Picking scabs

The Pediatric Insider

© 2010 Roy Benaroch, MD

S.A. asked, “What kind of discipline strategy can I use to get my daughter to stop picking at scabs. She’s three years old, and she has a lot of scars already.”

I don’t think a traditional “discipline strategy” is really what you’re looking for—at least no one based on rules. You shouldn’t “forbid” the picking, or make a rule that says “No Picking,” because you won’t be able to enforce that kind of rule. For young children, it’s important that any rule you make is 100% enforceable, all of the time. That’s the best way for children to learn that rules are rules, and rules can’t be broken. If you make a “don’t pick” rule, as soon as you turn your back the picking will resume. So what your daughter will learn is “I don’t have to follow rules when mom isn’t watching.” And she’ll still be picking!

Instead of trying to forbid the picking, try distraction instead. When you see picking, give your daughter a toy, or suggest something else to do. Something that’s new or different is more likely to get her attention, and a game with mom is always fun.

You can also make a positive reinforcement chart. You can work out the details, but you could start with something like: If a day goes by without picking, she gets one sticker. Three stickers earns a trip to the dollar store; six stickers ears a trip out for ice cream.

Once wounds heal, they won’t attract picky fingers. Help minor skin wounds heal faster by washing them gently every day with soapy water. Afterwards, rinse, dry, put on a dab of antibiotic ointment (like Polysporin), and cover it with an adhesive bandage. Colorful or cartoony Bandaids might be more likely to discourage picking. If any of the sores are draining, painful, or spreading, take her to her doctor.

Though picking can make sores and scabs more prominent, and can learn to dark spots, it’s rare for these spots to be permanent. They may take a while to fade, but superficial sores, even picked-at ones, rarely leave any permanent marks. If your child is truly digging at these things aggressively and constantly, talk with her doctor to make sure that there isn’t a more-serious developmental issue going on.

The ears, they are a-piercin’

The Pediatric Insider

© 2010 Roy Benaroch, MD

BB has mixed feelings about getting her daughter’s ears pierced: “What are your thoughts on the safety of piercing a baby or toddler’s ears? I’ve read mixed info about the ‘best’ age to pierce a young girl’s ears. I’d like to know what pediatricians typically recommend. I know this isn’t likely a pressing medical issue, but I want to make a safe, wise, informed choice for my daughter.”

Early or later piercing are both safe, so it’s mostly just a matter of family choice. Some families prefer to pierce early, before a baby could remember it; others want to let a child decide for herself when to do it. Some people like to pierce ears even in the newborn period, and I’ve never seen or heard of any sort of important complication from early piercing.

In fact, the few complications I have seen have been in teenagers rather than babies. Teens aren’t always as good about keeping new piercings clean (new piercings are far more likely to get infected than old, established holes.) I’ve seen a few teens (boys, naturally) ignore their posts completely, so skin grows over the front or the back. Also, teens are more likely than young children to develop keloid scars after piercing.

Whenever you do pierce, follow the instructions on keeping the area clean and using an antiseptic solution. It’s best to do the first pierce with good gold posts, and leave them in for a long while; don’t swap them over to little skinny loops until the hole is mature. The backing should never be tight against the back of the ear—leave a little wiggling for growth and to allow good air and blood circulation. Though the backing shouldn’t be tight against the ear, it does need to be tight on the post to keep the earring in the ear and out of a young child’s mouth. If there are signs of infection like increasing pain, warmth, redness, swelling, or drainage, go see your doctor.

Every once in a while, I get asked about doing ear piercing in my office. I’m not so sure that’s a great idea. Personally, for my own daughters, I’d rather have a piercer who does these all day, every day.

What about piercing other body parts? Holes through ear cartilage are somewhat more likely to get infected, and those infections can be more difficult to treat. Still, they’re usually fine. Lips and noses and eyebrows don’t seem to lead to many problems. However, tongue pierces can increase the risk of some very serious infections—like brain abscesses—and can cause speech problems and broken teeth. As for more exotic piercings south of the mouth—I don’t even want to know.

Just say no

The Pediatric Insider

© 2009 Roy Benaroch, MD

Here’s a request from Rhonda: “I was wondering if you could post something about negativity in children. I am sure I can’t be the only parent dealing with a child who can’t help himself from constantly complaining and using negative talk all day long. It’s exhausting to live with someone who sees the glass as always half empty.”

Negativity is a behavioral “rut”—a way of looking at things or doing things that tends to reinforce itself over time. If you or your child acts negative and says negative things often enough, soon you’ll find that a negative outlook is the “automatic” response.

