Pediatric Q & A

We have provided an abundance of information regarding pediatric care below. 

Newborn FAQs

Sleep

Newborns sleep the majority of the day up to 18 hours per day and sleep cycles typically do not get regulated until 3-6 months.  Occasionally, babies will sleep through the night as early as 3 weeks (just be thankful if this happens).  Most likely your baby will be getting up to feed every 2-3 hours regardless of the time.  After your baby has regained his birth weight or after 1-2 weeks, let your baby sleep as long as he/she can during the night but, during the day, do not let your baby sleep more than 3 hours at a time.  This will help stimulate a more regular night time sleep pattern.

Most infants can “sleep through the night” (at least 6 hours) somewhere between 3-6 months of age, when they can tolerate 6 ounces of milk at a time which usually correlates to a weight of 13-15 pounds.  This is the point at which their stomachs can hold enough to sustain them through the night and they are no longer awakening due to hunger.  There will come a point when it is clear they are getting up solely because of habit and just wanting to be comforted and held rather than being truly hungry.  Once they reach this milestone we recommend beginning to train them to sleep through the night (see below).  Sleeping through the night would be considered at least 6 hours.  This is a good time to get them into a separate room.

Infants should sleep on their backs and/or their sides with no loose or thick bedding or pillows in the crib.  Be careful with loose-fitting bumpers or bumpers with long ties since a baby could get stuck between the bumper and the mattress.

Not Sleeping Through the Night

Once you are prepared and your baby has reached the milestones outlined above, we recommend the Ferber method. Essentially, this involves letting your baby cry if he/she gets up.  Go in at 10-20 minutes intervals to let him know you are there and that they are safe.  Do not pick her up, feed him or make a lot of eye contact.  Be prepared for this! Your baby may cry for hours for the first couple of days.  Eventually, your baby will begin to realize that he can put himself back to sleep if he wakes up and that he is safe.  The hardest part about this is the guilt parents feel about the perception of abandoning their child.  Just remember it is all worth it as several days of hardship is trivial compared to months to years of sleepless nights.​

Umbilical Cord Care

Our recommendations are to just leave the cord as it is until it falls off on its own which typically happens around two weeks of life. Sometimes, after the cord has fallen off, a small yellow discharge is often present or bits of dried blood. This can be safely cleaned with a alcohol swab. Occasionally, some red, beefy tissue called granulation tissue is noted at the base of the umbilicus. This usually resolves spontaneously but if it is growing, it should be treated in the office with a topical sealant called silver nitrate.

Bathing

After the umbilical cord has fallen off, you may submerge your baby in water and start giving baths. Babies do not have the same sweat glands as adults and do not need baths every day. Every 2-3 days is usually sufficient for infants.

Stools and Constipation

Once the thick, black meconium stools have passed, stool frequency and consistency is variable depending on the type of feeding.  With breastfeeding, stool color transitions over to a yellow, seedy color with a loose consistency sometimes just as thin as water. Color of stool is variable and can be green, yellow, brown or just watery. Frequency can also vary from every diaper change to every 3-5 days.  Yes, it can be normal with breastfeeding to have bowel movements as infrequent as every 3-5 days.  Breast milk is often so well absorbed that sometimes nothing is left after digestion.  It is rare to have true constipation with breast feeding.  As long as the stools are not hard and there is no pain with bowel movements, we would not recommend giving anything extra to stimulate more bowel movements.  Just enjoy it - things will change once solids are added!  With formula, constipation can be an issue.  Formula is thicker than breast milk, not as rapidly absorbed, and contains iron which, for some babies, can be constipating. With formula, the stool pattern should be, at a minimum, every 1-2 days.  Also remember, it is normal for babies to push and strain during bowel movements but it is not normal to have pain or hard stools.  If your baby is having infrequent or hard, painful bowel movements, you should consider several options:

1)      Start with a glycerin suppository up to twice per day to stimulate the rectum.  Along with this, you can try organic prune juice (mixed into the bottle) 1-2 tsp up to twice daily as needed.  Sometimes, it is just a matter of giving the digestive tract time to get used to the formula.  If this doesn’t work, then:

2)      Start adding fiber to the formula.  I recommend Benefiber 1 tsp mixed in formula once per day (up to twice per day as needed) and probiotics (can be purchased as Sprouts market or Whole Foods) mixed in formula once daily.  If this is inadequate after 1-2 days, then:

3)      Switch the formula.  I would not recommend going to a low iron formula although this usually solves the problem short term.  Instead, I recommend switching to a soy-based formula (Isomil or Prosoybee) or trying Nestle Good Start (this has probiotics added in and often times aids in digestion).  If this is unsuccessful,

4)      Prescription stool softeners.  A stool softener called Colace can be mixed in to the formula at this point.  However, it is rare that it comes to this step.

