Thumb Sucking and Pacifiers

Adapted from Am Fam Physician. 2009Jul15;80(2):139-142.

Thumb sucking is an innate reflex and one of the most common security and self-soothing mechanisms. In infants, thumb sucking and pacifier use are often classified together as nonnutritive sucking methods. Pacifier use has been linked to decreased breastfeeding duration, but the same effect of thumb sucking on breastfeeding has not been reported. In some studies, combinations of the use of pacifiers and thumb sucking have been reported to lead to decreased breastfeeding. Pacifier use has been documented to be protective against sudden infant death syndrome (SIDS) in children younger than six months and was included in the 2005 American Academy of Pediatrics SIDS guideline update; however, there have been few studies advocating thumb sucking as an equally preventive measure against SIDS.

The incidence of thumb sucking among children decreases with age, and most children spontaneously stop thumb sucking between two and four years of age.

When Should Children Stop Thumb Sucking?

School-aged children with persistent thumb sucking should be referred to a pediatric dentist. At this age, when the permanent teeth erupt, thumb sucking can affect a child's teeth alignment and mouth shape. The greatest risk of developing malocclusive problems, such as overbite and crossbite, occurs in children who have persistent thumb sucking problems beyond four years of age.

American Dental Association Recommendations to Stop Thumb Sucking

• Praise children when they don't suck their thumb (e.g., verbal praise, stickers).

• Reward your child for not sucking his or her thumb (example: for every day children do not suck their thumb, they get to mark an “X” on a calendar. After a certain number of “X's,” they can receive a reward).

• Find alternative ways of comforting and soothing for children (e.g., stuffed toy or special blanket).

• Provide reminders or negative reinforcement for thumb sucking (e.g., placing topical bitter liquids on the thumb, putting a bandage around the thumb to remind the child not to suck on it).

• Involve older children in ways in which they can stop sucking (e.g., have children help create their own reward system).

Featured Image: Topical bitter liquids marketed to help discourage thumb sucking: Mavala Stop, Thum

Picky Eating

Adapted from Am Fam Physician. 2015 Aug 15;92(4):274-278.

Kids don't need as much food as you think!

One way children start to show their independence is by choosing what they want to eat. You should make meal times as pleasant as possible. The amount of calories and nutrition a child needs is less than many parents realize. You can find out how much your child needs by going to choose my plate.

Parents often describe their toddlers and preschoolers as picky eaters. The reluctance to eat or try new foods (food neophobia) is a normal developmental stage that the child usually outgrows. However, there are picky or fussy eaters who restrict their intake to only a few food items, regardless of whether they are new or familiar.

Some ways to reduce picky eating

• Avoid offering many sweetened foods or foods with high carbohydrate content (breads, sweetened cereal, rice).

• Don't let your child drink too much milk or juice. The calories in liquids can take away appetite. A child should have no more than 16 to 24 oz of milk and 4 to 6 oz of juice per day.

• Follow the rule of 10s: children should try a food at least 10 times before deciding they don't like it.

• Offer foods that are similar to ones your child likes. (For example, if your child likes canned peas, offer cooked carrots instead of raw carrots. The softness of the food may make a difference.)

• Use an older sibling as a role model to help children try things they think they don't like.

• Mix foods, even if the mixture doesn't make sense to you. (For example, a child may eat “ants on a log” because it is a fun way to present celery, peanut butter, and raisins.)

Mealtime roles for parents and children

The main approaches to picky eating include social modeling of normal eating behaviors, repeated exposures to new foods, and positive mealtime experiences. There is a strong correlation between parent and child nutritional behaviors. Parental efforts to control the child's intake of food using pressure to eat a certain food or quantity of food, restriction of certain foods, or promise of a reward have negative effects on food acceptance and are discouraged. In the Satters' Division of Responsibility Model, the parents' role is to provide mealtime structure, positive social modeling, and a variety of healthy foods, whereas the child decides how much and which foods to eat.

Satters' Division of Responsibility Model

Parents

• Provide mealtime structure: time and place.

• Create a positive environment: pleasant interaction.

• Allow the child to feed himself or herself.

• Provide a variety of healthy foods.

Children

• Eat if he or she wants to.

• Choose what to eat out of the offered foods.

• Stop eating when full.

Infant Sleep

Adapted from: Am Fam Physician. 2009Jul15;80(2):139-142.

Newborns usually wake up every two to three hours. Each baby will have different sleep habits. Babies will sleep longer as they get older. Most babies sleep through the night by one year of age, but some babies start sleeping through the night by four to six months of age.

If your baby is not sleeping through the night by the end of the first year, you can try some things to help him or her sleep longer. Responding less often to your baby's cries may help. For example, at first go to your baby within five minutes of crying, then wait for 10 minutes the next time, and then a little longer each time. After awhile, your baby will learn to calm down and go back to sleep.

Having your baby wake up at the same time each morning and go to sleep at the same time each night can help. Waking up your baby before expected middle-of-the-night awakening times also might help. For example, if your baby usually wakes up at 1:00 a.m., 4:00 a.m., and 7:00 a.m., wake him or her 15 minutes earlier each time. Your baby may eventually sleep through his or her predicted times.