I’ve written about one good approach to getting out of a negative rut before, a method I call “The Greenies.” That works best for ages 3-7 or so, and can be a great way to develop positive habits for both parents and children.

Also, look at your own way of communicating. Are you saying “no” a lot to your child? Parents of toddlers probably say no hundreds of times a day, and kids will pick up on that and begin to imitate it. If your response is usually “no”, your child will get very used to saying that, too.

You want to teach toddlers to communicate without whining and begging. A great way to do this is to train yourself to try to always say yes to any safe request—IF it’s asked in a reasonably nice way. What constitutes “nice” depends on the age—a friendly-sounding point and grunt is pretty nice for a 13 month old, but you ought to require a four-year-old to say “please”. Silly requests are fine (as long as they’re safe). This is a great age for kids to go to The Home Depot dressed as Bob the Builder, or draw on the walls of the shower with pudding or shaving cream. On the other hand, you must ignore any request that isn’t asked nicely. Whining, cajoling, begging, repeating, tugging, nagging—all of that gets, well, nothing.

Ask multiple-choice questions rather than yes/no questions. Instead of saying “Do you want to wear the red shirt?”, ask “Do you want the red or the blue shirt today?” Too many choices can be overwhelming, and you shouldn’t pepper your child with questions all day long, but try to phrase the questions you do ask in a way that makes “no” not an answer.

There may be particular times when negativity is strongest. Children may be more likely to act whiney when they’re hungry, or tired. It may be best to “steer clear” of your child during those rough times, to give him a chance to sort it out. You can also offer some affirmation and sympathy–“I know it’s hard to smile when you first get up. I’ve got breakfast ready for you when you’re feeling up to coming downstairs.” Don’t expect the best behavior all of the time.

When your child does whine and complain, you ought to ignore it. Don’t argue or try to talk him out of his negative mood. The interaction with you will reinforce negativity. Even a punishment is at least some interaction with mom, and that’s what kids crave. Instead, look for times when your child is positive (or at least vaguely less negative), and make sure to pay plenty of attention to him then. Reflect a positive attitude back, and you’ll get more of that positive attitude in the future.

Talk with your children

The Pediatric Insider

© 2009 Roy Benaroch, MD

Language skills are fundamental to success, and speech skills learned in early childhood are strongly associated with later cognitive development. There are many products available that claim to give a child a “leg up” on learning—special videos, interactive toys, flashcards—but a recent study supports an old notion that the best way to help your children learn to speak is to simply talk with them.

In the 2009 study, published in Pediatrics, researchers used small digital recorders worn by about 275 children to determine how many words they heard each day, how much television they listened to, and how many interactive conversations they had with adults in their lives. They also measured each child’s language performance. On average, the children in the study heard about 13,000 words each day.

The number of words spoken to the child was strongly associated with improved language skills, but an even stronger effect was seen with conversational turns—that is, the number of times adults spoke with the child, taking turns in a conversation. Television was a negative predictor of language skills. More time listening to TV correlated with fewer conversations, and poorer speech development.

Speaking to your child is good; speaking with your child is better. Tell stories, interrupt yourself for questions, and allow your child to make up the next few sentences. Encourage back-and-forth conversations. Give your child time to think and respond, and show with body language and patience that you want her to ask questions back. You’ll get some laughs, you’ll learn about your child’s world, and you’ll help your child grow.

Bring on the Greenies!

The Pediatric Insider

© 2009 Roy Benaroch, MD

Gretchen has a behavior quandary: “My 3 1/2 year old is suddenly having major behavior problems and is really wreaking havoc on the household.  She is whining, hitting, calling everyone ‘bad’ and has started ‘hating’ everything and everyone. I’m sure this is just one of her many phases and is probably worsened by summer boredom but do you have any ideas as to how we can minimize the frustration?   I feel like I am constantly yelling and punishing.”

We all have behavioral “ruts”—patterns of doing things that we end up doing over and over, soon enough becoming habits. It’s easy to make a rut, and easy to stay in a rut. Some ruts might even be a good thing, like a toddler learning to clear his plate or put his toys away. But other ruts can be aggravating, like Gretchen’s example. It sounds like the child is in a new negative rut, and mom has formed her own rut of “constantly yelling and punishing.”

It’s time for a new plan: The Greenies!

This is a method of discipline that relies on positive reinforcement. It’s especially useful to break a cycle with a child who is “constantly” disruptive or disrespectful, and is most suitable for ages 3-7 or so.

Every adult in the house should carry a washable green magic marker with them at all times.