If you child has had chronic constipation since birth, other tests to rule out anatomic abnormality may also be indicated.  Blood in the stools is never normal and most commonly an indicator of a food allergy or local trauma from an anal fissure.

Feeding Your Baby

Nutrition Requirements: The average baby after 2 months of age will take 24 ounces per day (about 2 ½ to 4 ounces every 3-4 hours).  At 4 months, the average baby will take 32 ounces per day.  Formula or breast milk is all that they need.  We do not recommend giving water until 6 months of age and then no more than 6-8 ounces per day.
Starting Solids: We recommend starting solids (pureed Stage 1 foods) after 6 months. From an allergic standpoint, it is safe to start solids at 4 months, but from a mechanical standpoint, it is easiest to just start at 6 months after the tongue protrusion reflex has subsided.  If your baby demonstrates a lot of interest at 4 months, give them a trial of solids and see how they do.

Breastfeeding

Below are some of the common questions I hear but by no means a comprehensive list.  For more information, please refer to  www.breastfeeding.com or ask your lactation consultant.

Not Enough Breastmilk: For starters, make sure your baby has an adequate latch and suck to give you the proper stimulation and that you are keeping hydrated and maintaining good nutrition.  If these are adequate, options include over-the-counter supplements such as fenugreek and mother milk tea.  If this is unsuccessful, the next step is a medication called domperidone (also known as motilium).  Domperidone acts on the neurotransmitter dopamine which is responsible for prolactin secretion, the main signal from the brain for milk production.  The IV form is not available in the US due to an FDA warning about cardiac arrhythmias with large doses of IV domperidone which is not used anymore.  The oral form at correct dosages is safe and approved by the American Academy of Pediatrics.  Side effects include abdominal cramping and sometimes headaches, both of which usually resolve with a lower dose.  The dose is usually 20 mg 4 times per day for 2-3 weeks, then weaning down to 10 mg three times per day for 3 weeks then twice a day for a baseline dose.  Most women stay on this regimen for an average of 3 months but it is safe long term. The best place to obtain this is from the internet at www.inhousepharmacy.com. It is not available in US pharmacies because of the black box warning with IV domperidone.

Feeding Non-stop (every hour): In the first 2 weeks of life this can be a common phenomenon called cluster feeding.  Try to keep up and as your breast milk supply increases and peaks, usually at 2-3 weeks, this typically will resolve and your baby is satiated.  If it seems that your baby is continuing to cluster feed for hours at a time after the age of 3-4 weeks, there is probably an issue with caloric volume.  At this point, we should consider changing the feeding plan as this can take an unbearable toll on a mother’s well being.

Will Not Take the Bottle: We recommend introducing the bottle at around 3-4 weeks.  This is late enough that your baby will not get lazy or confused with breastfeeding and early enough that he will accept the bottle.  If your baby will not take a bottle, try different types of nipples.  Unfortunately, there is no clear-cut solution.  Sometimes this situation culminates in a very hard first week of daycare.

Gas

All babies have gas, some more than others.  Factors associated with breastfeeding usually have to do with the mother’s food intake.  The most common foods associated with increased gas production for infants are milk products, caffeine, spicy foods, peppers, onions and the cruciferous vegetables (broccoli, cauliflower).  Rarely, wheat or gluten products can bring on gas too.  Keep a food diary and see if you can diagnose which foods are the culprit.  With formula, it is more common to have gas as formula is not as readily absorbed.  Switching from a cow milk-based formula (Enfamil, Similac) to a soy-based formula (Isomil, Prosoybee) may help.  Mylicon (or simethicone) drops are also safe to use and can help in some instances.

Normally, gas is not painful.  If gas is painful and associated with excessively loose bowel movements, this probably represents an intolerance to either lactose or a food allergy.  Milk protein allergy is the most common and is associated with blood in the stool and/or a diffuse rash.  In this instance, we recommend first changing from the milk-based formula to a soy formula (or if breastfeeding, avoiding all dairy).  Soy formula contains a different sugar (not lactose) and a different protein (soy protein instead of cow milk protein) so this change usually solves both problems of lactose intolerance and milk protein allergy.  Twenty percent of children with true milk protein allergy can also be allergic to soy.  The next step if the soy formula does not help is to switch to a hydrosylated formula (such as Nutramigen or Alimentum) in which all of the milk proteins have been broken down.

Formulas: Which ones should you use?

