn on the shower and let the bathroom fill up with steam. Stay with your child in the steamed bathroom 'or 15-20 minutes. If the child's breathing does not improve call the pediatrician for further help and we may advise an office/ER visit. Taking your child for a walk or car ride in the cool night air may help the child breathe better. Remember to use a cool mist humidifier in the child's bedroom during the night. If your child's breathing improved and you did not need to call the pediatrician please call in the morning for further assessment and advice.

COUGH Most coughs are triggered by an upper respiratory infection, which is due to a viral infection. Keep in mind coughing is the body's way to clear the lungs and protect them from pneumonia. If you have been diagnosed with asthma, start your prescribed medications. TREATMENT: To loosen the cough and thin the secretions: drink plenty of fluids, especially warm liquids (Example - lemonade, apple juice, tea) and I tsp. of honey, if older than 1 year, or corn syrup. To suppress a dry cough that interferes with sleep or school attendance: you can use Dextromethorphan (DM), which is found in many over-the-counter medications. Dosage is 0.2 mg/lb. every 4-6 hours. You can also use a cool mist humidifier. Avoid exposure to cigarette smoking. Call the office immediately if your child's breathing becomes fast and labored (when your child isn't coughing).

Call during regular office hours if cough: I. Lasts >3 weeks 2. Causes vomiting >3 times, 3. Causes bad chest pain or Causes exhaustion or lost sleep.

Diaper RASH Change your baby's diapers at least every two hours during the day and once night. When practical keep the baby's diaper off altogether. Use super absorbent &disposable diapers and be sure the diaper does not fit too tightly. Resist excessive cleaning or washing. After your baby urinates it is not necessary to clean him/her. Bowel movements may be followed with gentle cleansing using warm water and a small amount of mild soap, such as Dove, Johnson's Ultra Sensitive or a Cetaphil cleansing bar. Be sure to rinse away the soap well. It's best to stay away from diaper wipes when the baby has a rash. Consider using a barrier cream, such as Balmex or Destin. If the rash doesn't

respond to these steps within three days, call our office. Also arrange an appointment if the rash seems to be getting worse, or is bright red or raw EAR INFECTIONS A verbal child will tell you if he/she has an earache. A nonverbal child usually presents with cold symptoms for a few days, then develops fever and starts to wake up from a nap or at night screaming in pain and touching the ears. You can give Tylenol or Motrin to ease the pain and the fever. You can also use a decongestant. Keep your child propped up, keep a heating pad against the ear (no more than 10-15 mm) or warm up cooking oil and use a few drops in each ear. Make sure it is only warm to touch, not hot. During office hours call for an appointment. After hours if all these measures did not work within one hour, please call the pediatrician for further help. Do not go to the emergency room.

ECZEMA Eczema is an allergic skin disorder that can be triggered by certain allergens, e.g. cow's milk or local irritant. Formula change to a soy-based formula will help, in many cases. Avoid frequent bathing, and do not use soap (use Cetaphil cleanser). Pat the skin dry, and then apply Aquaphor ointment to help keep the skin moist. Double rinse the child's clothes and linens and do not use any kind of fabric softeners. Cotton clothing is preferred. Avoid wool and polyester clothing directly on the skin. Occasionally steroid cream may have to be prescribed for severe cases.

FEVER Fever is your child's friend. DO NOT PANIC, do not panic, and do not panic. Fever is a natural response from the body to fight infection. It is defined as a rectal temperature of 100.5 F or higher. Fevers tend to rise in the evenings. You do not have to treat fever unless your child seems uncomfortable or has a history of convulsions with fever. Remember, children tend to tolerate fever better than adults do. Fever less than 106 F will not cause brain damage. Also remember that every time you treat fever you interfere with the body's natural defense to fight infections. Do not treat fever unless you see below. *For infants less than 3 months consult our office. · For infants older than 3 months and for older children use Tylenol or Tempra (both are acetaminophen) according to the schedule printed below or on the package. Repeat dose every four hours as needed. · Use tepid water sponge baths if your child's temperature is above 103 in addition to Tylenol. Do not use alcohol. Do not try to bring your child's temperature down rapidly as your child will shiver and the temperature will shoot up again. Remember it will take up to one hour to get the full effect of the Tylenol. If Tylenol and sponge bathing do not bring down the temperature by 2 to 3 degrees within one hour you can give a dose of Motrin (or Advil or ibuprofen) suspension (no prescription necessary). Use the appropriate dose as directed (see dosing schedule below). Do not use Motrin as a first line treatment for fever. It is not as safe as Tylenol, particularly if your child has not been drinking enough fluids as it can affect the kidneys. Remember: Always use Tylenol first even for fever above 103. Use Motrin only as Backup. · You can repeat the Motrin dose every 6 hours, only if needed. · If your child is vomiting you can use Feverall (acetaminophen suppositories). No prescription is necessary. Use the same dose as for oral Tylenol and repeat every four hours as needed. · Do not combine rectal and oral acetaminophen at the same time. Call the office if. · Your child is less than 3 months · Your child looks “toxic" (listless, child whimpers rather than cries vigorously, no eye contact with familiar faces, lethargic) · Your child has any severe medical condition (heart disease, severe asthma, sickle cell disease, diabetes, etc.) Your child has any localizing signs (difficulty breathing, neck stiffness, redness or swelling in any extremity, joint or soft tissue, and problems with urination, severe diarrhea or severe abdominal pain

Acetaminophen dosing chart Acetaminophen (Tylenol) may be given every 4-6 hours Weight Children's Drops/suspension Children's Junior strength chewable chewable 160 mg/5 ml 80 mg each 160 mg each Teaspoon Tablet Tablet/Caplet 6-11 lbs. 1.25 ml 12-17 lbs. 2.5ml 18-23 lbs. 3.75 ml 24-35 lbs. 5ml 2 36-47 lbs. 7.5 ml 3 48-59 lbs. 10 ml 4 2 60-71 lbs. 12 5 ml 5 2 1/2 72-95 lbs. 15 ml 6 3 95 + lbs. 4 MAX. 650

Ibuprofen dosing chart Ibuprofen (Motrin, Advil) may be given every 6-8 hours for children > 6 months old. Weight Infant's Children's Chewable Chewable drops suspension tablets 50 mg tablets 100 mg Dropper Teaspoon Tablet Tablet 12-17 lbs. 1.25 ml 1/2 18-23 lbs. 1.875 ml 3/4 1 1/2 3/4 24-35 lbs 2.5 ml 1 2 1 36-47 lbs. 1 1/2 3 1 1/2 48-59 lbs. 2 4 2 60-71 lbs. 2.5 5 2.5 72-95 lbs. 3 6 3

FIFTH DISEASE Fifth disease is a viral illness that usually affects school age children. It presents with red cheeks (slapped face appearance), then a flat lacy rash appears on the extremities and the body. The rash comes and goes for several weeks and gets aggravated by heat. (The child is contagious only before the rash appears). No treatment is needed and it resolves spontaneously. If a pregnant woman is exposed she should inform her obstetrician as the virus might affect the fetus.