• Catch your child being good at least once every ten minutes.
• Give immediate feedback that is specific:
  • Good: “Thanks for helping!”
  • Better:  “It’s great when you get yourself ready.”
  • Better: “That was great when you helped by putting your own shoes on. Thanks!”
• Along with your verbal praise, use your green marker to make a quick dash on the back of the child’s hand.
• Within a few hours, there will be many dashes.
• At the end of the day, the backs of your child’s hands should be covered with green marks.
• At bedtime, go over some of the marks—point to one or two, and say things like “Remember that one? That was when you kissed grandma! And this one here—this one was when you put your dinosaur toy away!” Again, your praise should be as specific as possible.

This is a method only for positive reinforcement. There are no punishments, and the child cannot “lose” any green marks. It builds only on positive praise.

Give it a try, and let us know who it goes!

Fever part 4: The Fever Action Plan

In prior posts, we’ve covered what a fever is, and why the body runs a fever, and how to tell if a fever is something serious to worry about. Putting all of this together in one practical plan has been the goal of this series. We want to keep children healthy and safe, and avoid unnecessary Emergency Room visits—while looking out for occasions when a child might really need evaluation right away. So here it is, what you’ve been waiting for, The Pediatric Insider fever “action plan.” Clip and save, or even better, share this with friends to bring more eyeballs to my blog. You found it here first!

What to do if your child feels like he has a fever

1. If your child looks very ill—he’s unresponsive, having trouble breathing, or has a blue or grayish color—call 911 or bring him to the nearest emergency room.

2. If the child has not reached his four month birthday, measure the fever with a thermometer, rectally. If the number is 100.4 F or higher, call your child’s pediatrician for instructions. Fevers in very young babies are far more likely to be caused by a serious problem, and usually need to be evaluated right away. Even if the measured temperature doesn’t show that your baby has a fever, call your pediatrician if your child seems unwell.

3. If your child has a poor or abnormal immune system, or has a disease that you’ve been told predisposes to serious infections, call your physician. You should also contact your physician if your child has a fever and has not been immunized—these kids are at much higher risk for serious bacterial infections that may need urgent evaluation and therapy.

The remainder of this action plan is only for normal, otherwise healthy and immunized children 4 months of age or older.

4. (Optional) Measure the temperature in an appropriate way with a thermometer. There is no reason to check a rectal temperature on an older child. An axillary (armpit) or temporal artery temperature is a good enough estimate. (I haven’t found ear thermometers, pacifier thermometers, or skin thermometer strips to be accurate) If you don’t have a thermometer handy, it is not essential to measure the temperature; but it can be handy for monitoring to keep track of the temperature trend, especially if the fever lasts more than a day.

5. If you child feels ill (achy, or just “blah”), give a dose of fever-reducing medicine such as acetaminophen or ibuprofen. You’re giving the medicine to help your child feel better—not necessarily to reduce the fever—but it will probably help the fever drop, too.

6. After the fever decreases, see how your child feels. If he’s still feeling ill, contact your physician for instructions or bring him to the doctor. If he’s looking and feeling better, see how he’s doing in the morning and call your pediatrician for a non-emergency appointment within a few days for evaluation if the fever or other symptoms persist.

Fever itself can be an unpleasant symptom, often accompanied by chills and aches. Parents should treat fever with medicine not because the fever itself is harmful, but to help the child feel better. Even if the fever medicine doesn’t reduce the temperature back to normal, it will help how your child feels. It’s also easier and more accurate to judge just how sick a child is after the fever has been brought down.

During a fever, you’ll also want to offer your child extra fluids. It doesn’t matter what Junior drinks, as long as it’s wet. Milk and other dairy products are fine during a fever (even an extremely high fever isn’t nearly warm enough to “curdle” milk.) Jello, applesauce, pudding, ice cream, and Popsicles are all also good choices. For little babies, encourage frequent nursing or offer an extra bottle. If your child doesn’t feel like eating, that’s OK—as long as he’s drinking, he won’t get dehydrated.

“Fever phobia” is an unwarranted fear that fever is really going to harm your child. In the past, fevers could often have been a harbinger of a truly devastating illness. Nowadays, almost all of the serious fever illness are easily prevented with vaccines and simple hygiene. The few serious fever illnesses that still occur are far more easily recognized and managed. Though fever ought to be treated if it makes your child feel bad, it’s nothing to be afraid of. Protect your child with vaccines, look out for the few red flags that we’ve discussed, and help your child stay comfortable when the occasional fever strikes.

Previous posts in this series:

Part 1: What is it?

Part 2: Why?

