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Just a reminder! Thanks for visiting us at Shots Hurt Less Blog! This is just a reminder that the information on this site is intended to be for informational purposes only. It should never replace the recommendations of your doctor - check with your doctor if you have any specific questions! We will always honor and protect patient confidentiality, and we ask that you all do the same, if you choose to comment on our posts. Thanks for visiting!


Potty Training in Action: Step by Step Guide to a Child Oriented Apporach

Okay, now is go time! Either you've carefully prepped your child and noted the signs of readiness as discussed in my earlier blog post Getting Down and Dirty: Potty Training Part 1 or, perhaps, you are one of those lukcy parents whose child is self-motivated and has excitedly proclaimed they are ready to use the potty.  Whatever has led up to this moment, now your potty training adventure is about to begin.

The general approach most pediatricians recommend these days for toilet training a child between 2-3 years of age is based on the work of Dr. Terry Brazelton, a well respected pediatrician and expert in child development who first developed this "Child Oriented Approach to Potty Training" in the 1960s.

Dr. Brazelton suggests waiting until your child shows some signs of readiness (staying dry for at least 2 hours during the day or after naps, child can follow simple instructions, child can walk to the potty and at least partially undress, child shows interest in potty). Once you've noted these signs, you're ready for the stepwise appraoch:

  • Step 1: Sit your child on the potty fully clothed (to read a book for example) for several minutes 2-3 times per day for several days to get them comfortable with the idea.  Use a stool to help them feel secure while sitting on a regular sized potty or introduce a small, portable potty (or both).
  • Step 2: Encourage your child to sit (bare bottomed) on the potty at regular times (upon awakening in the morning and after nap, after meals, before bath) but with no pressure to perform.  Also start emptying your child's dirty diapers into the potty to reinforce that the potty is where we dispose of poop.
  • Step 3: BREAKTHROUGH! this happens at random when, by chance, your child either urinates or stools in the potty at one of the regular sitting times.  Parents are instructed to praise their child and reward them for this accomplishment.

If at any point you encounter resistance, parents are instructed to back off and wait until their child shows interest.  For the majority of self-motivated children this approach will eventually work, but it may take several months (3-12). 

A slight variation in Brazelton's approach includes the parent encouraing "practice runs" at key times throughout the day.

  • Make sure your child is wearing minimal, easy-to-remove clothing. If it’s warm enough, consider going pantsless.
  • Watch your child for signs that he needs to urinate or stool (grunting, making faces, squirming, pulling at the diaper, etc).
  • When he is about to void, remove his diaper or underwear and place him on the potty. Encourage him to use the potty (for example, say “try to go pee-pee in the potty"). If he does, reward him with praise, affection, and special treats (stickers or a snack). If he doesn’t void, allow him to stay on the potty for up to five minutes. If nothing happens by that time, end the practice run. But don’t force the child to sit. If he’s restless, let him off the potty with an encouraging word (“good try").
  • Troubleshooting: If you have trouble telling when your child needs to pee, Schmidt suggests that you hold practice runs about 45 minutes after your child has finished a large drink, or after two hours without urinating. If you have trouble detecting when they will stool, stage a practice run after a large meal or after 24 hours without a bowel movement.

Important tips to keep in mind while potty training:

Stay positive! Praise your child for any attempt (even if they are not successful and nothing comes out).

Expect accidents.  When your child has an accident, change her as soon as possible. You want your child to get accustomed to wearing only clean, dry pants. Encourage your child to keep trying to use the potty. Avoid a show of negative emotions. Be patient, affectionate and upbeat.  Keep encouraging them "That's okay, we can clean you up.  I know you'll be able to keep your underwear dry soon.  You're getting bigger each day."

Teach Toileting Hygiene. When you're potty training, it's important to include a lesson on keeping clean. Instruct both girls and boys how to wipe front to back, to flush, and to wash their hands with soap and water afterward. You can buy sparkly or colorful kid-friendly soap as an incentive to get kids excited about washing. Make sure your child is washing long enough by asking him to sing the Alphabet Song while he cleans up.

Please keep in mind that for more sensitive, anxious or more strong willed children potty training can be more difficult.  Look for my next post on Toilet Training Troubleshooting coming soon.


Getting Down and Dirty: Potty Training (Part 1)

I love children.  I love being a parent.  But potty training is my least favorite part of parenting, so far.  It’s not particularly enjoyable even for the kids who potty train quickly.  But in some cases, like with our first child (a strong willed boy who was not at all interested in using the celebrated potty) parents have to try many, many different approaches until we finally figure out what it takes to motivate our little ones to become toilet trained.  Now, I’ll pass along what I’ve learned (both professionally as a pediatrician and some personal lessons I learned along the way that may help other families).  First, I’ll give you an overview of the general approach to potty training and then give some specific tips for younger kids and older kids.

When to potty train?

According to the American Academy of Pediatrics, there is no right age to toilet train a child. Readiness to begin toilet training depends on the individual child.  In the United States, experts typically recommend toilet training between 18 months and 3 years.  One research study found that the average age for completing toileting in girls is around 2.5 years (about 32 months) and in boys is closer to 3 years (about 35 months).  I think there is a wide range of ages when a child can successfully potty train and while some children may be able to do so at 18 months, others can not. 

It's best to start the potty training process during a stable period of your child’s life. If there are stressors happening at home (moving to a new home, a new baby, starting a new school or meeting a new caretaker) then it’s best to wait until your child adjusts.

As an aside, some parents are interested in "infant potty training" which is a different approach.  This is not wrong but involves a different strategy and involves trying to read your child's signs (scrunched face when preparinig to stool for example) and then repeatedly placing them on the toilet.  You can read more about this concept here. Many other cultures use this method but traditionally in the United States we recommend child led potty training which is what I will be discussing here.

Signs of Toilet Training Readiness

1. Periods of dryness: If your child’s diaper is dry for more than 2 hours at a time or dry after naps, they may be ready.

2. Interest in the toilet: Some children may simply verbalize their desire to use the toilet.  Others become very distressed when their diaper is wet or dirty (this is the perfect time to show them the solution to feeling wet or messy - the toilet!!)