FLU The flu (influenza) is a viral illness that occurs between November and March every year. Symptoms may include high fever up to 1050, body aches, chills, headaches, runny or stuffy~ nose, sore throat, cough, abdominal pain and loose stools. The illness can last for one week. Treatment consists of symptomatic therapy to keep the child comfortable. Antibiotics are not indicated and will not help the flu. Flu vaccine is available every year starting in October through the flu season. It is

indicated for patients with chronic illnesses like asthma, diabetes, kidney disease and it should be covered by insurance for high-risk patients. It is also optional for any patient who does not want to catch the flu but it is not usually covered by insurance For healthy patients. The vaccine is effective and safe and it does not cause lie flu, but it takes 2 weeks to build up immunity. During this 2-week period patients should be careful not to be exposed to the flu. Pediatrics flu deaths over few years are 2003-04 flu season - 152 pediatric flu deaths 2004-05 flu season - 39 pediatric flu deaths 2005-06 flu season - 41 pediatric flu deaths 2006-07 flu season - 68 pediatric flu deaths 2007-08 flu season - 88 pediatric flu deaths 2008-09 flu season - 133 pediatric flu deaths 2009-10 flu season - 348 pediatric flu deaths 2010-11 flu season - 123 pediatric flu deaths 2011-12 flu season - 34 pediatric flu deaths 2012-13 flu season - 161 pediatric flu death

Hand, FOOT, MOUTH SYNDROME SYMPTOMS: · Small ulcers in the mouth, usually painful · Small water blisters or red spots on palms or soles and between fingers and toes · Fever · Mainly occurs in children 6 months to 4 years CAUSE: Coxsackie virus COURSE: Fever for 3-4 days. Mouth ulcers resolve in 7 days, rash in 10 days. HOME CARE: Avoid giving your child citrus, salty, or spicy foods. Change To a soft diet with plenty of clear fluids. Popsicles and sherbet are often Well received. Have your child swish and swallow an equal mixture of Benadryl and Maalox 30 minutes before meals, can be repeated every 6 hours as needed. 4 hours as needed for fever (no more than 5 doses in 24 hours). CONTAGIOUSNESS: The spread of infection is extremely difficult to prevent and the condition is harmless. Therefore, these children do not have to be isolated. They can return to normal activities when the fever returns to normal. CALL IMMEDIATELY IF your child shows signs of dehydration.

CALL DURING REGULAR OFFICE HOURS IF 1. Your child isn't drinking much despite the suggestions above, but is not dehydrated. 2. Fever >4 days. 3. Gums become red and swollen. 4. Your child is getting worse. .

Head INJURY (concussion) Toddlers and children fall a lot and many times will hit their head. Not uncommonly they will sustain a bump on their head from falling. You can apply cold compresses to cut down on the swelling. Usually the child does lot need a skull x-ray or to be seen by a physician unless he has a large bruise (2 inches in diameter or more), has a deep cut with gapping edges that ill might need stitches, or develops any of the following signs: · Drowsiness, dizziness, stupor or unconsciousness · Personality changes · Confusion · Weakness or numbness of arms or legs · Persistent vomiting · Blurred or double vision · Difficulty walking or maintaining balance · Blood or clear fluid draining from nose or ear INSTRUCTIONS:

· Do not use any medication other than Tylenol (acetaminophen) unless prescribed by a doctor. No aspirin. · It's okay to eat, if hungry and not vomiting. Keep things light. · Rest for a few hours after head trauma. It's okay to sleep, but if it is bedtime, there should be someone who will awaken the patient once or twice during the night to make sure the child is responding appropriately. Hives Symptoms Itchy rash · Raised pink spots with pale centers (look almost like mosquito bites) · Rapid and repeated changes of location size and shape CAUSE: It's an allergic reaction to a food, drug, viral infection, insect bite, etc. Frequently the cause is not found. It is not contagious.

TREATMENT: Benadryl every 6 hours as needed

Child’s Weight (lb) 20 40 60 80 100 120 Benadryl Liquid (12.5 mg/5 ml) 3ml 6ml 10ml 13ml 16ml 20ml Benadryl Chew. Tabs. (12.5 mg) 1/2tab 1 2 3 3-1/2 4 Benadryl Reg. Tabs. (25 mg) — — 1 1 1-1/2 2 Call immediately if: (1) breathing becomes difficult or (2) tongue becomes swollen. Call during regular office hours if: (I) most of the itch is not relieved after taking the medication for 24 hours, (2) hives last more than I week, (3) fever, joint swelling or pain occurs.

. PINK EYE (CONJUNCTIVITIS) Conjunctivitis could be due to infection with either bacteria or viruses. Bacterial infection is usually associated with yellowish eye discharge. Conjunctivitis could also be due to allergies (usually associated with itching and tearing). Bacterial pink eye can be treated with antibiotic eye drops. You can use warm compresses and call during office hours for eye drops. If the redness remains after a few days the child has to be seen. Call us if child has high fever, severe eye pain, appears lethargic, or has swelling or redness around the eye or can not move the eye in all directions. Allergic pink eye can be treated with Naphcon A drops from age 6 and up. Bacterial Conjunctivitis is contagious until the yellow discharge stops! .

RASHES There are many causes for rashes. Generally itchy rashes are due to allergies e.g. hives, or eczema. A few infections can also cause an itchy rash e.g. chickenpox, scarlet fever. Other non-itchy rashes could be due to roseola, fifth disease, hand foot mouth syndrome. Measles are a rare cause of rashes since children are immunized and usually these children are quite sick with high fever, red eyes and cough. Diaper rash is the most common type in babies. Other causes of rashes ~ire fungal (ringworm or tinea) which is usually mildly itchy, appears like a ring with clearing center. You can use Lotrimin cream 3 times a day for 4 weeks though you should notice some improvement in one week (otherwise call for appointment When you should call: Rashes are not emergencies unless the child has a high fever that is not responding to medication, is acting sick and lethargic or the rash is petechial rash marks that don't blanch or disappear with pressure) or has a stiff neck.

ROSEOLA Roseola is a viral illness that affects babies between 5 and 24 months of age. It presents with 2-3 days of recurrent fever as high as 1050 that will partially respond to Tylenol or Advil. Then the fever breaks and a red flat rash appear all over the body, face and extremities. Again this will last for 2-3 days then disappear. Once the rash appears the temperature will not go up again. There are no other symptoms except for puffy~ eyelids and the child usually eats okay when the fever is down. Except for sponge bathing and fever medication to keep the child comfortable, no other treatment is required.

SINUSITIS Sinusitis usually develops after your child has had a cold for at least 10 days. Signs of sinusitis are: · Persistent nasal discharge 2 weeks or longer · A cough during the day and night that often gets worse at night · Tenderness in the face · Headaches Yellowish or green nasal discharge at the tail end of a cold that lasted less than 10 days does not need to be treated with antibiotics. Sinusitis is not an emergency since the process develops over several days and weeks. Please call the office for an appointment for proper evaluation and treatment.

SORE THROAT (including Strep throat) Signs of strep throat include a sore throat, fever and swollen glands in the neck. (If there is also a skin rash the condition is called scarlet fever). Since many viruses can cause similar symptoms your child should be seen during office hours to make the proper diagnosis. In the meantime you can make your child comfortable by giving Tylenol or Motrin for fever and pain. You can also use lozenges (if your child is over five) or chloraseptic spray. If the child is old enough to gargle, use warm salt and water or diluted peroxide with warm water. If the diagnosis of strep throat is confirmed in the office, your child will receive antibiotics for 5-10 days. He/ she will feel better in 24-36 hours after starting antibiotic and will no longer be contagious.

STOMACH PAIN If your child complains of stomachaches on and off but goes on with his/ her normal activities, usually the reason is not serious. The most common reason is constipation; Please refer to the section on constipation for advice. The second most common reason is lactose intolerance. Try a lactose free diet for two weeks. Use LACTAID milk and 2 chewable caplets of LACTAID or DAIRYEASE with any dairy products (e.g. yogurt, cheese ice cream). If the abdominal pain improves on this diet, this will confirm the diagnosis. There are rare serious causes of abdominal pain (e.g. urinary tract infection or appendicitis) but usually the pain is severe, persistent and associated with other symptoms. In this case please call the office immediately.