Part 3:  Dispelling fever phobia

The best parenting advice you’ll ever get from a two word post

Be patient.

Fever part 3: Dispelling fever phobia

Worry about fevers is the most common reason for an urgent call or visit to a pediatrician. Parents worry about fevers because it makes their child look and feel ill, but also because they’re concerned that the fever means there is a serious medical problem going on, or that the fever is going to harm their child.

Historically, fever did once mean that something terrible could be going on. One of the most common causes of fever world-wide, malaria, is no longer seen in the developed world thanks to improved mosquito control. Likewise, many other serious fever illnesses have become rarities thanks to improved sanitation (like typhoid fever, plague, and dysentery.) Vaccinations now protect against most of the more serious bacterial infections (including meningitis and blood poisoning), as well as many viral infections that had been so devastating in the past (like polio and measles.) Other potentially serious infections have now become easy to identify and treat (scarlet fever, pneumonia, kidney infections.) Compared to a century ago, we are far more able to access reliable health care that can accurately diagnose and treat almost any illness. So while it made sense for parents 100 years ago to worry that a fever could mean the death of their child, this fear is not justified today.

If your child does have a fever, how can you tell if it’s caused by something serious?

In the past, a general rule was that the height of the fever predicted how serious the underlying problem was—so a fever of 105 was far more of a worry than 101. But in a fully vaccinated, otherwise healthy child, this “rule” doesn’t hold true. Even a 105 fever in a healthy child is quite unlikely to be from any serious condition. The best way to determine how likely it is for a child to have a serious medical issue causing a fever isn’t to look at the number on the thermometer, it’s to see how the child acts when the fever goes back towards normal. Give a dose a fever-reducer, wait 30 minutes, then see how Junior feels. If he’s doing much better, it’s very unlikely that you have a serious infection to worry about. We’ll cover this in more detail in the next (and last) installment of my fever series.

When is a belly ache “real”?

Holly asked: “My almost-3-year-old twins have recently started telling me on occasion that their tummy hurts. It almost seems like it’s a catch-all phrase for any malaise, but I also think that they have figured out that a statement like that brings on immediate attention. So far, in every instance, either food or a distraction has resolved the issue, but I did wonder if there’s way to recognize when the complaint should be taken seriously – absent the obvious symptoms like fever.”

I love this question. It speaks to something I consider my main goal as a doctor: teaching parents to become self-reliant, and teaching them how to teach their own children to become self-reliant. It’s a circle-of-life thing, without the smarmy Elton John soundtrack, sort of a recursive zen way of looking at what I consider the point of my life as a parent and a pediatrician. Teach parents how to deal with belly aches in a way that helps their own children deal with their own belly aches, that’s been a good day.

I wrote a chapter, called “Communication Remedies,” about this in Solving Health and Behavioral Problems from Birth through Preschool. It’s sort of a whole philosophy of parenting, plus a practical guide to dealing with things like common headaches and belly aches. Here’s an excerpt:

Any body complaint can be caused by social stresses or psychology. Think especially about this sort of problem when a preschooler complains about any of the following symptoms:

• Belly ache
• Dizziness
• Headache
• Tiredness
• Sleep problems

I’ll go more into the various causes of these problems in other chapters, but it is important to not always assume any of these has a “medical” cause. More frequently, there are both biologic and psychological issues at work, and to help a child feel well parents should be prepared to look for the stresses that are contributing to the symptoms.

A good scheme for listening and responding to a child’s complaints follows these steps:

1. Listen right away. Don’t force a child to get your attention with more dramatic or painful symptoms. When a child complains of a headache, it’s best to quickly listen.

2. Listen with attention. Show with body language that you are listening and interested.

3. Try an “explore question”. Often, a quick “How was school today?” type of question will get you to the root of the problem. If you don’t ask, they won’t tell.

4. Encourage the child to discuss the symptoms. Ask a few brief clarifying questions to allow the child to discuss the pain for a few moments. This allows the child to talk with your attention, which is therapeutic. This step should not last longer than 30 seconds or so. Use open-ended questions like:

• Tell me about the pain.
• Where does it hurt?
• What does it feel like?
• Why do you think it hurts?
• What could I do to help it feel better?

Avoid yes/no or leading questions:

• Does it hurt right here?
• Does your throat hurt too?

5. Touch the child. Touch is powerful and important. Try a kiss in the middle of the forehead for a child’s headache. You’ll be amazed how well it works.

6. Attack the problem. You need a firm, confident plan. It may include medicine (for example, a safe antacid for belly pain, or acetaminophen for a headache), comfort measures (hugging a heating pad), or resting in a certain way (“Lie here on your side for five minutes.”) The plan should always include specific steps and be time-limited.