3. Ability to walk to the potty and undress (for traditional potty training for children over 18 months).  It's helpful to avoid overalls or tight pants or belts that will make it difficult for a child to remove themselves.

Most children show some interest and then have set backs (more accidents or refusal). The most important thing if trying to potty train early is to STOP if you meet signs of resistance so as to avoid power struggles that can lead to major toileting resistance and refusal.

Setting the Stage:

First, I recommend introducing the idea of using the potty by modeling for them (let Junior come and watch you use the toilet and explaint that he or she will too as they get older).  Reading books about potty training is also very helpful for explaining what is involved.  A few of my favorites are Once Upon a Potty (comes in a girl version and a boy version), Potty Time, and Potty Superhero.  Also, there's a great Daniel Tiger episode about potty training (episode 111).

Secondly, I recommend taking your child shopping with you for all the "big kid" supplies for potty training. Make this into a special outing and tell him or her that you are so excited to watch them growing up into such a big kid.  

- A small potty seat or seat reducer inserts for the regular toilet seat (etiher removable or these that you can install to raise or lower with your regular toilet seat). If you are going to have a child sit on an adult sized toilet, make sure to get a stool that they can place their feet on (it's easier to push out stool if you can brace your feet on the floor or a stool).

- Big kid underwear (try to find a design that your child loves, perhaps a favorite carachter from book or movies, dinosaurs, etc).

- Kid friendly soap (love the foaming soap)

I also keep a package of wipes, lots of disposable trash bags, a roll of paper towels, and some Lysol cleaner in a nearby cabinet for easy clean up for near misses or accidents that are sure to occur.

Stay Tuned for Potty Training in Action (Part 2) and Troubleshooting for Potty Training Stubborn Toddlers (Part 3).



Introducing Ear Piercing at our TCP Clemmons Office! 

We are excited to announce that we will begin offering ear piercing services this summer at TCP. 

We have researched the best available medical ear piercing product and our clinic has decided to use Blomdahl Medical Ear Piercing (which is only available only in a physician's office). 

The Blomdahl Medical Ear Piercing system is a sterile, single cartridge piercing system

that uses medical grade plastic or titanium earrings for piercings. This system reduces

the risk for skin infections and allergies. Also, patients have access to a doctor, who is

trained in wound care management and sterile technique. We can answer any health

questions and concerns prior the ear piercing.

We strive for each child to have a positive experience with piercing by offering topical

numbing cream to reduce pain and aftercare solution and instructions to reduce the risk

for infection.

Please call our office with any questions about ear piercing or to schedule your child’s

piercing appointment!

Click to read more ...


Parenting Tips For Your Puking Child: What to do when the stomach bug hits your house

We have seen a large number of pitiful patients in the past two weeks with a gnarly stomach bug.  Most of these kids have had vomiting for just a couple of days but then lingering stomach aches and diarrhea for 1-2 weeks. And a lot of these kids, more than we typicaly see, have gotten dangerously dehydrated (some even are requiring hospitalization for IV fluids).  

So I was preparing to write this blog post last week with all my pediatrician tips for how to help your child through a stomach bug....and then it hit at my house!  Luckily, we avoided a trip to the hospital, but now I'll add a few practical tips from my very recent personal experience of caring for my own vomiting child.

What is a stomach bug? Though many refer to this as "stomach flu," it is NOT truly flu (as in influenza). Instead, the medical term for a stomach bug is "viral gastroenteritis" which simply means a virus that attack the small intestine causing abdominal pain, vomiting, diarrhea, and sometimes fevers.  Many viruses could cause gastroenteritis including Rotavirus (which we have a vaccine for but still can cause disease in some kids), Norovirus, Adenovirus, etc. 

What happens if your child gets a stomach bug?  Typically, a child starts with nausea (in smaller kids they may be more fussy and lose their appetite) and possibly a fever.  Vomiting occurs the first couple of days and then diarrhea comes next and may last up to 2 weeks.  Not all children get both vomiting and diarrhea.  Some children have no fever.  And although we say the vomiting only lasts a day or two, some particularly strong strong viruses can cause more severe symptoms and the vomiting may persist for several days OR if a child tries to eat or drink too much while their stomach is still upset, they may begin vomiting again.

Where did the stomach bug come from?  This can be very difficult to pinpoint because a child can become sick anywhere from 12 hours to 4 days after being exposed to the virus.  Infected patients are most contagious to others while they are running a fever or vomiting, but unfortunately some of these viruses can be passed on even 1-2 weeks after a patient's symptoms have resolved.

What can you do to help your child with a stomach bug?

1. Push fluids SLOWLY:  I saw first hand last week who heartbreaking it can be to watch your thirsty child beg for more drink after vomiting but if you let them drink too much, too quickly, you'll just trigger more vomiting. The key is to go very slowly (start with just a teaspoon every 5-10 minutes, then increase to 1/2 an ounce every 20 minutes or so for the first hour).  For small children, use a syringe to give 10 mL (which is 1/3 of an ounce) if you must. After an hour, you can increase up to 1-2 ounces every 20-30 minutes.  After two hours since they last threw up, you can double the amount up to 2-4 ounces every 20-30 minutes.  

2. Advance their diet (from clear liquids to milk to solid foods) SLOWLY:

For an infant who is vomiting, we recommend continuing to breast or bottle feed if possible.  So if you are still breastfeeding, give them 20-30 minutes after vomiting and then nurse them (this is comforting plus heps restore the nutrients they lost).

For older children or infants over 4-6 months who are refusing their milk, try Pedialyte (a special formula with extra salt and less sugar that helps replace the nutrients a child's body needs after vomiting and diarrhea).

If your child hasn't vomitted for at least 6 hours or so, you can move beyond "clear liquids" to milk.  After 8 hours of no vomiting, it's okay to try solid foods.  

Stay away from herbal teas and sodas as the caffeine can worsen dehydration.  Also, full strength fruit juice has a lot of sugar and can sometimes make diarrhea worse, so dilute it down to half-strength (or mix it with unflavored Pedialyte).

We doctors now believe that the traditional BRAT diet (bananas, rice, applesauce, and toast) that we used to recommend for diarrhea actually doesn't give kids enough protein or calories. But remember to limit high-fat foods like chicken fingers and ice cream, which are harder to digest (may be thrown back up) and avoid spicy foods and fruit juices, which can irritate the gut and cause worsening stomach aches.

