Friday, April 25, 2014

Cutting your baby's nails

I have had multiple parents actually offer me bribes to cut their infant's sharp  little nails.
Sorry folks. Guess what? I hate it just as much as anyone else. Nail clipping (as well as splinter removal) are not among my many talents.
I will tell you a secret. In my family the task of nail clipping belonged completely to my husband Sandy.
Our kids referred to it as "snip snip"
Daddy cut  their nails when they were babies and continued his job as they got older, clipping nails and applying polish on request to his daughters' fingers and toes.
If he accidentally cut them and drew blood at any point, I have blocked that out of my memory and in any case, they survived.

Babies have sharp nails that grow quickly.
It is not uncommon for them leave scratch marks on themselves if you don't keep those nails short.
Some babies actually manage to scratch their eyes, leaving little red marks in the sclera.
I know some parents who put little mittens on the hands, but really, as tempting as it  is to keep those on, it is not a realistic long term solution.
Here are a few tips related to nail cutting.
Keep in mind that babies nails tend to be much thinner than adult nails.

Use special tools for the job, there are baby nail clippers and nail scissors available. Some clippers come with a magnifying glass attached. The reviews are mixed on this, but there are parents who swear by them.
The special kid scissors have rounded tips that can help avoid injury if your baby moves suddenly.
Adult clippers and scissors are often quite a bit sharper and therefore not as safe.  
If you can get away with just a file, good for you, but most of the time the nails need some more trimming than that. 

Some folks do the nails right after a bath when they tend to be softer
Some people actually nibble the nails down.
Most medical sources will warn you that this is tremendously unhygienic. True enough, but grandmothers have done that for generations and I haven't ever heard any issues.

Many  folks cut the babies nails when the infants are in a deep sleep cycle. You can identify this sleep stage because the baby is completely limp and relaxed, The hands are usually unclenched.
If you choose this option consider keeping a little pair of nail clippers with you in  your diaper bag as you go on outings. If your baby is asleep in the car seat, you can seize the moment.

At some point, as your child gets a bit older, it is reasonable to  simply want and expect cooperation. You may have to work towards this goal

When we got our puppy many years ago, we were advised to handle her all over so that she didn't have any areas that were "off limits".
I would do that with your baby. Get in the habit of doing a gentle, relaxing little hand and foot massage that includes all the fingers and toes so that they get used to you handling the nails.
Do a little rhyme or song as you do it. Think "my little piggy".
Of course you are only clipping the nails some of the time, but they may stay more relaxed when it is actually nail clipping time. Who doesn't enjoy a little hand or foot rub!

If you do accidentally cut a finger or toe, just hold pressure for a few minutes.
You can apply a dab of Neosporin if it seems like more than just a superficial little nick. Hopefully the little cut doesn't need more than a few minutes of pressure but if you need to apply pressure for a bit longer, you can put a band aid on a finger or toe and then put a sock over the hand or foot so that your baby doesn't pull  it off. Band Aids can be choking hazards so you need to be wary.

Toe nails should be cut straight across, fingernails can be rounded a bit.
If your child does develop an ingrown nail, try to soak it or apply a warm compress. Apply Neosporin a few times a day.
Infections on fingers and toes can actually get pretty nasty, so if it doesn't look like it is improving or there are any red streaks running down the finger or toe, it needs same day medical attention.
For your older children it is lovely to have the treat of a manicure or pedicure at a local salon, but do your due diligence and make sure the you use a place that sterilizes the equipment. Fungal infections acquired from a dirty salon can be a nightmare to get rid of.  

Friday, April 18, 2014

Conjunctivitis/ includes eye drop tips

Conjunctivitis, also known as pinkeye, is an inflammation of the conjunctiva. The conjunctiva is the thin clear tissue that lies over the white part of the eye (the sclera) and lines the inside of the eyelid.
When small blood vessels in the conjunctiva become inflamed, they're more visible. This is what causes the whites of the eyes to appear reddish or pink.
Sometimes the sclera will look just fine, but the inside of the eyelid will look red.
The easiest way to check this is to put your finger on the upper part of the cheek and gently pull down until you can see the inside of the lower lid. You can see if the lining is a normal light pink or an infected beefy red. Check both eyes. Do they look the same? Consider looking when your child is fine so you can see what normal looks like. 

Pinkeye has a number of different causes, including:
Allergies (dust or pollen)
Irritants like smoke, pollution, or a strong chemical odor (some heavily chlorinated pools can do induce this)

Symptoms include
  • Redness in the white of the eye or inner eyelid
  • Increased amount of tears
  • Thick yellow discharge that crusts over the eyelashes, especially after sleep
  • Green or white discharge from the eye
  • Itchy eyes
  • Burning eyes
  • Blurred vision
  • Increased sensitivity to light

Bacterial conjunctivitis is usually treated with antibiotic eye drops.
The most common culprits are Staph or Strep.
It can clear up on it's own, but might take quite a bit longer if untreated. If your child is in school or daycare, that can be an issue.