URINARY TRACT INFECTIONS Urinary tract infections can cause the following symptoms: Painful and frequent urination Fever Vomiting Abdominal pain Call if your child has symptoms suggestive of UTI. A clean urine sample will be needed to confirm the diagnosis and your child will go on antibiotics. 'The urine could be obtained in our office during office hours or your child will be sent to the hospital laboratory' after hours to do the test and then start on an antibiotic. Do not go to the ER. Please call physician first after hours.

VOMITING AND DIARRHEA Vomiting and diarrhea is usually caused by a viral infection. It usually lasts only about a day or two but in some cases it can last up to a week. If your child is throwing up give nothing by mouth for the

first hour. Then start with small sips of clear fluids (®, , 7-Up, chicken broth). For babies under six months give only Pedialyte or KAO-. In-crease the amount of fluids gradually to spoon feeding, then 1/2 ounce every 10-15 minutes, then one ounce and soon. If the child starts to vomit again back off on the amount of fluids and start all over again. If the vomiting stops give as much fluid as the child wants. After 12 - 24 hours start giving easy to digest foods, depending on the child's age (toast, rice, potatoes, carrots, applesauce, bananas). For formula fed baby’s give diluted (1/2 formula, 1/2 water) for the next 24 hours, in addition to the age appropriate food mentioned above that the child was on before the illness. On the third day start full strength formula as usual. For breast-fed infants continue breast-feeding and give Pedialyte in between. For older children start introducing low fat yogurt, and chicken breast on the third day and advance gradually to regular diet. If your child is improving you can restart on regular milk. If diarrhea recurs try Lactaid milk for one week, or Isomil® DF depending on the child's age Watch for signs of dehydration which include: · Decreased urination or dry diapers (for infants 8-10 hours without urination, for older children 12-16 hours without urinating) · Decreased wetness of the tongue and dryness inside the mouth · Decreased amount of tears when crying · Lethargy (this is seen when dehydration is severe) Observe your child for signs of dehydration. Call the office if your child: · Is less than three months old · Exhibits any of the above signs of dehydration Has blood in the stool has only vomiting and abdominal pain (without Diarrhea) · Continues to have diarrhea for a week or more

Vaccines/ Immunization Why ? Immunization has been called the most important public health intervention in history, after safe drinking water. It has saved mil- lions of lives over the years and prevented hundreds of millions of cases of disease. None of us wants to see our children get sick. And getting them immunized can protect them from a number of very serious diseases. It Can also protect their friends, schoolmates, and others from those same diseases? Some children can’t get certain vaccines for medical reasons, or some children are not able to respond to certain vaccines. For these children, the immunity of people around them is their only protection. If enough parents fail to get their children immunized, diseases that had been under control can come back to cause epidemics. This has happened in several countries. It Could, ultimately, even help rid the world of diseases that have been crippling and killing children for centuries? Immunization allowed us eradicate smallpox. Today polio is nearly gone, and in the future measles and other diseases will follow. . How Vaccines Work What is Immunity? When disease germs enter your body, they start to reproduce. Your immune system recognizes these germs as foreign invaders and responds by making proteins called antibodies. These antibodies’ first job is to help destroy the germs that are making you sick. They can’t act fast enough to prevent you from becoming sick, but by eliminating the attacking germs, antibodies help you to get well. The antibodies’ second job is to protect you from future infections. They remain in your bloodstream, and if the same germs ever try to infect you again — even after many years — they will come to your defense. Only now that they are experienced at fighting these particular germs, they can destroy them before they have a chance to make you sick. This is immunity. It is why most

people get diseases like measles or chickenpox only once, even though they might be exposed many times during their lifetime. This is a good system for preventing disease. The only drawback is obvious — you have to get sick before you become immune. Vaccines are made from the same germs (or parts of them) that cause disease — measles vaccine is made from measles virus, for instance, and Haemophilus influenzae type B (Hib) vaccine is made from parts of the Hib bacteria. But the germs in vaccines are either killed or weakened so they won’t make you sick. Vaccines containing these weakened or killed germs are introduced into your body, usually by injection. Your immune system reacts to the vaccine the same as it would if it were being invaded by the disease — by making antibodies. The antibodies destroy the vaccine germs just as they would the disease germs — like a training exercise. Then they stay in your body, giving you immunity. If you are ever exposed to the real disease, the antibodies are there to protect you. Immunizations help your child’s immune system do its work. The child develops protection against future infections, the same as if he or she had been exposed to the natural disease. Except with vaccines your child doesn’t have to get sick first to get that protection.

Selected Vaccine-Preventable Diseases, United States

1. Diphtheria Diphtheria caused by a bacterium called Corynebacterium diphtheriae. It lives in the mouth, throat and nose of an infected person and can be spread to others by coughing or sneezing. A child with diphtheria can infect others for about 2 to 4 weeks. It can initially cause a sore throat, fever and chills. But if it is not properly diagnosed and treated it produces a toxin (poison) in the body that can cause serious complications such as heart failure or paralysis. About 1 person out of 10 who get diphtheria dies from it. Diphtheria used to be a major cause of childhood illness and death. Through the 1920s about 150,000 people a year got diphtheria in the United States, and about 15,000 of them died.

2. Hepatitis A Hepatitis A is a liver disease caused by the hepatitis A virus. It is the most frequently reported type of hepatitis in the United States, causing an estimated 125,000–200,000 cases each year. About a third of these cases occur in children younger than 15. The virus is found mainly in bowel movements and is spread through personal contact or by eating contaminated food or drinking contaminated water. Children under 6 often don’t show any signs of illness, but for older children signs include fever, loss of appetite, tiredness, stomach pain, vomiting, dark urine, and yellow skin or eyes (jaundice). Hepatitis A does not cause long-term illness or liver damage, but about 100 people die each year from liver failure caused by severe hepatitis A.

3. Hepatitis B Hepatitis B is also a liver disease (the word “hepatitis” comes from the Greek words for “liver” and “inflammation”). It is caused by the hepatitis B virus. It is spread through contact with the blood, or other body fluids, of an infected person. Adolescents and adults can be infected through sharing drug needles or through unprotected sex, and health-care and public safety workers are often exposed to blood in the course of their jobs. Pregnant women can infect their newborn babies. People infected with hepatitis B might not feel sick, or might suffer loss of appetite or tiredness, muscle or stomach pains, diarrhea or vomiting, or yellow skin or eyes (jaundice). People usually recover from hepatitis B after several weeks, but others may become “chronically infected.” They might not feel sick themselves, but they continue to carry the virus and can infect other people. A baby who is born to a chronically infected mother has a 70%–90% chance of being infected at birth. Many people who are chronically infected will suffer from serious problems such as cirrhosis (scarring of the liver) or liver cancer.

In the United States there are more than 1 million people who are chronically infected. In 1996 an estimated 200,000 people became infected, and 4,000 to 5,000 people die each year from hepatitis B.

4. Hib disease (Haemophilus influenzae type b) Hib disease (Haemophilus influenzae type b) used to be the leading cause of bacterial meningitis in children less than 5 years old. As recently as the mid-1980s it struck one child out of every 200 in that age group. About 1 in 4 of these children suffered permanent brain damage, and about 1 in 20 died. Hib disease is spread through the air by coughing, sneezing, and even breathing. If the bacteria stay in a child’s nose and throat, the child will probably not get sick. But if they spread to the lungs or bloodstream, the child can get meningitis (inflammation of the covering of the brain), pneumonia, epiglottitis (inflammation in the throat), arthritis, or other problems. A child who is infected can spread the disease to others for as long as the bacteria remain in the body. Antibiotics can stop spread in 2 to 4 days.