There are basically 4 types of formula-

1)      Cow milk protein based formula- Enfamil, Similac or Good Start. Other generic brands such as Kirkland brand or Target brand are also perfectly suitable as long as they contain DHE.
- within this group are also available: lacto free formulas, lower lactose formulas with partially hydrolyzed proteins (Enfamil Gentle Ease) (for babies with lactose intolerance) and thickened formulas (Enfamil AR) (for babies with reflux)

2)      Soy protein based formula-Prosoybee or Isomil.

3)      Hydrosylate formulas- Nutramigen or Alimentum (for milk protein allergies)

4)      Formula for Premature babies- Neosure 22- this is a formula with extra calories and nutrition.

I personally recommend starting with Enfamil Lipil and the Enfamil line of produtcts because it has the highest concentration of DHE. DHE has been proven to help with brain and eye development.
- For excessive gas/loose stools/pain-
1) 1st  try Enfamil Gentle Ease (partially hydrolyzed proteins and less lactose) or Nestle Good Start (has probiotics mixed in) or adding over the counter probiotics.

2) 2nd line would be to switch a soy formula (Prosoybee) for presumed milk protein allergy.

3) Lastly, would be to switch to a hydrosylated formula (Nutramigen) (with pre- digested proteins) for presumed true milk protein allergy.

- For excessive pain with reflux

1) Try Enfamil AR- this formula is mixed with a rice substitute than becomes more viscous after it hits the stomach, making it less likely to reflux.

Circumcision

To Circumcise or Not to Circumcise

The official recommendation on circumcision has changed over the last 15 years.  In the past, circumcision was recommended for medical reasons because it decreases the risk of urinary tract infections, scarring conditions of the foreskin and carcinoma of the foreskin later in life.  However, after thorough research, these problems have turned out to be quite rare if proper hygiene is followed.  The decision to circumcise is now more of a cosmetic and cultural choice rather than recommended for medical reasons.

When to Do It

Both Dr. Upton and Dr. Mansour have extensive experience with performing newborn circumcision.  This can be done in the hospital at Sharp Mary Birch or later in the office.  In most instances the circumcision is performed in the hospital.  Office circumcisions can be performed on Tuesdays and Thursdays.  Note, circumcision is covered by most insurance plans with the exception of MediCal and Molina.  In these cases, circumcision can be performed on a cash pay basis in the office.

NB - 6M FAQs

Eye Discharge

One of the most common problems with newborns is a blocked tear duct also called the nasolacrimal duct. The duct is a small opening on the inside of the eye which drains tears into the inner nasal area. When it is narrowed or blocked, tears build up forming a yellow, crusty discharge. Typically, this discharge is intermittent, lasting days to weeks at a time, usually building up during sleep and controlled with a warm washcloth to wipe away the tear build up. One can also massage the duct by gently rubbing your finger down the bridge of the nose. The natural course is that as baby grows, the duct grows too and opens up usually by 6- 9 months.
Rarely, the tears get superinfected and form a thicker, green, stringy discharge which does not resolve within 2-3 days and often associated with conjunctivitis, which needs antibiotics. If recurrent infection occur, sometimes ophthomology consultation is warranted for mechanical opening of the tear duct.

Nasal congestion

In addition to narrow tear ducts, many babies also have narrow nasal passageways at birth causing nasal congestion. Babies are obligate nasal breathers which means they preferentially breath through their nose. This means that small nasal canals can make a lot of noise but usually pose no threat to your baby. As long as your baby is feeding well and has no increase work of breathing, no treatment other than nasal bulb syringe aspiration is necessary. This usually resolves by 3-6 months.

Irregular Breathing

Infants can have an irregular breathing pattern during sleep called periodic breathing where rapid breathing for 10-20 seconds is followed by a pause. This is considered normal and resolves as the breathing center in the brain matures. If you notice color changes (blue color around the lips) or pauses lasting longer than 10 seconds, this is not normal and needs evaluation to other causes.

Spitting up or gastro esophageal reflux disease (GERD)

All babies spit up, some more than others, Typically this is not painful and is more noticeable after large volume feeds, feeding fast or laying down right after a feeding. GERD usually resolves by 6-9 months.
For some infants, GERD can be painful and cause symptoms of persistant crying, and back arching during or after feeds. If severe, this can lead to feeding aversion and poor weight gain. First line treatments involve slowing down the volume or speed of the feeds, keeping the baby upright for 20 minutes following the feed and elevating the head of the be to 30 degrees. If your baby has persistent symptoms despite these reflux precautions or is not gaining weight, adding prescription antacids is the next step and often can provide huge relief.