3. Give probiotics: Probiotics are live microorganisms (good bacteria) used to restore the balance of normal intestinal bacteria which is often wiped out with diarrhea.  Some studies have shown that probiotics can shorten the severity and duration of diarrhea.  Probiotics are especially important for children with bad diarrhea (more than 6-8 stools per day) or diarrhea lasting more than 2-3 days. I don't recommend any particular brand (common brands include Culturelle, BioGia, Florastor) but recommend child dosing (usually half the adult dose) for kids under 12 years.  Probiotics come in liquid form or powder that can be sprinkled into a drink and served wtihin 20-30 minutes. Give probiotics 1-2 times per day until your child's diarrhea resolves.

DO NOT use any anti-diarrheal medications which can make children with diarrhea a whole lot sicker! 

4. Watch for Red Flag signs that may signal dehydration or another serious problem:

Signs of dehydration:

- Decreased urination (fewer than 3-4 wet diapers in 24 hours for infants and not urinating for more than 12 hours for older children).

- Not making tears when they cry

- Dry, cracked lips 

- Feeling dizzy when standing up

If your child is still playful and active, he or she is not dehydrated. If you're concerned your child may be dehydrated, please call the office.

Red Flag symptoms that mean your child needs to be evaluated:

- Any of the above signs of dehydration

- Vomiting blood or dark green (like the color of a Christmas tree)

- Bloody diarrhea 

- Severe pain in their right lower abdomen 

- Vomiting for more than 2 days

How do you prevent everyone at home from getting the stomach bug?  

1. Wash Hands! Wash Hands! Wash Hands! Use warm water and soap (not just hand sanitizer).  

2. Wash their bedding, clothes, etc in hot water and dry on high heat.  

3. Wash hard surfaces frequently with disinfecting wipes.

4. Don't share utensils, cups, pillows, or towels.

Other miscellaneous tips:

- Take Cover!  If your child is in a crib, try putting an extra waterproof mattress cover on the crib and an extra sheet (so you can just peel off the top sheet and cover if your child vomits in the crib in the middle of the night).  For older children, cover everything with towels - the bed, the couch, the floor beneath, pillows, anything within range that will be a pain to clean. Have a stack of spare towels ready for when the old ones need to be changed.   And even drape a towel on yourself before you scoop up your puking child. This way you don't have to change clothes too every time they throw up and you're whisking them to the bathrrom.

- Empty a laundry basket and keep it nearby to toss in the dirty towels and clothes. Then later you can throw everything into a heavy wash together when you have a minute.

- Use Pedialyte freezer pops to help quench your child's thirst but keep them from drinking too much too quickly.  Have them hold it with a small hand towel so that their fingers don't get too cold.



Beyond the Basics: Toddler Gear 

Life lately has been busy in our clinic (Hello flu and strep and croup and mono) and equally busy at home.  My children are increadibly energetic and keep me on my toes every minute they are awake.  My son is 4 years old and we are preparing for my daughter's 2nd birthday next month.  We're in the throws of toddlerhood at the Brown house and anytime I stumble across an item that makes life a little easier these days it's a BIG victory.    So as follow up to my earlier post (with all my favorite Infant Gear) I've decided to share with you all my favorite Toddler Gear recommendations too.

1. Okay to Wake Children's Alarm Clock: This clock has been worth its weight in gold!  It's able to be programmed to light up (a bright green light) at a specified time.  We set our son's clock to "alarm" at 7:00am and he knows he's supposed to stay in his room each morning until his light turns green.  The best part is that you can turn the actual alarm sound feature off so that, on the rare occasion that our early riser is still asleep at 7:00am, the clock doesn't wake him up!  And, what's more there is a nap timer which can be set for a set duration and then the clock will turn green at the end of the timer so this is how we keep track of our little guy's nap/quiet time (he can come out of his room when the light turns green).  

2. Potty Seat Toilet Lid: Potty training is not my favorite part of being a parent (but a definite necessary step in finally being free of diapers).  Friends of ours found these awesome toilet lids that you can purchase at Lowes or Home Depot with a built in child's size potty seat inside the regular lid.  Unfortunately, our toilets are a brand that these lids don't fit on but it's definetely worth checking out.  For your potty training experience, I'd also recommend purchasing a toilet tank potty hook for easy storage of a potty seat.  And you'll need a sturdy, no-sip step stool too (so they can climb on the potty and also up to the sink to wash hands afterwards).

3. Avent Natural Cup : These were my favorite cups for early toddlerhood for teaching a child how to drink out of a real cup without a lid.  The genius design features a spoutless cup with a unique spill-proof valve that's lip activated. Toddlers learn to drink from the rim so they're ready for grown up cups, while trainer handles make it easy for their little hands to hold on tight.

4. WaterWow Coloring Books and Reusable Sticker Pad : These are big favorites at our house.  Both activities are mess free and keep our kiddos entertained for long stretches of time.  WaterWow is a great on the go toy also (I whip it out at the restaurant while we're waiting for food, we throw it in the stroller, and use it on car trips too).  The sticker pad has few more parts (so not as good for the car or stroller) but is also great for honing those fine motor skills.

5. Doodle board: Another go to toy for the stroller and car trips, both kids love to draw on these boards, then wipe it clean and start again! 

6. Waterproof Name labels: I use these to label coats, backpacks, cups, lunch bags, etc.  There are tons of cute designs on and lots of other websites as well

7. Strider/Balance Bike : These are great for teaching young kids how to ride a bike.  There are a lot of brands out there of balance bikes (and quite a range in price).  I found this article was very helpful in choosing a bike for the size and age of each child. And before Junior takes his new bike out for a spin, be sure to pick up a helmet too!  

8. Faucet Extender: This is a simple device  which attaches to a faucet to direct the water out towards the edge of the skin.  Simple but so helpful in allowing little ones wash their own hands (and I've seen some examples of how you can make your own).

