Pinworms/ updated treatment options

 

Itchy butt at night? Uh oh. It might be pinworms. This post will review What are they? How they spread? How to Diagnose Treatment options Clean up tips All things considered, in the big scheme of things there are a lot of worse things that can happen, but you are certainly entitled to give a big groan if this is happening to you or one of your family members. Who Gets Pinworms The Pinworm (Enterobius vermicularis if you want to impress folks the next time it comes up in conversation) is the most common worm infection in the USA. The target age range for the primary infection is children between the ages of 5 and 10. It is fairly uncommon under age 2. These preschool and school age kids are usually the culprits bringing it home, but it is really easy for the pinworms to spread among family members if you live in close quarters and spend any snuggle time in the same bed. Animals do NOT get pinworms, but they can carry them around on their fur and spread them that way. How Pinworms Spread The most common way for a person to get infected is by ingesting the eggs. They can also be inhaled through the nose. The eggs can live out of the body for up to 3 weeks, although they lose infectivity after 1 to 2 days in hot dry climates. These eggs are way too small to be seen by the naked eye, but can be seen under a microscope. If you happen to touch a surface that is contaminated and then put your fingers in your mouth or handle food...tag you're it. It takes between one and two months after the exposure for the symptoms to appear. The eggs mature into the worms.. They live in the intestine and gradually make their way down the GI tract until they are close to the anus. The actual worms are very small, white and threadlike. There is no microscope needed to see them. The male worms die fairly quickly, but the female worms make their way out of the body and lay the eggs on the anus. They tend to do this at night.  Why is that? One theory is that the body temperature is a little higher when you are sleeping and this drives them out. When they emerge from the body, this might cause some itching. It is common for some children with pinworms to wake at night. Children that are old enough to use their words may tell you that they are itchy or that their butt hurts. Little girls might have itchy vaginas or vaginal discharge. Some kids just have mysterious tummy aches. Not everyone will be aware of them. In fact, many people with pinworms have no symptoms Diagnosis In some cases you can actually see little wiggling thread-like worms in the poop. You can just imagine the calls I get when that happens. But more often than not, diagnosing this condition won’t be quite as simple as glancing into the toilet. Some folks recommend putting a piece of scotch tape across the anus and looking in the morning to see if there is anything stuck on it. I prefer the actual ‘look and see’ method. I suggest that a parent go check in the middle of the night. Make sure that your child goes to sleep with a very clean butt, perhaps after a good bath. Once they have been asleep for several hours, take a flashlight and spread the butt cheeks far enough that you can actually visualize the anus. Unless your kiddo is a remarkably sound sleeper, I would tell them ahead of time that you are planning on doing a butt inspection. With a little advanced warning, if they wake up with a flashlight shining at the tush, they are not going to be startled. Pinworms will look like little white threads. They will likely be moving. If your sleeping angel has slept through this far, and you do see wriggling worms, try not to shriek and wake them up. Treatment Once the diagnosis is made, many folks opt to treat, even though most cases are asymptomatic. The medications do not kill the eggs, just the worms, so they should be taken initially and then repeated in one to two weeks. There is an over the counter medication called Reese pinworm (generic pyrantel pamoate), which has a rebate, making it even more affordable. They also have some very handy wipes to deal with the itching. If over the counter fails, there is a prescription medication called albendazole (Albenza) which can also be quite pricey. This also only comes in a tablet so it is a bit challenging for younger kids. This one is still over $400 but at least gives the 2 dose course. Check with your insurance to see if it’s covered, and if it’s not you can get the price down to ~$40-$70 on GoodRX. Singlecare is another option for getting it cheaper. Because most people do not have symptoms but can still spread it, the entire family should be treated if you want to really get rid of pinworms as quickly as possible. None of the medications have been rigorously tested for pregnant, breastfeeding (it does transfer into the milk) or children under two. While there have been no adverse reactions reported, if you are dealing with an infant, I am going to give you the unwelcome suggestion to ‘check with your doctor’. Natural Remedies Natural remedies include eating a diet high in garlic and/or believe it or not, enjoying some pumpkin seeds. Worms love carbohydrates. Limiting sugar and white flour (which is a good idea anyway) may keep them from thriving. Probiotics, which stimulate the healthy bacteria in the gut will also make the environment one where they can't flourish as well.  Vaseline around the anus at night will make it harder for the eggs to be laid. If you like natural remedies, try crushing up garlic and making a paste with the Vaseline and putting that around the butt every night. The fact is that if there were absolutely no further ingesting of the eggs, pinworms could resolve untreated after about 14 weeks (two life cycles), but the problem is most folks just keep on ingesting the eggs which gets them reinfected, and so the cycle continues. Preventing Spread It is gross, I know, but the most common issue is fingers scratching an itchy butt and then making their way to the mouth.  This might be why diaper-age kids don’t get impacted as often. They simply don’t have ‘butt access’. We must do our best to eliminate the eggs and prevent the egg to mouth circuit. Scrub under the fingernails and make sure that they are cut short. Focus on frequent and effective good hand washing. Do a nightly bath with particular attention to the butt. Add some apple cider vinegar to the bath water. If you are worried about dry skin, just make sure you apply a good all over lotion after the bath. Clean up As mentioned earlier, the eggs can live on a surface outside of the body for up to 3 weeks. They survive longer in moist environments. High heat will kill them. They can be easily dispersed into the air. Pay attention to this when changing the sheets. Avoid shaking the sheets out into the air as much as possible. Wash all sheets, towels, pajamas and underwear in HOT water. You want to vacuum or mop, NOT sweep. Scrub the bathroom and any surfaces. Clean your toothbrushes. Putting them through the dishwasher works.  Remind yourself that there are worse things. But this is indeed the proverbial pain in the butt.