Although often the eye drops will come with directions to give 4 times a day, many of our patients have a hard time managing that. Four times a day is ideal, but three times a day is usually adequate.
The directions will often come with a range of time that you need to do the treatment...for example 3-5 days.
Your child is no longer considered contagious after they have completed the first full day of the drops.
I suggest that you continue to treat for a full 2 days after the eyes have cleared up. (minimum 3 days) Don't partially treat or it is likely to come back.
4-5 days is usually standard.
If you don't notice an improvement after 48 hours, your child needs to be reevaluated.

Getting those drops in can be somewhat of an art.
It may be a two person job.
If your child is very uncooperative you may need to wrap them in a blanket so that they don't have their arms to flail around.
Gently pull down the lid. Even if they are clenching their eyes tightly shut, you should be able to find a little pocket in which to put the drops.
Some kids cooperate better if you let them hold onto a tissue and allow them to blot at the eye once the drops have got in.

Try not to touch the dropper tip to the eye. This is harder than you think, for that reason....
Please don't share drops between family members!

Most of the drops that we currently use don't sting, but there are some awful old ones on the market that are quite uncomfortable.
Some of my patients who are traveling were given the stingy ones from other clinics.
(so aggravating)
For your reference, 
The most common ones that we prescribe here are   
Tobramycin (Tobrex)


For older kids, before you go at them. Let them do some playing. Have them give "drops" to 2 different dolls or stuffed animals. Make one cooperative. Give them lots of praise for being brave.
Make the other one kick a fit. You get the idea.

When I see those goopy eyes show up, fully half of my patients have something else going on.
Most of the time the conjunctivitis is associated with an ear infection and/ or sinus infection.
Those kids will likely end up being treated with oral antibiotics. Generally these kids also have some congestion and fussiness (but not always)  

Because of this, I will usually suggest that they get seen in the office.
If your child is over 5, is acting perfectly well and it is difficult to get into the office, exceptions are sometimes made and drops can be phoned it, but it is usually better to have them checked.

Viral: Many cases of pinkeye come  from the same viruses that cause a common cold. Just as a cold must run its course, so must this form of pinkeye, which usually lasts from four to seven days. Viral conjunctivitis can be highly contagious. Avoid contact with others and wash your hands frequently.

Both bacterial and Viral can start in one eye and then spread to the other.
If there is a lot of green and yellow pus it is more likely (but not absolute) that it is bacterial.
Both the conjunctivitis from a virus or bacteria can be easily spread from one person to another.
Because it is contagious, good hand washing is essential.
Wash in  


If Allergies are the culprit, both eyes will likely be affected.
These eyes are usually watery and itchy.

There is an OTC drop called Zaditor that I really like for kids older than 3.

Often it is worth seeing if a couple of drops clear things up. If so, it is likely allergic and you don't need to be stuck doing a several day course of antibiotic drops.

If your baby is under  4 months, gooey eyes may be from a blocked tear duct.
If you happen to have breast milk, feel free to use it for any type of pink eye. You never know, I have seen it help.

What makes me worried?
If the area around the eye looks very pink or red and swollen, that could be something called periorbital cellulitis and it can be quite serious if untreated. This would generally come with a fever and a child who looks ill.

Friday, April 11, 2014


Roseola is a very common childhood illness.
Other rarely used names for it are exanthema subitum (which means sudden rash), roseola infantum, or sixth disease.

There are a few different strains of the Herpes virus that  can cause it, so some kids may seem to get it more than once.
It is most common among children between the ages of 6 months and 3 years.

Patients present with a very high fever, but here is the big clue...they are acting fairly normal.
I have had many phone calls when the parents call to report that their child has a temperature that is over 104, and yet I can hear the child chattering or even singing happily away in the back ground.

Keep in mind that anytime I have a child with a very high fever who is also very fussy, I am likely going to suggest that they get seen. Fussy kids might be telling us something. I would want to rule out an ear infection or a urinary tract infection. I would want to check their throats and listen to their lungs.
Roseola kids, on the other hand are typically not terribly fussy at all. The fever can hang on for about three days and then the fever is gone and here comes there rash.
This is a very rosy red rash that started all over the trunk and spreads.
It will lighten when you press on it.
Once the rash comes along many of my patients also may become somewhat fussy for the next several days. In general they seem to be a bit more miserable in the rash phase of the illness than they were with the fever.
Roseola is one of the reasons that I have my "3 day fever rule".
If I have a reasonably happy patient who is eating and drinking I am fine waiting to see if we are dealing with this very common illness.
At day 3, the fever is usually gone and the rash has declared itself.