Red Crystals in the Urine

This is a common finding more common with breastfeeding and represents urate crystals in the urine. These resolved spontaneously and do not require and treatment.

Flat heads

Since the guidelines for putting babies to sleep on their backs have come out, an increasing number of infants have presented with a condition known as positional plagiocehpaly (where the back of the head becomes flat and distorted). The best way to treat this condition is to prevent it. As long as you are aware of this problem and rotate your babies head to different positions, this probably will not become an issue.

Babies who often get this condition are ones who seem to prefer to always look in one direction. This can result from a neck muscle strain often suffered in utero from small bleeding into the anterior neck muscle (known as the sternocleidomastoid muscle) with resultant scar tissue which contracts the muscle. Often a small knot can be felt in the muscle. As it tightens, it turns the head to the opposite side. We call this condition torticollis. The treatment involves massaging the neck muscle opposite the side the head is turned, hanging things on your car seat or mobile to stimulate them to turn to the other side and laying them to sleep on the opposite side of the head. This condition usually resolves by 2-3 months.

Curved legs and feet

Most babies normally have feet that are intoed at birth and shin bones which have a bowed shape inward. This is from uterine positioning and will gradually resolve as your baby grows.

Skin

Dry skin

Newborn skin can develop a diffuse peeling in the first two weeks. This is the outer skin layer that sloughs off as the new skin grows in. This does need any specific treatment as it will resolve with time, usually by 2-3 weeks. For moisturizer for the skin, we recommend aquaphor, vasoline or Johnson and Johnson’s hypoallergenic lavender lotion.

Eczema

Dry skin occurring in patches and often with an itchy, thickened red component is called eczema. This is seen later in infancy usually first seen in the cheeks and then later on the extremities and in the skin folds in the elbow and behind the knees. It is extremely common and is more common with babies who have other allergies (history of wheezing or allergic rhinitis) or with parents with allergies. The cornerstone of treatment is with moisturizers (aquaphor or vasoline) often 3-4 times per day. Over the counter hydrocortisone for up to on week can be used on the body for flare ups. Another natural moisturizer we have used is called Emily moisturizer and can be found at emilyskinsoothers.com. CeraVe cream or lotion is another excellent moisturizer which can be purchased at Rite-Aid pharmacies or through the internet at www.drugstore.com.

Red bumps on the face and neck (papules)

Babies have very sensitive skin and often react to anything from heat to any contact with small red bumps of the face and neck. Some refer to this as the common “heat rash”. This usually is intermittent and mild in nature and requires no treatment other than aquaphor or vasoline to the area if it is dry to act as a barrier. Lesions which do not blanch (turn white after pressing on them with your finger) or blisters are not normal and need evaluation.

Stork bites

Also known as salmon patches, angle’s kisses or nevus simplex, these birthmarks are small blood vessels visible through the skin and are present in 30-50% of normal newborns. They are most commonly found on the eyelids, nose, in between the eyebrows and on the nape of the neck. On the face these uniformly resolved with time whereas the patches on the nape of the neck always fade but sometimes persists into adulthood. (Lots of parents have this and don’t realize it).

Strawberrry hamangiomas

this is a different type of birthmark with a raised, red bumpy appearance. It is typically is not seen or very small at birth and grows larger up until around 9 months, after which time it starts to shrink in size and usually has disappeared by 5-9 years old.

Mongolian spots look like dark bruises usually on the sacrum and also resolved on their own usually by 3-5 years of age.

Neonatal acne is marked by scaterred fluid filled spots and red break outs on the face neck usually appearing by several weeks of age and lasting until 2-3 months of age. NO treatment is required and the natural history is for complete resolution. This is a response to the high estrogen levels inside the womb.

Diaper Rash

There are two diapers of diaper rashes: fungal rash and regular diaper rash. Fungal rash is a beefy red rash found in the creases of the inguinal and buttock region from excess moisture. It is easily treated with Lotrimin cream over the counter. Regular diaper rash is on the mounds of the buttock usually around the anus and is due to the sensitive skin exsposed to stool and urine in the diaper. These are treated with avoiding stringent wipes (just rinse and pat dry for diaper changes) and any of the zinc oxide emollient creams (desitin, A +D ointment, boudros butt paste, aquaphor, balmex). I also have have success with calmoseptine ointment (available over the counter but often needs to be ordered by the pharmacy). The best way to treat a diaper rash is to prevent it by using prophylactic aquaphor or vasoline if your baby has soiled diapers more than 3-5 times per day.