9. Spin Toothbrush: I can't claim this idea as my own.  Dr. Kate Lambert (one of the great dentists at Spangler & Rohlfing Pediatric Dentistry) suggested having kids brush with a spin brush which accomplishes several things: a spin brush makes brushing more fun and enables your child to do a better job brushing.  Plus, kids who use a spin brush aren't as surprised when the dentist pulls out their brushing and polishing tools in their office. 

10. Color Bath Tablets and Bubble Bath: At one point getting kids upstairs for bathtime was a struggle.  Until we discovered the magic of color bath tablets (throw a few into the tub and the kids eyes light up as the bath water turns colors) and bubble bath.  Each night we let the kids choose if they want colors or bubbles.  And the colors don't leave any residue behind or stain the tub.

Honorable Mention Items:

Step Stool with Safety Rail - Pricey but very secure and slides right up to the kitchen counter while you cook.  This is a great way to get kids involved in cooking.

Wheely Bug: So fun! Both my kids adore this ride on toy (and they come in adorable designs).  And they also love the Plasma Car too, 

Kinetic Sand: The newer, cooler version of play dough.  The kids love this stuff and mold it into all sorts of shapes (we use some old cookie cutters to make animals and flowers).  I just have to make sure my wee one doesn't eat it! 

Whisper Ride : This is a win-win. Fun for kids and the long handle doesn't break the parent's back.  




Dr. Brown Knows Flu…Do You? Part 2 

In follow up to my previous post (Dr. Brown Knows Flu...Do You?  Part 1), here are answers to a few more frequently asked questions about the flu vaccine.

- Which is best? Flu Mist or Shot?  In the past, my answer was that, for most children, this decision was completely up to parents.  There are a few medical conditions which prevent a child from being able to receive the flu mist. Most needle wary children preferred the mist to a shot.  

But starting this year (2014-15), for the first time, experts are recommending the nasal spray (Flu mist) over the shot for children - specifically those who are 2-8 years old.  This new recommendation is based on recent studies suggesting that the nasal spray flu vaccine may work better than the flu shot in younger children. However, if the nasal spray vaccine is not immediately available and the flu shot is, children 2 years through 8 years old should get the flu shot. Don’t delay vaccination to find the nasal spray flu vaccine.

- Does timing matter? Nope, not if you're talking about how early each fall to get your flu vaccine.  But yes, if you're wondering if you need your flu vaccine each year.  Since the flu strands circulating in the US is constantly changing, it's important to get a new shot each and every year!  But the timing each fall shouldn't be a concern.

  • Don't worry about being too early:  Years ago, people worried that the protection the flu vaccine offered may only last a few months, so if you were vaccinated too early in the fall - you may not still be protected come February or March.  But the Centers for Disease Control and Prevention strongly recommend getting a flu shot as soon as it becomes available in your community. That's because the flu season could strike as early as October (we've already had cases in North Carolina this fall and in 2011-12, our flu season peaked in November here in the Triad).  Plus, it takes about two weeks for the shot to work and offer you protection should you be exposed to it.
  • Better late than never! If you don't get around to getting your flu shot until December or January, there is still time to get one (and especially if flu peaks late this year and more cases are late in the season).
  • What if you've already had the flu? Getting a flu shot after having the flu still counts: If you do wait too long and end up getting the flu, don't assume that you won't get it again.  Unfortunatley, there are always 3-4 flu strains circulating each season, so some unfortunate souls may get infected with more than one strain of flu in a single winter.  Getting one strain, sadly, does not protect you from the others.  So even if you've tested positive for flu - you should still come in for a vaccine too!  

- Kids with egg allergy can now get flu vaccines!   Flu vaccine grown in chicken eggs traditionally has not been given to people with egg allergies due to concern this could result in a serious allergic reactions such as breathing problems or a drop in blood pressure. However, recent versions of influenza vaccine have shown extremely small traces of egg protein and several recent studies show that thousands of people with an egg allergy have safely received the vaccine with no allergic reaction.  There's even a new "egg free" vaccine out for the first time this season, though at this stage it's only available for people over 18 years of age.....

So if you have a child with an egg allergy, please ask us about their flu vaccine options!  Here's the general rules:

- If your child can eat lightly cooked egg (scarambled eggs) without a problem - they can receive the vaccine and skip on out of our office immediately after their shot or Flu-mist is given.

- If your child gets hives (a rash) only after eating eggs - they can receive the flu shot (but evidence is limited about safety of FluMist in these patients so we recommend sticking with the shot)...but these kids will need to hang around for 30 minutes at our office so we can monitor them closely for signs of a reaction.

- If your child has a severe, anaphylactic reaction (vomiting, wheezing or trouble breathing) after eating eggs, we'll need to have an allergist weigh in and offer their expertise for the safest option



To Do: Flu Vaccines for Everyone! (with convenient drive thru service)

Now that we're settling in to the routine of school days and there is a little chill to the air, it's time to schedule your kids for their annual flu shot.  

For any parents out there with questions about the flu shot (yes, we whole-heartedly recommend it for all children ages 6 months and up), I encourage you to read through the information I provided in past blog posts (Frequently Asked Questions about Flu Vaccines Part 1 and Part 2).

If you're coming into the office for a checkup in the next few weeks you'll be able to get your child's flu vaccine then (flu mist for otherwise healthy kids over 2 years and flu shot for those under 2 years or with other medical conditions) And good news, we're scheduling lots of flu clinics in the evenings and even on weekends!

We know you are busy and flu vaccines is just another on a long list of "To Dos" for all our patients' families.  But we are always trying to find creative ways to deliver health care for our families that is top quality and super convienant.  One example is our annual No Flu Drive Thru clinics (when parents print off flu vaccine consent forms at home, then drive to clinic, and we come to the car to give flu mist to your child - while still strapped into their seat inside the car)!  It doesn't get much easier than that!! 

We will have our 1st No Flu Drive Thru on Sunday October 5th from 12:30-2:30pm in the upper parking lot at Medical Park.

Our 2nd No Flu Drive Thru will be on Sunday October 19th from 12:30-2:30pm in the Clemmons parking lot.

The last No Flu Drive Thru will be on November 9th from 12:30-2:30pm in the upper parking lot at Medical Park.

Remember, the No Flu Drive Thru's are for patients eligible to receive FluMist. We do not offer injectable Flu Shots at these events.