Any fever that is lingering longer than 3 days needs to be checked.
With Measles back on the horizon, we need to be a little more wary of the fever/ rash combination illnesses.
With Measles, the fever and rash may at the same time. 
The child will look sick.
To Review: 
Classic Roseola clues include
*child does not look or seem very sick even though they have a high fever
*the rash comes out AFTER the fever is gone

As with many viral syndromes the only treatment is symptomatic.
Keep your child hydrated and keep the fever down with baths, Tylenol or Advil.

Because about 10% of children can have a seizure (usually harmless but super scary) with very high fevers, I suggest treating a fever if it is higher than 101.5

Roseola is contagious.
The exposure period is about 9-15 days.
This means that  they usually won't get sick until a week or two after they were around patient X. 
Kids can spread the virus starting about a day or two before you know they are ill.
They are usually no longer contagious once the fever is gone.
Many schools want kids home for at least 24 hours after a fever is gone. This is not unreasonable.
Consider this one just another "right of passage" 

Saturday, April 5, 2014

Protecting your child's hearing

Please see the updated post July 2017

Often, an article in the news will cause a spike in calls about the related subject.
Earlier this month the New York times ran a piece about sound machines in babies' rooms.

In response to that I am re-running a blog post from last year that deals exactly with this issue.

Mammals are born with lots of very tiny and delicate hair cells in their inner ears. These cells help to amplify sound.
Your baby's ears are more sensitive than those of an adult. Not only do they have thinner skulls, but they also have a full complement of these little hair cells, so sounds will have full amplification. Exposure to loud noises over our lifetime damages these cells. The high frequencies are the first to go.

Your baby's hearing actually starts to develop between 24-28 weeks of gestational age. It is thought that the noises they hear are slightly muffled (imagine what it feels like when you are under an inch or so of water).
They can certainly hear well enough that they seem to recognize the voices of those who have been talking to them while they were in utero.

So yes, we need to make sure that we protect our baby's hearing, but the fact is that all of us need to pay attention to loud noises that can lead to hearing loss.

There are two different factors involved.

The frequency is measured on the Hertz scale.
The lower tones are the lowest numbers
People with the sharpest hearing may be able to hear frequencies ranging from sounds with tones as low as 20 hertz and as high as 20,000 Hertz
A sound higher that 20,000 is known as ultrasonic
Some animals, dogs for instance, can hear much higher frequencies than humans
Human speech tends to fall between 1000-5000

Because as we get older many of us lose the ability to hear the higher frequencies, some brilliant marketers have taken advantage of this.
There are now actually ring tones out there for teens only.  Most adults over the age of 20 have no idea when they ring.

The second aspect of sound that is relevant is the loudness
Sounds are measured in units called decibels.

To give you an idea of how loud various sounds are, take a look at the following list:
30 Whisper 
60 normal conversation 
80 Telephone dial tone
85 traffic noises from inside a car  
90 Bart train (average...actual sounds range from 73-99)
107 power mower
110 stereo headset
110-120 emergency vehicle siren
125  sand blasting or rock concert
140 Gun Shot

The longer the exposure to loud noises the more damage that can be done
OSHA has guidelines set for safe exposure on the job.

85 for 8 hours
88 for 4 hours
91 for 2 hours
94 for 1 hour
97 for 30 minutes
100 for 15 minutes
103 for 7.5 minutes 


For those of you who recognize a pattern, good for you!
For every 3 decibels over 85, the safe exposure time gets cut in half.

Okay, so what do we do with the above information?  
Make sensible choices.
Make sure that all headphones that your kids use are turned down to a reasonable level.
Avoid environments where your child will be subjected to PROLONGED long noises.
That BART platform is probably not going to cause any trouble unless you spend a lot of time down there.
If you know in advance that you will be in a super noisy place, consider some of the new baby friendly headphones that will cut about 20 decibels.
(Ear plugs are a little problematic, because they are a choking hazard and it may be hard to see if your baby pulls them out)

I have actually had parents call me to ask if it is okay to take their baby to a rock concert.

My "NO" possibly reached 100 decibels.

Have your child's hearing tested on a regular basis once they are over the age of  3 or 4 (sooner if you have concern)
You may not know this but most babies in this country are given a hearing test after birth, before they leave the hospital.  

When we do a routine hearing test in our office a child who can hear a 25 decibel sound in frequencies from 500-4000 will pass.

Any in-office hearing test has the risk of being inaccurate, especially for patients under the age of 4.
I will often have a patient who flagrantly failed the test but when I tell them I have a secret question, stand behind them and whisper, "would you like a sticker?" They answer, "yes please."
If you are concerned about your kids' hearing (and remember there is a great big difference between hearing and listening),
play a whispering game with them and see how they do.  
If there is a concern about your child's ability to hear, the next step will be a visit to an audiologist for a much more accurate exam as well as a visit to the ENT specialist.

Back to the NY Times article,
As long as the sound is on a low setting and not directly up against your baby's ear, you don't need to worry. Just be sensible.

If you are interested, my niece tells me that there is an Android app called Smart Tools that can measure decibels.