More Info: Development of Normal Sleep Pattern

An important part of the childhood development process is gaining independence, and one way in which an infant works toward this goal is by sleeping through the night. Approximately 80 percent of children sleep through the night by six months of age, and 90 percent by one year of age. The definition of “sleeping through the night” is variable, because sleep schedules for each family and person are unique. Some children sleep through the night at an early age, but temporarily revert to nighttime awakenings. These awakenings are usual in the nine- to 18-month age group, when separation anxiety is common.

American Academy of Sleep Medicine 2006 Recommended Methods for Prolonging Sleep in Infants (5 years and younger):

The Parental Guidance above is from on these recommendations. These recommendations were based on a review of 52 articles on sleep in children. There is insufficient evidence to favor one method of sleep intervention over another. There is also insufficient evidence to support a combination of methods as more favorable than one sleep intervention alone.

Unmodified extinction:  Lay the infant down to sleep at a designated time and do not respond to any crying until morning

Graduated extinction:  Gradually respond less frequently to the infant's cries (e.g., initially respond within five minutes of crying, then space out the response to every 10 minutes, then longer)

Bedtime routine

• Maintain the same sleep and wake schedule daily

• Scheduled awakenings before expected awakening time

• If the predicted awakening times for the infant are, for example, 1:00 a.m., 4:00 a.m., and 7:00 a.m., awaken the infant 15 minutes earlier than the predicted time; the infant will eventually sleep through the predicted times

Note: Some methods listed may not be feasible for some families; for example, a family that lives in a thin-walled apartment complex may have complaints from neighbors if they attempt to let their infant cry through the night. Parents can try a method that fits with their values, culture, and living arrangement.

Avoid Medications

Trial of Infant Response to Diphenhydramine (TIRED)
The TIRED study showed that diphenhydramine (Benadryl) was no more effective than placebo in reducing nighttime awakenings in infants. Medication should not be used to treat this normal developmental stage. Parents can be reassured that regardless of the method used, there is no difference in family functioning between children who have and do not have sleep issues.

Penile Adhesions

Adapted from: Penile Adhesions Parent Information CHOP Website

What are penile adhesions

Penile adhesions in circumcised boys occur when the penile shaft skin adheres to the glans of the penis. There are three types of penile adhesions: glanular adhesions, penile skin bridges and cicatrix.

Causes

Some adhesions may develop due to an excess of residual foreskin following a newborn circumcision. Adhesions can also form as an infant develops more fat in his pubic area (the area around the penis and scrotum).

Symptoms

The penis may appear that it is “buried” in the prominent pubic fat pad. Because the penis remains hidden there is a tendency for the shaft skin to adhere to the glans.

With all adhesions you may notice a white discharge coming from the area of the adhesions. This is called smegma. Sometimes smegma can be mistaken for a cyst or pus under the skin, but it is not an infection and does not require antibiotics. Smegma consists of dead skin cells that accumulate underneath the adhesions and help to break them apart.

Diagnosis and treatment

Penile adhesions are generally benign and cause no pain or discomfort to your son. You or your pediatrician may notice them during a physical exam.

Treatment is generally performed by a urologist. They will determine by physical exam the type of penile adhesion and what treatment approach is recommended.

Glanular adhesions

On exam you may not be able to see the complete coronal margin. This is the purple line that separates the glans from the shaft of the penis. This is because the shaft skin has adhered to the glans, covering the coronal margin. Glanular adhesions are benign and when left alone tend to resolve on their own. To help the adhesions separate more quickly, we may suggest applying Vaseline® directly to the adhesions. The Vaseline will soften the adhesions, and with spontaneous erections, the adhesions will begin to break apart on their own.

Penile skin bridge

In some instance, the penile shaft skin will become attached to the coronal margin and develop a thicker permanent attachment that cannot be separated and will not separate on its own. You may notice a band of skin from the shaft adhering to the glans with a small tunnel underneath. In many situations the skin bridge can be divided during an outpatient procedure. Treatment may also involve division of the skin bridge and circumcision revision.

Cicatrix

Following a circumcision, the penis may drop back into the pubic fat pad and the surgical area may contract, trapping the penis. In this situation, you will not be able to expose the glans of the penis at all. We have found that cicatrix can be safely and effectively treated with a topical steroid cream. Your child’s doctor will give you instructions on the proper use of the cream. If the steroid cream fails and the penis remains trapped, a circumcision revision and correction of a concealed penis may be necessary.

Allergy Medication Dosing for Kids

Quick reference of allergy med dosing for children.

Zyrtec (cetirizine) dosing:

• 6-12 months: 2.5 mg once daily

• 1-2 years: 2.5 mg once to twice daily

• 2-5 years: 2.5 – 5 mg once daily

• 6 years and up: 5 - 10mg once daily

Claritin (loratadine) dosing:

• 2 – 5 years: 5 mg once daily

• 6 years and up: 5 – 10 mg once daily

Allegra (fexofenadine) dosing:

• 6 months and < 10.5kg: 15mg twice daily

• < 2 years or < 10.5kg : 15 – 30 mg twice daily

• 2 – 11 years: 30 mg twice daily

• 12 years and up: 180 mg ER once daily

Flonase (fluticasone) dosing:

• 4 years and up: 1 spray per nostril once daily. If not working, ok to increase to 2 sprays each nostril, but reduce to once daily as soon as possible

• 12 years and up: 2 sprays each nostril once daily

Reference

• https://www.uptodate.com/

• https://www.pediatricsofavon.com/wp-content/uploads/2018/11/Pediatrics-of-Avon-Childrens-Dosage-Guide.pdf