7. Confirm the child is better. Use a statement, not a question. Say “I am glad you’re starting to feel better.” This is a special phrase: it does not imply that the pain is all gone, it is reassuring, and it helps children feel better by making their parents happy. It’s magic.

8. End the encounter. Gently change the subject and encourage your child to play, with a specific suggestion.

• Good: “I’m glad you’re starting to feel better. Go play with your sister.”
• Better: “I’m glad you’re starting to feel better. Go play dress up with your sister.”
• Best: “I’m glad you’re starting to feel better. Let me help you get your cowboy vest on to play dress up with your sister.”

I’m sometimes asked, “What if it is really serious?” Families will not miss a serious illness by first following the scheme above. If the problem is something to worry about, children will show you with their behavior that they’re truly ill. If after a few days symptoms persist in an otherwise well appearing child, consider a trip to the doctor.

Reassuring factors: (these are clues that pain is not caused by a serious medical problem):

• Pain in a vague location, or pain right in the belly button.
• Symptoms that are difficult to describe or talk about.
• Symptoms that only occur on school days, or are especially bothersome the few days after a school vacation.

Concerning factors: (clues that should raise your concern)

• Associated symptoms like fever, vomiting, diarrhea, or weight loss.
• Symptoms that wake a child from sleep.

Many symptoms have no definite medical cause, but are still stressful and upsetting to children. Watch how children act to help determine if immediate medical concern is justified, and listen to what they say to find ways to help alleviate the symptoms.

Fever part 1: What is it?

The normal human body temperature is thought to average 98.6 F. We all remember this from elementary school, and I’ll bet many of you remember the old glass thermometers, the one your mom used with the little red line right at 98.6. If you could top that, you got to stay home! But, like so many things we were told in elementary school, the truth is more complex and murky.

The classic 98.6 is based on a book by Carl Reinhold (sometimes his name is given as “Carl Reinhold August Wunderlich,” a wonderful name that I hope comes up in casual conversation this week). In 1868 he published The Course of Temperature in Diseases, in which he hand-calculated the averages of about a million measurements in 25,000 patients, coming up with 37 C (=96.8 F). He also declared that based on his observations, 38 C (100.4 F) was the upper limit of the normal temperature, essentially defining “fever” for the first time. It turns out that his thermometers weren’t calibrated very well, and were probably off by at least 1 or 2 degrees, but he gave it a good try—especially considering that his thermometer was a foot long, and took twenty minutes to register a stable measurement. (I don’t know where he put that in his patients, and I’m not sure I want to know.) More recent research pegs the average temperature at 98.2 F, but even this varies at least one degree between individuals. One’s own temperature can also vary at least one degree based on the time of day (normal temperatures are lowest first thing in the morning, unless you’re ovulating.) There is also evidence that carefully measured temperature averages vary between human races and genders (women tend to run hotter than men—no surprise there.) Thought it’s not technically correct, 98.6 F (37 C) still remains widely accepted as the “normal” human body temperature for everyone at any time.

If 98.6 F is the traditional (though inexact) definition of “normal”, then what’s a fever? There isn’t a universal definition. Most pediatricians consider a rectal temperature above 100.4 to be a fever; in adults, the number 100 is more often used, usually referring to an oral temperature (though in the elderly, normal “resting” temperatures may considerably lower than 98.2 F). Measuring rectal temperatures becomes more difficult past a few months of life, so often an armpit, oral, or forehead temperature is measured. To be clear in communicating with your pediatrician, say the number that the device recorded, followed by the method you took it: “Junior was 100.8 degrees measured orally.” Don’t add or subtract degrees to “correct” the temperature, just tell us what the number is. In most cases outside of the newborn period, the exact number is not actually very important, but we do like to have a general idea of how high the fever was.

Fever occurs in children most commonly from infections, but can be a result of many other rarer problems (such as adverse reactions to medicines, inflammatory arthritis, cancer, and thyroid disease). Fever can also occur as part of “heat stroke,” when dehydration combined with exposure to heat overwhelms the body’s capacity to control its temperature. Victims of heat stroke feel warm and dry—not sweaty—and are often delirious or sleepy.  This is a true medical emergency that can lead to kidney failure, brain damage, and death. It’s the only health condition where fever itself contributes to harm.

This is the first post in a little series I’m writing on fevers. In future posts, we’ll explore what fevers are for, why parents don’t need to fear fevers, and a super-simple “pediatric insider” action plan for parents to follow when their child runs a fever. Stick around!