5.Human Papilloma Virus Genital human papillomavirus (HPV) is the most common sexually transmitted virus in the United States. More than half of sexually active men and women are infected with HPV at some time in their lives. Most HPV infections don’t cause any symptoms, and go away on their own. But HPV can cause cervical cancer in women. Cervical cancer is the 2nd leading cause of cancer deaths among women around the world. In the United States, about 12,000 women get cervical cancer every year and about 4,000 are expected to die from it.

HPV is also associated with several less common cancers, such as vaginal and vulvar cancers in women, and anal and oropharyngeal (back of the throat, including base of tongue and tonsils) cancers in both men and women. HPV can also cause genital warts and warts in the throat.

There is no cure for HPV infection, but some of the problems it causes can be treated. The HPV vaccine you are getting is one of two vaccines that can be given to prevent HPV. It may be given to both males and females. This vaccine can prevent most cases of cervical cancer in females, if it is given before exposure to the virus. In addition, it can prevent vaginal and vulvar cancer in females, and genital warts and anal cancer in both males and females.

Protection from HPV vaccine is expected to be long-lasting HPV vaccine is given as a 3-dose series 1st Dose Now 2nd Dose 1 to 2 months after Dose 1 3rd Dose 6 months after Dose 1

6. Influenza (Flu) Influenza (Flu) is a seasonal illness, occurring mainly during the winter. It is caused by influenza virus. Influenza viruses are continually changing, meaning that immunity you acquire one year will not necessarily protect you in future years. This makes influenza different from most diseases, in that you can get it more than once. It also means that annual immunizations are recommended. Influenza is spread from person to person through sneezing, coughing or breathing. Signs and symptoms include fever, sore throat, cough, headache, chills and muscle aches. Young children might also have vomiting and diarrhea. Complications can include ear and sinus infections, pneumonia, myocarditis (inflammation of the heart), and death. Influenza causes more deaths (about 36,000 per year) than any other vaccine-preventable disease. Most of these are among the elderly, but some children also die. Hospitalization rates are high among children, particularly those less than 1 year old.

7. Measles

Measles is a viral illness that causes a rash all over the body. It also causes fever, runny nose and cough. About 1 out of 10 children with measles also gets an ear infection, and up to 1 out of 20 gets pneumonia. About 1 out of 1,000 gets encephalitis, and 1 or 2 out of 1,000 die. While measles is almost gone from the United States, it still kills about half a million people a year around the world. Measles can also make a pregnant woman have a miscarriage or give birth prematurely. Measles spreads through the air by breathing, coughing or sneezing. It is so contagious that any child who is exposed to it and is not immune will probably get the disease. Before measles vaccine, nearly all children got measles by the time they were 15. Each year about 450 people died because of measles, 48,000 were hospitalized, 7,000 had seizures, and about 1,000 suffered permanent brain damage or deafness. Today there are only about 50 cases a year reported in the United States, and most of these originate outside the country.

8. Meningococcal Meningococcal disease is a serious bacterial illness. It is a leading cause of bacterial meningitis in children 2 through 18 years old in the United States. Meningitis is an infection of the covering of the brain and the spinal cord. Meningococcal disease also causes blood infections. About 1,000 – 1,200 people get meningococcal disease each year in the U.S. Even when they are treated with antibiotics, 10-15% of these people die. Of those who live, another 11%-19% lose their arms or legs, have problems with their nervous systems, become deaf, or suffer seizures or strokes. Anyone can get meningococcal disease. But it is most common in infants less than one year of age and people 16-21 years. Children with certain medical conditions, such as lack of a spleen, have an increased risk of getting meningococcal disease. College freshmen living in dorms are also at increased risk. Meningococcal infections can be treated with drugs such as penicillin. Still, many people who get the disease die from it, and many others are affected for life. This is why preventing the disease through use of meningococcal vaccine is important for people at highest risk.

9. Mumps Mumps is best known for the swelling of the cheeks and jaw that it causes, a result of inflammation of the salivary glands. Mumps also causes a fever and headache. It is usually a mild disease, but it leads to meningitis in about 1 child in 10 who gets the disease. It can occasionally causeencephalitis, deafness (about 1 in 20,000 cases), or even death (about 1 in 10,000 cases). Mumps is caused by the mumps virus, which is spread from person to person through the air. Before a vaccine was available mumps was a very common childhood illness. About 152,000 cases were reported each year. Now mumps is very uncommon, with only 231 cases reported in 2003.

10. Pertussis (Whooping Cough) Pertussis (Whooping Cough) is caused by a bacterium called Bordetella pertussis. If you have ever seen a child with pertussis you won’t forget it. The child coughs violently and rapidly, over and over, until the air is gone from her lungs and she is forced to inhale with the loud “whooping” sound that gives the disease its nickname, whooping cough. Pertussis is a very contagious disease, and one that is fairly common in the United States, even today. In 2004, over 25,000 cases were reported. While this is down considerably from the approximately 150,000 cases a year before the vaccine, it still makes it one of the most common vaccine-preventable childhood diseases in the country. It is spread from person to person through personal contact, coughing and sneezing. At first pertussis behaves like a common cold, with sneezing, runny nose, fever and a mild cough. But after 1 or 2 weeks the severe coughing spells begin. Pertussis is most severe in infants less than 1 year old. More than half of these infants who get the disease must be hospitalized. Older children and adults can get pertussis too, but it is usually not as serious. Many infants who get

pertussis catch it from their older brothers and sisters, or from their parents — who might not even know they have the disease. About 1 child in 10 who get pertussis also gets pneumonia, and about 1 in 50 will have convulsions. The brain is affected in about 1 person out of 250 (this is called encephalopathy). Pertussis causes about 10–20 deaths each year in the United States.

11. Pneumococcal Disease Pneumococcal disease caused by Streptococcus pneumoniae bacteria. It is usually thought of as a disease of the elderly, but it also takes its toll among our children. In 1998, before a vaccine for children was licensed, about 188 of every 100,000 children younger than 2 years of age developed invasive pneumococcal disease (for instance, meningitis or blood infections). It is the leading cause of bacterial meningitis in the country, hitting children under 1 year old the hardest. About 200 children died from invasive pneumococcal disease each year. Pneumococcal disease is also a common cause of ear infections. There are about 90 subgroups (serotypes) of the pneumococcal bacterium, but 7 of these have accounted for about 80% of infections among children younger than 6 years of age. Pneumococcal disease is spread through the air. It can be spread by anyone who is infected, even if they don’t have symptoms. It is most common during the winter and early spring. All children are susceptible to pneumococcal disease, but some groups are more susceptible than others, including African Americans, American Indians, Alaska Natives, and children with certain medical conditions such as sickle cell disease or HIV infection, or those who don’t have a functioning spleen.