Umbilical hernias

Umbilical Hernias are quite common and often look dangerous than they are. No matter how big it seems, as long as the hernia is soft and easily reducible, these are safe and the majority do resolve on the own. Usually umbilical hernia will resolved by 1 year and persistant hernias after 18 months is my experience often require surgery.

Bumps behind the ear

Behind the ear is a lymph node chain called the posterior auricular chain. Often small pea sized lumps are felt behind the ear which are non painful and freely mobile. These are more common in babies with any scalp dermatitis such as cradle cap as the lymph nodes can swell as bacteria found on the scalp is destroyed and broken down in the lymph system. As long as the lymph node is getting bigger, or red or painful (signs of infection), we recommend to follow it conservatively with time. There is also a normal prominence of the bone in this area. If a lump feels “fixed to the bone”, asymmetric, or is growing in size, this needs evaluation.

Breast Lumps

Babies (boys or girls) can sometimes develop breast buds as infants from exsposure to high levels of estrogen in utero. This causes small non painful nodular swelling behind the nipple. These uniformly resolve by 3-6 months of age.

Sunscreen

Sunscreen is not FDA approved for children under 6 months of age. However, in San Diego, we have seen many babies with 1st degree sun burns from sun exsposure (even when parents thought they were covered with a hat or umbrella). Avoid direct sun exposure in the first 6 months and if sun exsposure cannot be avoided, we do think the benefits of sunscreen outweigh the risks. It is ok with us to use sunscreen under 6 months.

Vitamin D

New recommendations have come out for all babies to receive at least 200 IU of vitamin D each day. Vitamin D deficiency can cause a condition known as Rickets where the bones do not grow properly. Vitamin D in addition to in food, can also be made by the skin through skin exsposure. Ricekts historically has been prevalent in underdeveloped countries but after cases of rickets started showing up in the US, the AAP recently changed their recommendations for supplementation.

Formula (at least 16 ounces per day) is fortified with vitamin D and meets the daily requirements. If your baby is breastfeeding exclusively, they should received supplemental vitamin D 400 units per day. This can be obtained with a liquid multi vitamin called polyvisol (1 dropper per day), available at all pharmacies, given straight or mixed with breast milk in a bottle.

Swimming

We recommend infants can start swim classes only after 2 months or after their first set of immunizations.

Planes

The major risk with flying has to do with exposure to crowded places and sick people. We do not recommend taking your baby on a crowded plane before 2 months. Anytime after that, we would consider it safe. Just remember to feed on the way up and the way down to keep the eustachian tubes open. Benadryl can be used safely after six months to assist in sleep. (see benadryl dosing)

Ears pierced

We recommend ear piercing only after 3 months of age and we do not perform this in the office.

Pacifiers

We have no objection to pacifiers as they usually cause no feeding issues and can be a source of comfort for those infants with a strong oral fixation. The earlier you can wean off the pacifier the easier and you should have you baby weaned off by 18 months.

Nails

Long nails in infants can be a source for scratches on the face. It is safe to cut a newborns nails but you need to take extra caution to trim just those edges which overhang and cause scratching. Sometimes, to avoid cutting the skin behind the nail, it is easiest to just file the nails. Some babies are born with long nails and some don’t need to have their nails cut for 6 months.

Hiccups/Sneezing

Both hiccups and sneezing are normal newborn reflexes that are common and both resolve with time. No treatment is required.

Temperature

We do not recommend to take your babies temperature regularly unless they have symptoms such as feeling hot, crying without a clear cause or irritability. We would recommend to buy a normal digital thermometer (same as for adults). In the first 6 weeks, a temperature should be taken rectally and a fever is anything equal to or greater than 100.4 degrees. This needs evaluation in the hospital for a bacterial infection. The reason a rectal temperature is needed is because this is the gold standard and greatly affects management. After 3 months of age, an underarm measurement or ear measurement is adequate.

Crying/colic

As parents, you will learn your baby’s patterns. Crying usually indicates hunger, being cold, being soiled, or just wanting to be held. Gas and milk intolerance can cause excessive crying. Crying for greater than 3 hours per day with no other cause (as outline above) is a condition called colic.
Colic contrary to popular belief is not due to GI upset or food intolerance. New research shows it is a neurodevelopmental problem where babies are unable to self sooth. Typically, crying can last from 3 weeks of age up to 3 months, after which time it spontaneously resolves. Treatment involves outside factors to assist in soothing your infant such as rocking, swinging, cradling, white noise (running water), any kind of motion and soft music.