In addition ot the No Flu Drive Thru clinics, we will also offer after-hours flu clinics. These flu clinics are scheduled from 5-7pm on the following dates:

Maplewood- 10/22, 11/19, 12/3, and 12/17

Clemmons- 10/7 and 11/4.

These clinics are for either the FluMist or the Flu Shot. Please call the office to schedule an appointment or schedule online at

We may add additional dates for flu clinics as we progress through the season, so please check your MyChart messages and our website frequently.

Please read the guidelines below closely to know which type of flu vaccine your child is eligible for. If you are unsure which flu vaccine your child should get, please call the office.

Any child 6 months and older can receive the flu shot.

Children 2-4 years old can get the flu mist if they are healthy and have never had a wheezing episode.
Children age 5 years and older with Asthma are eligible for flu mist if they meet the following criteria:

- kids who have had flu mist in the past without any problems;
- kids with exercise induced asthma who only use albuterol with activity;
- kids with asthma on stable doses of controller medications.

Any child with Asthma or wheezing should NOT get the flu mist if:

- have asthma AND has needed oral steroids for wheezing in the last 12 months;
- have asthma AND has needed to increase maintenance inhaler dose (Flovent, QVAR, Pulmicort) in the last 12 months;
- kids who don't officially have asthma but have needed oral steroids for wheezing in the past 12 months.

Consent forms for these vaccines are available on our website under the Forms page. Please bring a completed and signed consent form for each child with you to the clinic.
It is important that you read the Vaccine Information Sheets prior to Flu Clinic. These are also available on our website under the Forms page. 



In the news: Outbreak of Respiratory Virus Hitting Kids Hard

You may have seen a news report about Enterovirus D68, a virus which has sickened more than 1,000 children across 12 states in the US over the past few weeks.

According to a report from the CDC, the first cases occurred in Missouri, where over 300 children have been hospitalized in the past month and 15% of those children have ended up in the intensive care unit!  This Enterovirus D68 is causing these kids to have trouble breathing.  Over half of the children who have been hospitalized had asthma or had previously had wheezing.   Children affected with the virus have ranged from 6 months to 16 years of age.  Since the initial reports from Kansas City, MO a similar outbreak has occurred in Chicago, IL and now a total of twelve states have contacted the CDC for help in investigating enterovirus — including North Carolina (though state health department officials reported this morning that no confirmed cases have been identified yet in NC).

Seeing cases of Enterovirus in the late summer and early fall is expected (cases typically peak in September) but the severity of illness occuring now is quite unusual.  Typically, enteroviruses (there are over 100 types of Enteroviruses) cause rashes and cold-like symptoms such as runny nose, cough, fevers, etc.  Some strains can cause more serious illness (like viral meningitis or encephalitis).

But recently one strain in particular, Enterovirus D68 (EV-D68) is causing severe respiratory illnesses in children. Symptoms include coughing, difficulty breathing and rash. Sometimes they can be accompanied by fever or wheezing.  This EV-D68 strain is uncommon, but not new. It was first identified in the 1960s but there have been fewer than 100 reported cases over the past 50 years.

The good news is that Enterovirus resolves on it's own (we have no ant-viral treatment for this and because it is not a bacterial disease, antibiotics do not help with this illness) within a week or two.  There typically are no long term complications from an Enteroviral infection.  

So what can parents do?  

WASH HANDS!  Enteroviruses are spread from person to person through contact with nasal secretions, saliva, stool, or by contact with contaminated surfaces.  So wash those hands with soap and water for at least 20 seconds very, very often!  Also, avoid touching eyes, nose and mouth with unwashed hands.  Disinfect frequently touched surfaces such as doorknobs.  

KEEP YOUR KIDS HOME IF THEY ARE SICK: Like many other respiratory viruses, EV-D68 appears to spread through close contact with infected people.  If your child is sick, especially with cough and any trouble breathing, keep them home to let them recover and prevent spreading the illness to others.

MONITOR CHILDREN WITH COLD SYMPTOMS CAREFULLY: If your child develops cold symptoms give them Tylenol or Ibuprofen as needed for any aches or fevers and watch their breathing closely.  Signs that they need to be evaluated include:

  • Breathing very quickly (more than 60 times per minute for infants, more than 40-50 times for older kids)
  • Sucking in between their ribs or flaring out their nostrils with each breath
  • Change in color (if your child is coughing and congested and appears blue - call for help immediately)
  • Lethargy (if your child will not respond to questions, is having trouble keeping their eyes open during the day when they are normally awake and is struggling to breathe this may be a sign their oxygen level is too low).

When in doubt, call our office!  Our nurses are available 24 hours a day to speak with you and listen to your concerns to help determine if your child needs to be seen in clinic or sent to the WFBH Emergency Department or is safe to be cared for at home. 



No Juice? No Problem! Rethink Your Drink!

Most kids love juice and would gladly drink it any time it's offered.  Those same kids may eventually refuse milk and water, opting instead for that beloved juice.  But juice, in moderation, is harmless right?  Maybe not! 

Juice, even the 100% fruit juice variety, is loaded with sugar and extra calories that our little ones do not need. And the category of sugar-sweetened beverages (SSBs) refers not just to juice, but also to soda, fruit-ades, and sports and energy drinks.  These SSBs are the largest source of added sugars and contribute a significant amount of calories to the diets of US children.  

Interestingly, a new series of studies published last month in the leading jourrnal Pediatrics shows that drinking juice as an infant primes these kids to crave sugary drinks and set the course for a lifetime of unhealthy choices.  Our taste preferences (in favor of sugary beverages or for or against fruits and vegetables) are set quite early when infants are first exposed to solid foods!  This finding emerged after looking at the results of 11 studies where investigators tracked the diets of approximately 1,500 6-year-olds, comparing their eating patterns to those observed in a study that followed them since their first birthdays.

This study found that babies who consumed any amount of sugar-sweetened beverages were twice as likely to drink them at least once daily at age 6. And another study found that infants ages 10 to 12 months who were given sugar-sweetened beverages more than three times a week were twice as likely to be obese at age 6 than those who consumed none as infants (17% risk for the juice drinks vs just 8.6% for those who were not served juice).