12. Polio Polio is a disease that has caused paralysis in millions of children worldwide over the years. In the United States, 6,000 people died and another 27,000 were paralyzed during a major epidemic in 1916. Polio reached a peak in the United States. in the 1950s, when parents were terrified that the disease would leave their children unable to walk or force them to spend the rest of their life in an iron lung. With the appearance of the Salk and Sabin polio vaccines the disease began to disappear, and there is no longer any wild polio in the country. Polio is caused by a virus that lives in the throat and intestinal tract. It is spread mainly through contact with the feces of an infected person (for instance, by changing diapers). Some children who get polio don’t feel ill at all. For others, it might resemble a common cold, sometimes accompanied by pain and stiffness in the neck, back and legs. But some children get severe muscle pain, and within a week can be paralyzed — in other words, lose the use of their muscles. Usually paralysis affects a child’s legs, but it can also affect other muscles, including those that control breathing. There is no treatment for polio, and some children die from it. Even though there is no polio in the United States, it is still common in some parts of the world. We are working towards eliminating it from the rest of the world within the next few years.

13. Rota Virus Rotavirus is a virus that causes gastroenteritis (inflammation of the stomach and intestines). The rotavirus disease causes severe watery diarrhea, often with vomiting, fever, and abdominal pain. In babies and young children, it can lead to dehydration (loss of body fluids). Rotavirus is the leading cause of severe diarrhea in infants and young children worldwide. Globally, it causes more than a half a million deaths each year in children younger than 5 years of age. Rotavirus was also the leading cause of severe diarrhea in U.S. infants and young children before rotavirus vaccine was introduced for U.S. infants in 2006. Prior to that, almost all children in the United States were infected with rotavirus before their 5th birthday. Each year in the United States in the pre-vaccine period, rotavirus was responsible for more than 400,000 doctor visits; more than 200,000 emergency room visits; 55,000 to 70,000 hospitalizations; and 20 to 60 deaths in children younger than 5 years of age.

14. Rubella (German Measles)

Rubella is sometime called German Measles or 3-day Measles. It is a generally mild disease caused by the rubella virus. It usually strikes in the winter and spring, and causes a slight fever, a rash on the face and neck, and (when teenagers or adults get the disease) swollen glands in the back of the neck and arthritis-like symptoms in the joints. It is spread from person to person through the air, by coughing, sneezing or breathing. The greatest danger from rubella is to unborn babies. If a woman gets rubella in the early months of her pregnancy, there is an 80% chance that her baby will be born deaf or blind, with a damaged heart or small brain, or mentally retarded. This is called Congenital Rubella Syndrome, or CRS. Miscarriages are also common among women who get rubella while they are pregnant. The last major rubella epidemic in the United States was in 1964–1965, when about 12.5 million people got the disease and 20,000 babies were born with CRS. Several years later a vaccine was licensed, and the disease has been disappearing ever since. Today there are fewer than 20 cases reported each year.

15. Tetanus (Lockjaw) Tetanus (lockjaw) differs from other vaccine-preventable diseases in that it is not contagious. It does not spread from person to person. Clostridium tetani bacteria are usually found in soil, dust, and manure, and they enter the body through breaks in the skin. Children usually become infected through deep puncture wounds or cuts, like those made by nails or knives. But the bacteria can enter through even a tiny pinprick or scratch. Children can also get tetanus following severe burns, ear infections, tooth infections, or animal bites. When tetanus gets into the body it can take up to 3 weeks for the first symptoms to appear. These are usually a headache, crankiness, and spasms of the jaw muscles. The bacteria produce a toxin (poison), which spreads throughout the body, causing painful muscle spasms in the neck, arms, legs, and stomach. These can be strong enough to break a child’s bones. Children with tetanus might have to spend several weeks in the hospital under intensive care. The number of tetanus cases in the United States has fallen from about 500 a year in the 1940s to only about 50 cases a year today. But 1 out of every 10 people who get tetanus dies from it.

16. Varicella (Chickenpox) Varicella (Chickenpox) was, until recently, one of the most common of childhood diseases. Before there was a vaccine, almost everyone got it — there were about 4 million cases a year in the United States. Chickenpox is caused by the varicella zoster virus. Its most recognizable feature is an itchy rash all over the body. It also causes fever and drowsiness. It is spread from person to person through the air, by coughing, sneezing or breathing, and can also be spread by contact with fluid from the blisters. It usually takes 2–3 weeks from the time of exposure to become ill, and an infected person is contagious from 1 or 2 days before the rash appears until all the blisters are dried up, usually 4 to 5 days after. Chickenpox is usually mild, but it occasionally causes serious problems. The blisters can become infected, and some children get encephalitis. Among infants less than 1 year old who get the disease, about 4 in 100,000 die. For older children, about 1 in 100,000 dies. If a woman gets chickenpox just before or after giving birth, her baby can get very sick, and about 1 in 3 of these babies will die if not treated quickly. About 1 child in 500 who gets chickenpox is hospitalized (this figure increases to about 1 in 50 for adults). After a person has chickenpox the virus stays in the body. Years later it can cause a painful disease called herpes zoster, or shingles.

Vaccine Side Effects While vaccines are very safe, like any medicine they do sometimes cause reactions. Mostly, these are mild “local” reactions (soreness or redness where the shot is given) or a low-grade fever. They may last a day or two and then go away. Sometimes more serious reactions are associated with vaccines. These are much less common. Some of them are clearly caused by the vaccine; some have been reported after vaccination but are so rare that it is impossible to tell if they were caused by the vaccine or would have happened anyway. We will mention any side effects specifically associated with each vaccine in the descriptions below.

Some children also have allergies, and occasionally a child will have a severe allergy to a substance that is component of a vaccine. There is a very small risk (estimated at around one in a million) that any vaccine could trigger a severe reaction in a child who has such an allergy. Should one of these allergic reactions occur, it would happen within several minutes to several hours after the vaccination, and would be characterized by hives, difficulty breathing, paleness, weakness, hoarseness or wheezing, a rapid heart beat, and dizziness. Doctors’ offices are equipped to deal with these reactions. Always tell your provider if your child has any known allergies.

Childhood Immunization Schedule, United States Look at end of booklet or www.cdc.gov/nip/recs/child-schedule.htm.

What ingredients go into vaccines, and why? The major ingredient of any vaccine is a killed or weakened form of the disease organism the vaccine is designed to prevent. Therefore, measles vaccine is mostly measles virus. Pneumococcal vaccine is mostly the surface coating from pneumococcal bacteria. In addition, vaccines can contain: * Diluents A diluent is basically a liquid used to dilute a vaccine to the proper concentration. It is usually saline or sterile water. * Adjuvants Adjuvants are chemicals added to vaccines to make them provide stronger immunity. Various forms of aluminum salts are the most commonly used adjuvants in vaccines. * Preservatives Preservatives are included in some vaccines (mainly ones that come in multi dose vials that might be used several times) to prevent bacterial growth that could make the vaccine unsafe. * Stabilizers Some vaccines contain stabilizers (for example, gelatin or lactose-sorbitol), to keep them safe and effective under different conditions or different temperatures. * Remnants from manufacturing Chemicals are often used during the vaccine manufacturing process, and then removed from the final product. For example, formalin might be used to kill a vaccine virus, or antibiotics might be used to prevent bacterial contamination. When these chemicals are removed, a tiny trace may remain. While some of these chemicals might be harmful in large doses, the trace amounts left in vaccines are too small to have a toxic effect. But what if your child has a more serious reaction, such as a severe allergic reaction? Signs of a severe allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness. If your child shows these symptoms after getting vaccinations — or if she shows other unusual symptoms, such as a high fever or behavior changes — don’t hesitate: * Call a doctor or get the child to a doctor right away. * Tell your doctor what happened, the date and time it happened, and when the vaccination was given. Reporting Adverse Reactions In the event your child has a vaccine-associated injury — or even if you think a medical problem your child has might have been caused by a vaccine — you should report the problem. VAERS (the Vaccine Adverse Event Reporting System) collects reports of suspected vaccine injuries. Generally, the doctor fills out a VAERS report and sends it to the program. But a parent or individual can also file a VAERS report. You can get more information about VAERS from their toll- free information line at 800-822-7967, or visit their website at www.vaers.hhs.gov If your child were to suffer a serious injury that proves to have been caused by a vaccination, a program called the National Vaccine Injury Compensation Program will provide compensation to help with their care. You can learn more about the National Vaccine Injury Compensation Program from their website at www.hrsa.gov/osp/vicp, or by calling the program toll-free at 800-338-2382.