Colds & Fevers

Advice for Common Cold in Children

Cough, runny nose and congestion are the most common signs of upper respiratory viral infections also called “URI” or the common cold. As long as symptoms are not associated with prolonged fever or dehydration, this infection, although very frustrating is a benign condition that will resolve on its own. Typically secretions can last up to 3-7 days and cough for up to 10-14 days.
Reasons to call the doctor are if these symptoms are associated with a deep productive cough with fever for more than 5 days (signs of pneumonia), associated with ear pain that doesn’t resolve in 2 days (ear infection), dehydration or signs of increased work of breathing with wheezing.
Upper respiratory infections can also cause wheezing (a chest whistle with expiration) which in infants is most commonly from an infection called bronchiolitis or stridor (a chest whistle while breathing in) which causes a syndrome know as croup.​

​The first 6 months of life:
This can be a very frustrating time to develop a URI because young infants are obligate nose breathers meaning they preferentially breathe through their nose. If the nose is filled up with secretions, it can make if difficult to feed and can make babies very fussy. As long symptoms are not associated with prolonged fever or dehydration, this although very frustrating is a benign condition that should resolve on its own.
Treatment involves normal saline and the bulb syringe to mechanically suck out all of the nasal secretions (especially before feeds) and elevating the head of the bed. A humidifier by the bedside (both warm or cool work, I like the warm best but be careful about putting it too close to the bedside for risk of burns) and vicks vapo rub can be used safely as well. The only medication which is safe in this age range are neosynephrine infant decongestant drops (also called phenylephrine) 0.125% drops to each nose every 4 hours as needed for up the 5 days (the brand which makes these is called “Little Noses”)
MY CHILD HAS A FEVER, WHAT SHOULD I DO?

Fever is the bodies natural response to infection and is a sign of a healthy intact immune system doing its job to help fight off infection.​

Fever in the first 3 months of age-
Fever in the first 3 months of life needs to be evaluated. In the first 6 weeks of life, we consider a fever of anything equal to or greater than 100.4 degrees. Temperature in this neonatal period should be done rectally (as this is the gold standard) and is one of the few times when the degree of fever changes our clinical management. Any temperature above 100.4 needs evaluation in the emergency room to rule out a serious bacterial infection. Temperature above 100.4 from 6 weeks of life until 3 months of age can safely be seen in the clinic if your baby is otherwise doing well.

Fever after 3 months of age-
There is a natural panic response that occurs with a fever. There is a common misconception that the higher the fever, the more dangerous the illness. The fever itself is not dangerous. If the fever is 104 or 100.4 degrees, this usually means the same thing- the body’s immune system is intact and generating a fever to kill off an infection (usually caused by a virus, less commonly a bacterial infection). Most common viral infections involve: upper respiratory infections with cough/runny nose/congestion and GI virus infections with vomiting and/or diarrhea. Some virus infections cause just fever with no other signs. With most virus infection, the fever lasts anywhere from 2-5 days long, vasolating up and down, with children appearing tired during spikes of fever then regaining energy and “perking up” like their usual self when the fever is down. Fever can safely be treated with Tylenol and/or Motrin (if over 6 months) (see dosing chart). Everyone with fever will have a decreased apetite. Eating is not as important as drinking to prevent dehydration. Virus infections go away on their own and do not require any specific treatment.

Reasons for concern are for signs of bacterial infection. These include fever lasting longer than 5 days, lethargy (even when the fever is down), fever associated with ear pain which does not get better after 2 days, abdominal pain, pain with urination, back pain, or signs of dehydration (decreased urine output less than twice per day, inability to tolerate any fluids by mouth).

Vaccines

Standard Vaccine Schedule

2 M/O

DTaP

HBV

IPV

Hib

PCV

Rota

4 M/O

DTaP

HBV

IPV

Hib

PCV

Rota

6 M/O

DTaP

HBV

IPV

Hib

PCV

Rota

12 M/O

MMR

Varicella

PCV

15 M/O

DTaP

Hib

HAV

2 Yrs

HAV

4-6 Yrs

DTaP

IPV

MMR

Varicella

11-13 Yrs

DTaP

Meningitis

Gardasil

DTaP= Diptheria, Tetanus, Pertussis

HBV- Hepatitis B
IPV- inactivated Polio vaccine
HiB- Haemophilus influenzae (for meningitis)
PCV- Pnuemococcal conjugated vaccine (for pneumonia, meningitis, blood infection)
Rota- Rotavirus oral vaccine (for viral diarrhea)
MMR- Measles, Mumps, Rubella
Varicella- “Chicken Pox”
HAV- Hepatitis A vaccine
Meningitis- Meningococcal vaccine- (for meningitis and blood infection)

Gardasil- HPV vaccine (to prevent the virus which causes cervical cancer)

Reactions to the Immunizations
15 % of babies can experience a reaction to the immunization which could include low grade fever, irritability or fussiness. This can be treated with Tylenol every four hours as needed. These reactions are not dangerous a usually a sign of a healthy immune system which is being stimulated to produce protective antibodies. Occasionally, a hard lump may be present at the site of the intramuscular injection. This is also an immune reaction and a sign that the immunizations are working. This can last from days to weeks and resolves spontaneously. If your child experiences overall lethargy or actual tenderness, redness or warmth at the injection site, call us immediately.