Not to mention the higher risk of cavities for children whose teeth are slathered in those sugary drinks daily.

The main point here is that juice offers no nutritional advantage over offering your child whole fruits (an actual orange instead of orange juice or a handful of grapes instead of grape juice) as the fruits offer fiber and other nutritional advantages compared to the sugary drinks. Also, fruit juice conspumption contributes to toddler's diarrhea (the most common cause of chronic diarrhea in preschoolers) .  And finally, many pickier eaters prefer to fill up on juice than to eat any solid foods and while these kids will still get a lot of calories, they will mostly be from sugars or carbohydrates, and not from the much needed fats or proteins that are required for a healthy diet for these growing children.

So rest assured, it's perfectly acceptable to only offer milk and water to your children.  In fact, not offering juice early on may just set them up for a healthier life long term.




Back to School: Packing healthy lunches!

Happy Back to School Day for Winston-Salem schools! As we say goodbye to lazy summer mornings and start getting back in the routine of the school year, it's time to start thinking about packing lunches again. If you're like me, I often feel like I get in meal "ruts" and need some fresh ideas. I've dug into the archives for this post, but it's been revamped with a few more links to check out with some great ideas. 

The kids are back to school this month, which means it’s time to start thinking about packing lunches again. Packing a healthy, nutritious lunch for your children provides them with the nutrients that they need to get through a long school day. Unfortunately, school lunches aren’t always the answer, as they are often high in calories and don’t meet nutrition guidelines. So, take matters into your own hands to ensure that your child gets the healthiest meal possible! Here are some tips for packing a healthy lunch:

Plan ahead: Weekday mornings are always hectic as you try to get kids up and dressed, lunches packed, and out the door. Make your life easier by packing lunches the night before. Also, consider taking the weekend as an opportunity to put bulk items (i.e. crackers, trail mix, pretzels) in baggies to grab and go during the week.

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Introducing Dr. Forrest

We are thrilled to welcome a new doctor to the Twin City Pediatrics family.  Dr. Stephanie Forrest joins us this summer after competing her residency training at Levine Children's Hospital in Charlotte.   But Dr. Forrest is no stranger to Winston-Salem (she spent eight years here for undergrad at WFU and then medical school at Wake Forest School of Medicine).

Here's some more background information Dr. Forrest shared with us:

I grew up just outside of Seattle, Washington, where I began nurturing a passion for both medicine and children at an early age. I was known as the "neighborhood babysitter" and as soon as I was able to drive, coached gymnastics at "The Little Gym."
My first visit to Winston-Salem was for a look at Wake Forest University. I was immediately taken with the city's beauty and charm. There was little doubt that I would ever stray too far from the East Coast again. I spent the next eight years in Winston as I completed both my undergraduate education and medical school at Wake Forest.
During my three years of residency training at Levine Children's Hospital in Charlotte, North Carolina, I married the man of my dreams, Chris, and we grew our family with our first dog, Cubbins. We are all thrilled to call Winston "home" once again.

I have a special interest in the management and prevention of childhood obesity, care of former premature infants (all those NICU graduates), and in international medicine.  I spend time getting to know my patients as individuals and understanding their specific needs to that I can deliver truly personalized care every step of the way. I am a strong advocate of proper nutrition and physical activity as the keys to a healthy and fulfilling life. I enjoy working with children and their parents to get started down the right path as early as possible.

Outside of Twin City Pediatrics, I enjoy reading, running, camping and hiking, baking, crafts and nearly any other outdoor project or adventure. You can also find me cheering on the Seattle Seahawks, the Carolina Panthers and the Demon Deacons. We also love to travel and I look forward to continuing my experiences in international medicine.


Child Safety: Teaching your teen to drive

Though I still have quite a few years before I have to worry about teaching a teenager to drive, I’m sure the time will be here before I know it…and the thought is already anxiety provoking! I had the privilege to attend a talk recently about teen driving by Dr. Dennis Durbin, Director of the Center for Injury Research at the Children’s Hospital of Philadelphia (CHOP). This talk really hit home with me, as I realized how important it is that we take the time as parents to teach our children to drive as safely as possible.

First of all, it’s important to know that motor vehicle accidents are the number one cause of death among adolescents.  It is also true that the greatest lifetime risk of a crash occurs in the first 6 months of driving. Gulp. How will we ever let our teens out of the house?

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First Birthday and the Transition to Whole Milk 

Around the time that you're singing Happy Birthday to your babe, you'll also be introducing them to whole milk. Pediatric nutrition experts recommend that children between 1-2 years of age should drink 12-24 ounces of whole milk daily (older children should switch to low fat milk rather than whole milk). However, like all other milestones, some kids take the switch in stride, while others have a harder time adjusting. Here are some tips on easing the transition if you hit a few bumps in the road:

Introduce milk in a sippy cup at the times your child would have had a bottle or breastfed.  Try all sorts of sippy cups (sometimes the fancier cups are more problematic.  Many kids (my own included) initially prefered the cheaper "Take and Toss" variety to any of the more expensive "no spill" varieties.  Many parents opt for the "cold turkey" approach to stopping bottles and this works well for many kids. 

If Junior isn't too excited about the milk in a cup - try warming the milk at first (gradually you can warm it less and less until they accept cold milk straight from the fridge).

Be sure your child isn't filling up on other liquids (juice being the main culprit here).  Water is fine, but if juice is also an option, many kids will bypass the milk in favor of the juice all day long! 

Some kids refuse to drink the milk from a cup at first.  Don't panic! Here are two ways to tackle this problem.

- First, realize that milk is now just a small part of your child's overall nutrition (as opposed to the first 12 months of his life when milk was his main nutrition with solid foods taking a backseat to the formula or breastmilk).  If he refuses to drink milk, just increase dairy intake of other calcium rich foods (yogurt, cheeses, etc).  But be sure to look for products that also contain Vitamin D and/or discuss with your pediatrician whether your child may need any additional Vitamin D supplements.

- Mix it up.  To ease the transition to cow's milk, many parents find that mixing it with breast milk or formula works well.  For example, if your daughter has been taking a 6 ounce bottle of formula, start by mixing 5 ounces of formula with 1 ounce of whole milk. The next day, mix 4 ounces of formula with 2 ounces of milk. Each day continue increasing the amount of whole milk by one ounce and decrease the amount of formula by one ounce. 