Recommended Immunization Schedule From Birth----6 Years 2013

1 2 4 6 9 1 15 18 4—6 Birth Month Months Months Months Months Year Months Months Years HEPATITIS B 1st 2nd << 3rd >> ROTA Virus 1st 2nd 3rd PNEUMOCOCCAL 1st 2nd 3rd < 4th > H. INFLUENZA (Hib) 1st 2nd 3rd 4th DTaP 1st 2nd 3rd 4th 5th POLIO 1st 2nd 3rd 4th 5th VARICELLA < 1st > 2nd MMR < 1st > 2nd INFLUENZA (FLU) 1st Then Yearly >> >> HEPATITIS A 1st 2n Tuberculin Test 1st 2nd

Recommended Immunization Schedule for Persons Aged 7 Through 18 Years 2013 7--10 11—12 16--18 VACCINE Years Years Years Tetanus, Diphtheria, Pertussis 1st Catch Up Meningococcal If High Risk 1st 2nd Human Papilloma Virus (HPV) 1st (3 doses series) Catch Up Influenza (FLU) << YEARLY >> Varicella (Chicken pox) << Catch Up >> MMR << Catch Up >> Polio << Catch Up >> Hepatitis A << If High Risk >> Hepatitis B << Catch Up >> Pneumococcal << If High Risk >>

Disease Disease spread Disease symptoms Disease complications by Chickenpox Air, direct contact Rash, tiredness, Infected blisters, bleeding disorders, headache, fever encephalitis (brain swelling), pneumonia (infection in the lungs) Diphtheria Air, direct contact Sore throat, mild fever, Swelling of the heart muscle, heart weakness, swollen failure, coma, glands in neck paralysis, death Hib Air, direct contact May be no symptoms Meningitis (infection of the covering unless bacteria around the brain enter the blood and spinal cord), mental retardation, epiglottis (life threatening infection that can block the windpipe and lead to serious breathing problems) and pneumonia (infection in the lungs), death

HepA Personal contact, May be no symptoms, Liver failure contaminated fever, stomach pain, food or water loss of appetite, fatigue, vomiting, jaundice (yellowing of skin and eyes), dark urine HepB Contact with May be no symptoms, Chronic liver infection, liver failure, liver blood or fever, headache, cancer body fluids weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain Flu Air, direct contact Fever, muscle pain, sore Pneumonia (infection in the lungs) throat, cough, extreme fatigue Measles Air, direct contact Rash, fever, cough, runny Encephalitis (brain swelling), pneumonia nose, pinkeye (infection in the lungs), death Mumps Air, direct contact Swollen salivary glands Meningitis (infection of the covering (under the jaw), fever, around the brain headache, tiredness, and spinal cord) , encephalitis (brain muscle pain swelling), inflam mation of testicles or ovaries, deafness Pertussis Air, direct contact Severe cough, runny nose, Pneumonia (infection in the lungs), death apnea (a pause in breathing in infants) Polio Through the May be no symptoms, sore Paralysis, death mouth throat, fever, nausea, headache Pneumococ Air, direct contact May be no symptoms, Bacteremia (blood infection), meningitis cal pneumonia (infection (infection of in the lungs) the covering around the brain and spinal cord), death Rotavirus Through the Diarrhea, fever, vomiting Severe diarrhea, dehydration mouth Rubella Air, direct contact Children infected with Very serious in pregnant women—can rubella virus sometimes lead to miscar have a rash, fever, and riage, stillbirth, premature delivery, and swollen lymph nodes. birth defects Tetanus Exposure through Stiffness in neck and Broken bones, breathing difficulty, death cuts in skin abdominal muscles, difficulty swallowing, muscle spasms, fever

POST PARTUM DEPRESSION

1 woman in 10 Experiences depression during pregnancy. These symptoms are like the baby blues but happen before the baby is born. 8 women in 10 Experience the baby blues after giving birth. They may cry for no apparent reason, feel impatient, irritable, restless, and anxious. 1 woman in 8 Experiences postpartum depression.

A woman with PPD may feel sluggish, sad, confused, anxious, irritable, guilty, and have difficulty- remembering things. She may have trouble eating and sleeping. She may have fears of harming the baby or herself. Her moods might change from being very happy to very sad. She may feel out of control. She may want to avoid seeing people or talking about her feelings. 1 woman in 1,000 Experiences postpartum psychosis, which Usually happens within the first three months after birth. This illness is rare, and symptoms are very severe. A woman with psychosis does not know what is real and what is imagined. She may have hallucinations or delusions. She may not be able to sleep. Her actions may be unpredictable. In New Jersey Between 11,000 and 16,000 women suffer from PPD every year. PPD: Temporary & Treatable having a baby is a major life change. PPD can affect any woman who: • Is pregnant • Has recently had a baby • Has ended a pregnancy or has miscarried • Has stopped breast-feeding PPD can appear days or even months after . The warning signs are different for everyone but include: • Trouble sleeping, or sleeping too much • Changes in appetite – eating much more or much less • Feeling irritable, angry, or nervous • Feeling exhausted • Not enjoying life as much as in the past • Lack of interest in the baby • Lack of interest in friends and family • Lack of interest in sex • Feeling guilty or worthless • Feeling hopeless • Crying uncontrollably • Feelings of being a bad mother • Trouble concentrating • Low energy • Thoughts of harming the baby or herself Family and friends may feel upset by these mood changes; in fact, they may notice that there is a problem even before the new mom does. They can help by being patient and supportive. Love and support, however, may not be enough. When symptoms last longer than two weeks or affect a woman’s ability to enjoy her daily life; loved ones should encourage the new mother to get help right away. Whether symptoms are mild or severe, with proper treatment, anyone can recover from PPD.

Young & Older, Urban & Suburban: PPD Can Affect Anyone No one is 100 percent sure why postpartum depression happens, but risk factors include: • Changes in the body’s hormone levels • A difficult pregnancy • A birth that did not go as planned • Medical problems with the mother or baby • Not getting enough sleep • Feeling alone • Loss of freedom • Sudden changes in the home or work routines • Personal or family history of depression • Previous experience with PPD • Not having enough support from family and friends • High levels of stress Although some women are more likely to experience depression than others, PPD can happen with any pregnancy or birth, even if a woman has had other babies without emotional problems. Women of every culture, age, income level, and race can have PPD.