THE CONTROVERSY WITH VACCINES AND AUTISM: OUR STANCE ON PEDIATRIC IMMUNIZATIONS

Very common questions we are asked every day are concerning the standard vaccines: their risks, possible association with autism, and alternate vaccination schedules. Firstly, let us say that the vaccines have been thoroughly studied and are safe. There is no evidence to suggest any link to autism- both in the MMR vaccine and from thimerasol (which is not present in the vaccines now reagradless). This section is to give you more information about these confusing issues and to present our feeling on the vaccines. We do support all of the immunizations such that both Dr Mansour and Dr Upton have immunized their own children using the standard immunization schedule.

Overview on Autism-
Autism is a delay in the development of multiple basic functions including communication and language, social interaction and repetitive behaviors. Historically, only severe cases of autism were recognized. As our understanding of the disorder heightened, the diagnostic criteria for autism changed and in 1994, autism was now defined as autism spectrum disorder- comprising spectrum of disorders felt to be on a continuium. This could range from mild awkward social skills with no language deficits (often diagnosed as Asperger’s syndrome) to severe global developmental delays (classic autism). Since the revision of this diagnostic criteria, autism has been one of the most commonly diagnosed conditions in the world- affecting somewhere in between 1 in 150-400 people. It is prevalent in all areas of the world. Autism may seem like a modern disease but it is not. Reports dating back to the 1700’s can be found of people now believed to have suffered from autism. In the 1950’s, the disorder officially was named. It was not until 1994 that rates of autism began to dramatically rise. Studies suggest that the majority of this is from increased reporting and better knowledge of the disorder, more so than a disproportionate increase in number of cases. Thousands of people previously thought to have learning disabilities, mental retardation or ill defined psychiatric illness residing in institutions now are recognized as suffering with autism. To date, we do not have a cause or a cure for autism but have marked progress into greater understanding of the disease.

Causes of Autism
Autism has a strong genetic component. Identical twins with a sibling with autism have a 75% chance of having the disorder while fraternal twins have only a 3% chance. Autsim is more common in several genetic syndromes and more common with parents with autism. Autism is also 4 times more likely to occur in boys. Autism is believed to be from several different genes rather than 1 single genetic mutation, making it much harder to identify. Prenatal genetic factors and insults soon after birth are believed to play a role and have yet to be identified. Environmental factors can’t be ignored and this is also being heavily investigated and studies are now underway to look into the medical burden of pollutants, pesticides, hormones in our food, PCB’s and heavy metals.
Although we do not know what causes autism, we do have lots of evidence to suggest that the immunizations including the MMR does not cause autism.

Does The MMR cause Autism?- No
Even though it is believed that genetic factors or insults soon after birth account for the majority of cases of autism, most children are usually not diagnosed until after 18 months of age after children fail to meet their developmental milestones. Developmental exsperts believe the majority of children often had subtle signs earlier which were not diagnosed because there is such a large range of normal development. Parents often disagree with this. A small minority of children have what has been termed “regression” autism where development was totally normal until a relatively acute onset of developmental delay. This spawned the start of the parental concern about the vaccines (both MMR or thimerasol containing vaccines) being the cause as these are given prior to the diagnosis of most cases of autism.

This concern gained rapid momentum in 1998 after a study of 12 autistic children was published in Britain hypothesizing that the MMR caused intestinal inflammation and an autoimmune reaction which could have caused autism. Since that time, numerous studies from around the world looking at thousands of cases have shown that there is no evidence for any relationship between the vaccines and autism. The authors of the original paper suggesting a link recanted their hypothesis in 2004 due to lack of sufficient evidence. The Institute of Medicine, CDC and the Academy of Pediatrics after independent review have all issued statements about the safety of the vaccine and it not being linked to autism. Although reviews of “regressive” autism from hundreds of children showed signs did not show up with 2, 4 or 6 months of the immunization, there are still case reports of infants developing autism shortly after the MMR vaccine. This has also happened after unrelated febrile illnesses.