But I warn against switching over to chocolate milk early on, as this usually results in a child who ultimately refuses regular milk (and is just frustrated that the chocolate milk isn't the option every time milk is presented).



Sunbathing Babes: Selecting Sunblock for your Infant

The American Academy of Pediatrics recommends that for infants (especially those under 6 months of age) the best way to protect their skin is to keep them out of direct sunlight.  And certainly, light weight blanketshats, and protective clothing can be hugely helpful for keeping them covered.  But, realistically, exposure to the sun is difficult to avoid entirely during our North Carolina summers.  So here are my tips for protecting your babies from the sun (including those under 6 months of age).  

Tip 1:  Look for SunBLOCK rather than SunSCREENS:  The distinction here is that you're after a "physical" sunblock rather than a "chemical" sunscreen. Sunblocks use zinc oxide and/or titanium dioxide which sit on top of the skin and work by reflecting the UV rays away from your child's skin.  Chemical sunscreens, on the other hand, contain UVA absorbing avobenzene and/or a benzophenone (such as dioxybenzone, oxybenzone, or sulisobenzone), in addition to UVB-absorbing chemical ingredients.  And while there's currently no evidence that chemical sunscreens are dangerous or toxic, unfortunately, we just don't know enough yet about how young children react to these ingredients.  Here are a few additional reasons we prefer Sunblock to Sunscreen:

-  Physical Sunblocks are automatically broad spectrum (which means they work against both UVA and UVB rays).

- Physical Sunblocks work immediately after application.  Chemical products, on the other hand, need to be slathered on 15 to 30 minutes before heading out into the sun (so that they have time to be absorbed). 

- Physical Sunblcoks are less irritating and cause fewer allergic reactions than chemical sunscreens.

Tip 2: Look for SPF of 30-50.  Most experts agree that SPF sunscreens above 50 don't provide that much extra protection. Some experts even recommend that the SPF rating should be capped at SPF 30 or SPF 50, which provides protection against 97 to 98 percent of UVB rays.  See my earlier post with more explanation about sunscreens (including information about what SPF really means and why broad spectrum protection is necessary).

Tip 3: Try a Test Patch: Whenever you purchase a new sunblock or sunscreen, apply to a small patch on the inside of your child's arm or on the top of your child's foot first and then wash off several hours later.  If they develop skin irritation, it would be best to avoid slathering your child all over with that product.  This is especially a good precaution if you're using a chemical sunscreen (since these creams are absorbed into the skin and are more likely to cause irritation or a allergic reaction).

Tip 4: Use the correct amount!  Lay the sunscreen on thickly (around 1 ounce - enough to fill a shotglass -is needed to adequately cover tweens and teens and slightly less for youngsters), making sure every part of your child's body gets a good coating. Pay special attention to burn-prone areas like the ears, nose, back of the neck, and shoulders.


Tip 5: REAPPLY!  This is the most frequent mistake resulting in sunburn for kiddos.  Most parents are very conscientous about applying before heading out to the beach or pool, but forget to reapply (or don't do it frequenlty enough).  Even for products that are labeled "water resistant" you'll need to grab hold of junior to reslather them after an hour or two.  According to the FDA, “water resistant” sunscreens must maintain their SPF after 40 minutes of water immersion, while “very water resistant” sunscreens must maintain their SPF after 80 minutes of water immersion. Either type of water-resistant sunscreen must be reapplied (every 40-60 minutes is the safest since heavy perspiration and towel drying remove the sunscreen too).

Finally, here is a list of several commercially available sunblocks:

• Neutrogena Sensitive Skin® with PURESCREEN® SPF 60+ lotion
• Neutrogena Pure & Free® Baby with PURESCREEN® SPF 60+ lotion/stick
• Neutrogena Pure & Free® Liquid with PURESCREEN® SPF 50
• Aveeno® Baby Natural Protection Mineral Block® SPF 30 lotion/stick
• Blue Lizard Sensitive® SPF 30+ lotion
• Blue Lizard Baby® SPF 30+ lotion
• California Baby® Sunblock SPF 30 stick
• Mustela® High Protection Sun SPF 50 lotion
• Mustela® Suncream for sensitive areas SPF 50
• TruKid® Sunny Days® SPF 30+ lotion/stick
• The Honest Company - Honest Sunscreen SPF 30
• Badger® All Natural Sunblock SPF 30+ lotion



Caring for Your Child's Smile: An interview with Dr. Kate Lambert (from Spangler & Rohlfing DDS)

As a pediatrician, I want your children to be as healthy as possible, which means I care about their dental health very much!  Some parents are surprised to hear that the recommended age for a first dental visit is when their child is 1 year old.  To provide you with more information about pediatric dental care, I turned to Dr. Kate Lambert from Spangler and Rohlfing Pediatric Dentistry.  Dr. Lambert comes highly recommended by many of my patients (and their parents) who report her friendly smile puts kids at ease immediately.

Dr. Brown: What is the difference between a pediatric dentist and a family dentist?

Dr. Lambert: Pediatric dentists can be thought about as the pediatricians of oral health. Just as pediatricians focus on a certain age group, pediatric dentists specialize their practice on preventative and comprehensive care of infants through adolescents, including children with special health care needs. After four years of dental school,

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Apps for Parents: Car Seat Check

I promise, I haven't forgotten about our blog readers - life has gotten a little crazy around our house, to say the least! I'm planning a series of posts on child safety topics (stay tuned!) AND in the market for a convertible carseat, and in the process of my research, I came across a new app from the American Academy of Pediatrics that I thought I'd share (Dr. Brown mentioned it in her previous post on new carseat rules for 2014). It's called Car Seat Check, and it's a great resource for all of those car seat questions that come up. 

To start, enter your child's age and height/weight to find out which type of car seat is recommended. From there, you can find a product guide for the various types of recommended car seats. It lists the name, weight and height limits, and an average price. You can sort any of those topics (by price might be most helpful). It took me a few minutes to realize that you had to scroll to the right to see all of the information for each seat. 