It is important to remember that PPD is no one’s fault, and treatment is available. HELP LINE P H O N E 1 - 8 0 0 - 3 2 8 - 3 83 8 W E B S I T E njspeakup. gov

Medications Commonly Prescribed for Maternal Ailments During Breast-Feeding

Condition Recommended agents Alternative agents Use with caution Allergic rhinitis Beclomethasone (Beconase)Cetirizine (Zyrtec) Loratadine Fluticasone (Flonase) (Claritin) Sedating Cromolyn (Nasalcrom) antihistaminesDecongestants Cardiovascular Hydrochlorothiazide (Esidrix) Nifedipine (Procardia XL) Atenolol (Tenormin) Metoprolol tartrate Verapamil (Calan SR) Nadolol (Corgard) (Lopressor) Propranolol Hydralazine (Apresoline) Sotalol (Betapace) (Inderal) Labetalol Captopril (Capoten) Enalapril Diltiazem (Normodyne) (Vasotec) (Cardizem CD) Depression Sertraline (Zoloft) Paroxetine Nortriptyline (Pamelor) Fluoxetine (Prozac) (Paxil) Desipramine (Norpramin) Diabetes InsulinGlyburide (Micronase) Acarbose (Precose) Metformin Glipizide (Glucotrol) (Glucophage) Tolbutamide (Orinase) Thiazolinediones Epilepsy Phenytoin (Dilantin) Ethosuximide (Zarontin) Valproic Phenobarbital Carbamazepine (Tegretol) sodium (Depakote) Pain Ibuprofen (Motrin) Naproxen MorphineAcetaminophen (Naprosyn) (Tylenol) Meperidine (Demerol) Asthma Cromolyn (Intal) Nedocromil Fluticasone (Flovent) (Tilade) Beclomethasone (Beclovent) Contraception Barrier methods Progestin-only agents Estrogen-containing contraceptives

ANALGESICS Of the nonsteroidal anti-inflammatory drugs (NSAIDs), ibuprofen (Motrin) is the preferred choice because it has poor transfer into milk and has been well studied in children. Long half-life NSAIDs such as naproxen (Naprosyn), sulindac (Clinoril) and piroxicam (Feldene) can accumulate in the infant with prolonged use. Epidural use of bupivacaine (Marcaine), lidocaine (Xylocaine), morphine, fentanyl (Sublimaze) and sufentanil (Sufenta) is generally safe in breast-feeding mothersMorphine, codeine and hydrocodone are considered compatible with breast-feeding by the AAP. Meperidine (Demerol) is not the preferred analgesic for use in breast-feeding women because of the long half-life of its metabolite in infants. Repeated exposure to analgesic agents, especially meperidine, may result in drug accumulation and toxic effects in young or compromised infants because of their underdeveloped hepatic conjugation. When possible, mothers should breast-feed their infants before taking the medication, and low to moderate dosages should be used

CONTRACEPTIVE AGENTS Hormones contained in combination oral contraceptive pills (OCPs) are not harmful to infants but, because estrogen diminishes the maternal milk supply, these products should be avoided in breast- feeding mothers whenever possible, especially during the first two months of breast-feeding. Progestin-only contraceptives are preferable, although these also may decrease milk supply. Delaying the use of OCPs, including the progestin-only mini-pill, until six weeks after starting breast- feeding and then using a progestin-only mini-pill (such as Micronor) will allow the mother to assess the drug's effect on her milk supply. If the medication is well tolerated, repository medroxyprogesterone (Depo-Provera) can be used. When appropriate, the use of an intrauterine contraceptive device or other barrier method of birth control is ideal.

Medications Not to Be Used in Breast-Feeding Mothers

Antineoplastic agents Ergotamine tartrate (Ergomar) Bromocriptine (Parlodel) Lithium Cyclophosphamide (Cytoxan) Methotrexate (Rheumatrex) Cyclosporine (Sandimmune) Radiopharmaceuticals*

Resources for Information on Medication Use in Breast-Feeding Women

LACTMED : HTTP://TOXNET.NLM.NIH.GOV/CGI-BIN/SIS/HTMLGEN?LACT

Thomas W. Hale. Medications and Mothers' Milk. 8th ed. Amarillo, Tex.: Pharmasoft Medical Publishing, 1999.

Riverside Pediatrics Travel advisory

Peel it, boil it, cook it, or forget it.

We will talk about three major issues. First travel preparation second vaccinations and finally protection when you arrive.

Before you traveled with the kids make sure you have enough information about flight duration, condition upon the destination and any pre-existing condition your child may have.

You should pack certain medications for plane travel itself, here is a brief list Fever management for example acetaminophen (Tylenol, pedicare fever reducer, or store brand) and ibuprofen (Advil, Motrin) in proper dosage form for example drops/ syrup/suppository. Ear drops, cough and cold drops/syrup and other things to keep ear pressure low (Gum, Pops). Some juice or electrolyte solution (pedialyte) Benadryl (Diphenhydamine) in case of allergy, hydrocortisone for bite, rash Sunscreen SPF 50 or higher (even with the sunscreen children should not been the Sun between 10 AM to 4 PM)!

Have your child’s vaccination record available!

Vaccinations The earliest opportunity to receive routinely recommended immunizations in the United States (except for the dose of hepatitis B vaccine at birth) is at 6 weeks of age. At least two weeks before vacation child should be vaccinated for measles, hepatitis A, typhoid besides other vaccines if required for example Meningococcal disease, yellow fever, cholera, and hepatitis B, Varicella. We at present do not offer yellow fever, Japanese encephalitis vaccine but will guide you to local facilities that provide these vaccinations.

Whooping Cough (Pertussis) A vaccine preventable disease that is on the rise! DTaP vaccine is given at 2,4,6,15months with booster at 4 years and kids who don’t have DTaP within last 10 years should get Tdap vaccine if going to California or out of country

2 .MMR recommended at age 12–15 months in the United States. However, children traveling outside the United States are recommended to get the vaccine starting at age 6 month! Center for disease control (CDC) has recently updated their recommendation for reason vaccination (5/26/11) Children 6–11 months of age who are traveling outside the United States (EXCEPT CANADA AND AUSTRALIA) Children 6–11 months age group should receive at least 1 dose of MMR. MMR vaccines given before 12 months of age should not be counted as part of the routine series. Children who receive MMR vaccines before age 12 months will need 2 more doses of MMR or MMRV vaccine, the first of which should be administered at 12–15 months of age. Children 12 months or older, adolescents, and adults who are traveling outside the United States International travelers in these age categories who cannot be considered immune according to the above criteria should receive 2 doses of measles-containing vaccine (separated by at least 28 days). If a patient has symptoms of a fever, cough, red eyes, runny nose, and a red, raised rash and has a history of any recent international travel, measles should be considered in diagnosis. Typhoid Typhoid (typhoid fever) is a serious disease. It is caused by bacteria called SalmonellaTyphi. Typhoid causes a high fever, weakness, stomach pains, headache, loss of appetite, and sometimes a rash. If it is not treated, it can kill up to 30% of people who get it. Boil it, cook it, peel it, or forget it" If you drink water, buy it bottled or bring it to a rolling boil for 1 minute before you drink it. Bottled carbonated water is safer than uncarbonated water. Ask for drinks without ice unless the ice is made from bottled or boiled water. Avoid popsicles and flavored ices that may have been made with contaminated water. Eat foods that have been thoroughly cooked and that are still hot and steaming. Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are easily contaminated and are very hard to wash well. When you eat raw fruit or vegetables that can be peeled, peel them yourself. (Wash your hands with soap first.) Do not eat the peelings. Avoid foods and beverages from street vendors. It is difficult for food to be kept clean on the street, and many travelers get sick from food bought from street vendors. Preventive Vaccine Inactivated Typhoid Vaccine (Shot) •Should not be given to children younger than 2 years of age. •One dose provides protection. It should be given at least 2 weeks before travel to allow the vaccine time to work. •A booster dose is needed every 2 years for people who remain at risk.

Live Typhoid Vaccine (Oral)

•Should not be given to children younger than 6 years of age. •Four doses, given 2 days apart, are needed for protection. The last dose should be given at least 1 week before travel to allow the vaccine time to work. •A booster dose is needed every 5 years for people who remain at risk.