These case reports are out numbererd by all of the scientific evidence but unfortunately, the vaccine controversy has all the makings of a great story: greedy rich pharmaceutical companies making billions at the expense of our children, a giant cover up, and the uncaring medical establishment favoring public health rather than our individual kids. Great stories make great headlines and spur controversy. In this case, our position is that the evidence is clear: the MMR vaccine has no clear association with autism.

Does Thimerasol cause Autism?- No
Thimerasol is a form of mercury which was used as an antimicrobial in the equipment used to manufacture to shots. It was banned from being used as a preservative by state law over 8 years ago. Our shots (all of them) have no thimerasol, not even trace amounts. Thimerasol has also been studied and hads never been shown to be related to autism. Regardless this is not an issue now with the new thimerasol free vaccines.

Do too many vaccines at once cause Autism? – No
This has also been studied in very small studies. Presently the standard schedule calls for 6 immunizations at 2, 4, and 6 months with 3 immunizations at 12 months and 3 immunizations at 15 months. Many in the holistic and naturopathic community are concerned that too many shots at once too early could be harmful to the immature immune system. This is a theory which has never made sense to me. Physiologically, babies immune systems are mature at term. In the first year of life, the average infant who is exposed to other children (play group or day care) will have an average of 9 virus infections (from upper respiratory, to febrile illness, to GI illness). These are live viruses. The immunizations in the first year are purified proteins, not live infections. New research shows that babies who play more in the dirt (with more bacterial exposure) have less chance of getting allergies and eczema as children. Many researchers in the immunologic community believe that we are not exposing our kids to enough foreign contacts and this is leading to more allergies later in life from a weakened immune system. Giving 5 shots at once is not too much for a babies immune system and I would say rather is helping to boost it.

Pediatric Medication Dosing

Dosages for Over the Counter Medications for Children Less Than 2 Years Old

Neo-synephrine Nasal Drops (phenylephrine nasal drops) - 0.125% solution-

These drops are indicated every 4 hours (1-2 drops per nostril) as needed for nasal congestion for no longer than 3 days. These are safe from to use from birth but we would not recommend these unless your infant has severe symptoms which are inhibiting feeding.

Acetaminophen(Tylenol) - indicated every 4 hours as needed for fever or pain.

Safe to use from birth.

​Weight (pounds)               Children's Suspension (160mg/5ml)

​6-11 pounds

12-17 pounds                      1/2 teaspoon (2.5ml)

18-23 pounds                      3/4 teaspoon (3.75ml)
24-35 pounds                      1 teaspoon (5ml)

​Ibuprofen (Motrin, Advil) – indicated every 6 hours only for fever, pain or swelling
- indicated after 6 months only

Weight (pounds)               Infant Drops (50mg/1.25ml)               Children's suspension (100mg/5ml)
12-17 pounds                     1.25 ml (50mg)                                      1/2 teaspoon (2.5ml)
18-23 pounds                    1.875 ml (75mg)                                     3/4 teaspoon (3.75ml)
24-35 pounds                     2.5 ml (100mg)                                      1 teaspoon (5ml)

Diphenhydramine(Benadryl) – indicated every 6 hours only as needed for congestion/ runny nose
- indicated after 6 months only

Weight (pounds)               Children's Suspension (12.5mg/5ml)
15-20 pounds                     1/2 teaspoon (2.5ml)
20-26 pounds                     3/4 teaspoon (3.75ml)
24-35 pounds                     1 teaspoon (5ml)

​Loratadine(Claritin)- indicated once per day as needed for allergic rhinitis- runny nose
- indicated after 6 months only

Weight/Age                                       Children's Suspension (5mg/5ml)
17-22 pounds/ > 6 months               1/2 teaspoon (2.5ml)
22-28 pounds/1-2 years                    3/4 teaspoon (3.75ml)
>28 pounds/> 2 years                       1 teaspoon (5 ml)

​Cetirizine(Zyrtec)- indicated once per day as needed for allergic rhinitis- runny nose
- indicated after 6 months only

Weight/Age                                       Children's Suspension (5mg/5ml)
17-22 pounds/ >6 months                1/2 teaspoon (2.5 ml)
22-28 pounds/ 1-2 years                   3/4 teaspoon (3.75 ml)
>28 pounds/ > 2 years                       1 teaspoon (5ml)


Dimetapp DM (cough and cold)- (brompheniramine/phenylephrine/dextromethorphan)

  - indicated for cough/runny nose/congestion every 4 hours. This has historically been recommended down to 6 months of age. Recently, many infants had been overdosed with side effects of sedation and respiratory depression. Due to these overdosages, the FDA has only approved this medicine after 2 years old.
- FDA approved after 2 years old