There's also various safety information included - ranging from installation help to travel tips to links to carseat recalls. There are several videos that help with installation (youtube works great too!) if you need some visual tips. Finally, they've included a list of FAQs that answers some common questions that come up.

The downside to this app is that it costs $1.99 (wish it was free). The comparison information is also available on the AAP website, which may be all that you need, but the interactive nature of the app is also nice. Keep in mind that the AAP is not endorsing any specific car seats, but instead is providing information to consider when purchasing a car seat, which is based on current AAP car seat recommendations. 

Car seats are life saving, but it can be confusing to figure out which one to buy and then how to install it. Take the time to ensure that the car seat you have is right for your child (you can always ask your pediatrician too). Also, make sure that your car seat is properly installed, as it can be tough to get them installed properly. Don't hesitate to find a Child Passenger Safety technician to help if you need it (the app can help you with that too)! 

Check out Dr. Brown's previous posts on new car seat rules for 2014 and rear facing guidelines for even more great information on car seats for your little ones!


In the News: Sound Machines Effect on Hearing 

Overall, our kids are pretty good sleepers.  We have our share of long nights with middle of the night awakenings, but overall we can't complain.  We have an established bedtime routine for each child involving bath time, stories, lullabies....and a sound machine.  Many sleep experts advise parents to use white noise to help soothe a fussy infant, and the noise-canceling effects are an added benefit.  So our kids, like many others, are lulled to sleep each night to the sound of white noise (in our case, we prefer the soothing sounds of ocean waves).  Our trusty sound machines are as essential to sleep for our kids (and hence for us parents as well) as anything else—be it the beloved blankie or pacifier.  And when we travel (bracing ourselves for expected sleep disruptions away from home) we check and double check to ensure the sound machines are packed!    

But, a recent study published in a major pediatric medical journal earlier this month has raised concerns that these sound machines are so loud they may cause hearing problems for children. The researchers compared the sound emitted at 30 centimeters (to simulate placement of sound machine on a crib rail), 100 centimeters (simulating placement near a crib), and 200 centimeters (to simulate placement across the room from the crib).

The results?

1. The sound machines, when turned up to maximum volume, were much louder than we may have realized.

  • All 14 machines exceeded 50 dBA (which is the current recommended noise limit for infants in hospital nurseries) and all but one exceeded the recommended noise limit even from 200 centimeters away.  
  • 3 of the sound machines, when turned all the way up and placed within a foot of infants’ ears, would bombard infants with a noise level exceeding 85 A-weighted decibels (which is the safety limit set by the U.S. National Institute for Occupational Safety and Health for workers exposed for eight-hour stretches). 

2. Machines positioned closer to the crib are louder.

3. Longer durations of exposure to loud noises would likely cause worse effects on hearing. 

To be clear, nowhere in this study did anyone show that a child who fell asleep with the aid of a sound machine has suffered any damage to their hearing.  It's just raising concerns that these machines COULD negatively impact hearing.  And therefore, based on these findings, many are calling for manufacturers to limit the volume on infant sound machines to remove the "potential for harm."  Read this article for a nice critical review of the study.

So what should we do with this information?  You don't have to unplug your sound machine just yet, but we should consider modifying its use to help reduce the risk of any effect on our child's hearing.  Dr. Marc Weissbluth, a pediatrician and author of “Healthy Sleep Habits, Happy Child (my favorite book about sleep for children) recommends the following:

- Place the sound machine across the room from your child.

- Use a lower volume. 

- Use for short periods of time rather than all night long. Many sound machines have a "timer" feature.  The timer allows you to turn the machine on for a set amount of time, drowning out the ambient noises while your child is falling asleep, but then automatically shutting off (hopefully, once your little one is snoozing away).





To Do: Schedule Check Ups in the Summer (for Kids 3 years and older)

You may have seen the recent headlines warning about children who have check ups in the winter being at higher risk of getting sick.  This is not rocket science.  Viruses like colds and influenza usually peak in the winter. And yes, if there is a doctor office filled with sick kids, then walking into that office with your healthy child for their annual checkup does expose your child to those germs, thereby increasing your child's chances of getting sick.  

But there are several things we can do to try to keep your kids healthy.

Most importantly, if your child is 3 years old or older and is generally healthy, please consider scheduling their yearly checkup in the late spring or summer!  That way we can ensure their up to date on all their

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First in Flight: Flying with an infant

My husband and I recently ventured onto an airplane for the first time with our 6 month old. I will say that the thought of traveling with an infant was fairly daunting (primarily because of all of the stuff you have to take along!), but it went pretty well despite some weather-related hiccups. Though I thought I was pretty prepared, I definitely learned a few things in the process! I get questions about this frequently in the office, so I thought I’d take a chance to share some pearls about flying with an infant that I learned.

  • Book a nonstop flight if at all possible! Even without a baby, I have learned that a nonstop flight is always a better option (if you can stomach the price difference). The AAP recommends reserving a seat for your baby so that they can stay in their carseat during the flight. This is definitely the safest (hands free!) option, but it’s also pretty expensive.
  • Arrive at the airport EARLY! I will spare you the dirty details of our flight drama (basically, we had 2.5 hours to get to Charlotte from Winston Salem to make a flight to beat an impending snowstorm), but it is much less stressful if you have time to check in and get through security without rushing. Going through security with a baby is a completely new experience!

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FYI: Does your child need ear tubes?

Ear infections are very common in children.  For most children who have an occasional infection here or there, antibiotics may be all they need (and many mild infections may actually go away on their own without any antibiotics - for more details about this please see Dr. Brown's prior blog post on ear infections).  But other kids, who get one ear infection after another, may need ear tubes (also called tympanostomy tubes).  

So which kids need ear tubes?  New guidelines were published several months ago to help us determine if your child should see an ear specialist (an otolaryngologist) to discuss ear tubes. We look at a few factors.  First, we consider the frequency of ear infections:  more than 3 infections in 6 months or more than 4 infections in 12 months.  But the new guidelines highlight one additional factor aside from how many infections.  The experts only recommend tube placement for kids with frequent ear infections who have fluid that stays behind their ear drum for more than 3 months.

So...why does fluid matter?

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