Cholera Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae. An estimated 3-5 million cases and over 100,000 deaths occur each year around the world. The infection is often mild or without symptoms, but can sometimes be severe. Approximately one in 20 (5%) infected persons will have severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours. How Can I Avoid Getting Cholera? The risk for cholera is very low for people visiting areas with epidemic cholera. When simple precautions are observed, contracting the disease is unlikely. All people (visitors or residents) in areas where cholera is occurring or has occurred should observe the following recommendations: Drink only bottled, boiled, or chemically treated water and bottled or canned carbonated beverages. When using bottled drinks, make sure that the seal has not been broken. To disinfect your own water: boil for 1 minute or filter the water and add 2 drops of household bleach or ½ an iodine tablet per liter of water. Avoid tap water, fountain drinks, and ice cubes. Wash your hands often with soap and clean water. If no water and soap are available, use an alcohol-based hand cleaner (with at least 60% alcohol). Clean your hands especially before you eat or prepare food and after using the bathroom. Use bottled, boiled, or chemically treated water to wash dishes, brush your teeth, wash and prepare food, or make ice. Eat foods that are packaged or that are freshly cooked and served hot. Do not eat raw and undercooked meats and seafood or unpeeled fruits and vegetables. Dispose of feces in a sanitary manner to prevent contamination of water and food sources Preventive Vaccine for Cholera CDC does not recommend cholera vaccines for most travelers, nor is the vaccine available in the United States. This is because the available vaccines offer incomplete protection for a relatively short period of time. Hepatitis A Hepatitis A, caused by infection with the Hepatitis A virus (HAV), has an incubation period of approximately 28 days (range: 15–50 days. HAV infection is primarily transmitted by the fecal-oral route, by either person-to-person contact or consumption of contaminated food or water Prevention Follow above precaution as for typhoid and cholera! Vaccine for Hepatitis A Vaccination is the most effective means of preventing HAV transmission among persons at risk for infection. Hepatitis A vaccination is recommended for all children at age 1 year, for persons who are at increased risk for infection with a booster dose 6months—1 year after first dose.

After you arrive at your destination then certain other things are important Travelers diarrhea Malaria Rabies Tuberculosis Travelers Diarrhea Traveler’s diarrhea is a significant problem that may be mitigated by attention to foods and beverages ingested and by appropriately treating suspected water sources. Chemoprophylaxis generally is not recommended. Educating families about self-treatment, particularly oral rehydration, is critical. Packets of oral rehydration salts can be obtained before travel or are readily available in most pharmacies throughout the world, especially in developing countries where diarrheal diseases are most common. During international travel, families may want to carry an antimicrobial

agent (e.g., fluoroquinolone for people 16 years of age and older and azithromycin for younger children) for treatment of significant diarrheal symptoms. Antimotility agents may be considered for older children and adolescents but should not be used if diarrhea is bloody.

Malaria Malaria in humans is caused by one of four protozoan species of the genus Plasmodium: P. falciparum, P. vivax, P. ovale, or P. malariae. Recently, P. knowlesi, a parasite of Old World monkeys, has been documented as a cause of human infections and some fatalities in Southeast Asia. Each year malaria causes 350–500 million infections worldwide and approximately 1 million deaths. Transmission occurs in large areas of Central and South America, parts of the Caribbean, Africa, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific Malaria is characterized by fever and influenza-like symptoms, including chills, headache, myalgias, and malaise; these symptoms can occur at intervals. Uncomplicated disease may be associated with anemia and jaundice. In severe disease, most commonly caused by P. falciparum, seizures, mental confusion, kidney failure, acute respiratory disease syndrome (ARDS), coma, and death may occur. Malaria symptoms can develop as early as 7 days (usually at least 14 days) after initial exposure in a malaria-endemic area and as late as several months or more after departure. Preventive Measures for Travelers Malaria prevention consists of a combination of mosquito avoidance measures and chemoprophylaxis. Although very efficacious, none of the recommended interventions are 100% effective. Mosquito Avoidance Measures Because of the nocturnal feeding habits of Anopheles mosquitoes, malaria transmission occurs primarily between dusk and dawn. Contact with mosquitoes can be reduced by remaining in well-screened areas, using mosquito bed nets (preferably insecticide-treated nets), using a pyrethroid-containing flying-insect spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. All travelers should use an effective mosquito repellent. The most effective repellent against a wide range of vectors is DEET (N,N-diethylmetatoluamide), an ingredient in many commercially available insect repellents. The actual concentration of DEET varies widely among repellents. DEET formulations as high as 50% (20—30% for children) are recommended for both adults and children older than 2 months of age. DEET should be applied to the exposed parts of the skin when mosquitoes are likely to be present. In addition to using a topical insect repellent, a permethrin-containing product may be applied to bed nets and clothing for additional protection against mosquitoes. Drugs used in the prophylaxis of malaria Overdose of antimalarial drugs, particularly chloroquine, can be fatal. Medication should be stored in childproof containers out of the reach of infants and children. Chemoprophylaxis can be started earlier if there are particular concerns about tolerating one of the medications. For example, mefloquine can be started 3–4 weeks in advance to allow potential adverse events to occur before travel. If unacceptable side effects develop, there would be time to change the medication before the traveler’s departure. The drugs used for antimalarial chemoprophylaxis are generally well tolerated. However, side effects can occur. Minor side effects usually do not require stopping the drug. Travelers who have serious side effects should see a health-care provider who can determine if their symptoms are related to the medicine and make an appropriate medication change.

Rabies Rabies virus causes an acute viral encephalitis that is virtually 100% fatal. Traveling children may be at increased risk of rabies exposure, mainly from street dogs in developing countries. Bat bites carry a potential risk of rabies throughout the world. There are two strategies for the prevention of rabies in humans.

Prevention of rabies encephalitis is based on avoiding bite or scratch exposures to potentially infected . A child can have a three-shot pre-exposure immunization series, on days 0, 7, and 21 to 28. In the event of a subsequent possible rabies virus exposure, the child will require two more doses of rabies vaccine on days 0 and 3. For children who have not been pre-immunized and have potentially been exposed to rabies, a weight-based dose of human rabies immune globulin and a series of five rabies vaccine injections are required on days 0, 3, 7, 14, and 28. Beginning in 2007, there has been a limitation in the supply of rabies vaccine in the United States. Pre-exposure rabies immunization is currently unavailable until the supply of rabies vaccine can be increased. TUBERCULOSIS The risk of acquiring latent tuberculosis infection (LTBI) during international travel depends on the activities of the traveler and the epidemiology of tuberculosis in the areas in which travel occurs. In general, the risk of acquiring LTBI during usual tourism activities appears to be low, and no pre- or post-travel testing is recommended routinely. When travelers live or work among the general population of a high-prevalence country, the risk may be appreciably higher. In most high-prevalence countries, contact investigation of tuberculosis cases is not performed, and treatment of LTBI is not available. Children returning to the United States who have signs or symptoms compatible with tuberculosis should be evaluated appropriately for tuberculosis disease. It may be prudent to perform a tuberculin skin test 8 to 12 weeks after return for children who spent 3 months or longer in a high- prevalence country. Pretravel administration of BCG vaccine generally is not recommended. However, some countries may require BCG vaccine for issuance of work and residency permits for expatriate workers and their families.

Centers for Disease Control and Prevention: http://www.cdc.gov/travel/ Travel Medicine Site: http://www.tripprep.com/ WHO Web site at www.who.int/ith/ The U.S. Department of State Travel Advisories: http://www.travel.state.gov/ Call CDC (877-FYI-TRIP)

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