Thanksgiving 2022

 

Like my mother before me, I have always loved Thanksgiving.    For more than 30 years, several close families have joined with ours to create wonderful holiday traditions. Our typical celebration includes deep fried turkey, boozy cranberry sauce, my grandmother's award winning apple chocolate chip cake. After dinner, if we aren't in a food coma, we play games. Everyone insists that none of it counts if my husband Sandy doesn’t wear his special 'uglier than you can imagine' Thanksgiving pants.   Covid messed things up for a few years, but this year we are gathering again. Now the kids have significant others and babies in the mix.    One fond memory from one of our earliest gatherings comes to mind. My daughters were probably 6 and 3 years old. We were taking turns sharing what we were thankful for. This was long before something like this would simply bring on heavy eye rolling from Lauren, but at the age of six, she embraced this activity with a gusto.   She was thankful for rainbows and sparkles, family and love...she went on for several minutes with a fairly classic list of things that made a 6 year old girl feel happy. The other kids at the table followed her lead and the lists of things to be grateful for were getting longer and longer. Then it was 3 year old Alana’s turn.    “Lani, what are you thankful for?”   There was a moment's pause and the one word answer.   “Soda”   Not everyone is able to gather in person and I understand how hard it is to be away from friends and family during the holiday season. I also know how lucky I am. That beats soda any day.   In honor of Thanksgiving, I am reposting my food safety guidelines. There are some useful links in here that you might want to bookmark for later. Food contamination issues can happen all year round. This post will give you some safe guidelines for foods that you buy and cook. Check the bottom of the article for some great links on food storage guidelines; everything from egg safety and turkey leftovers to breastmilk storage.  If you do a lot of eating out, restaurants are supposed to have their cleanliness rating publicly displayed. It is certainly not a sterile world. As soon as they are able, your baby will start putting anything that they can reach into their mouths. You can't even begin to imagine the phone calls I have gotten about icky things that some of my little patients have managed to get their hands and mouths on. Chap-stick, particles from an exploded hot pack, kitty litter, the little packet in shoe boxes that says do not eat. You name it, they lick it. So yes, the world is full of germs, and while I don't generally get too concerned about a little dirt here or a big sloppy dog kiss there, foodborne bacteria can be nasty, and we need to minimize any exposure. There were more than 300,000 reports of children under the age of five being impacted by tainted food last year alone. Infants and young children are particularly vulnerable to foodborne illness because their immune systems are not developed enough to fight off infections. This is especially important for infants under 6 months of age. Extra care should be taken when handling and preparing their food and formula. Here are some basic food safety guidelines. Wash hands for at least 20 seconds before food preparation. Soap is best. Hand sanitizer will do. Re-wash as needed after handling food that might carry germs. The most common offenders are poultry, meat, and raw eggs. Make sure kitchen towels and sponges are changed and cleaned frequently. Sponges can go through the dishwasher. Cloth can get easily contaminated and then spread germs. Watch out for potholders or other cloth items that come into contact with raw food. Wash your reusable grocery bags especially after they are used for milk or chicken. Keep your refrigerator temperature at 40 degrees or colder. It is worth investing in an appliance thermometer so that you can keep track. All the science says that the 40 degree number is essential for keeping the bacteria from multiplying. Your freezer should be below 0 degrees. To ensure the safety of your frozen food, you need to be sure that it has been actually kept constantly frozen. One clever trick to make sure of this is to keep a baggie filled with ice cubes in the freezer. If they remain cubes, you are in good shape; if they melt and refreeze as a block of ice that means that at some point your freezer was not cold enough. This can happen in a power outage or even if the door wasn't kept tightly closed. I am sad to say that if there was stored breast milk in there that has thawed and refrozen, I would no longer consider it safe. Label things in your freezer and rotate so that you are using up older stuff first. Check the dates of baby food jars and make sure the lid pops when you open them. Don't put baby food back in the refrigerator if your child doesn't finish it and you used the "used" spoon to take the food directly from the jar. Your best bet - simply don't feed your baby directly from the jar. Instead, put a small serving of food on a clean dish. Add more as needed with a clean spoon. Remember that once saliva has come into contact with the food it is no longer sterile and some bacteria can grow quickly. Powdered formula is NOT sterile. Don't mix up more than you need in advance. If the infant is less than 4 months, I would mix it with boiling water and let it cool. Don't leave open containers of liquid or pureed baby food out at room temperature for more than two hours. Bacteria thrive in temperatures between 40-140 degrees Don't store opened baby food in the refrigerator for more than three days. If you are not sure that the food is still safe, remember this saying: "If in doubt, throw it out." See links below for guidelines on how long food stays safe. Make sure that foods are properly cooked. A food thermometer is the best tool for this. Cook beef, pork, veal, and lamb (steaks, roasts and chops) to 145°F and allow to rest for 3 minutes. Hamburgers made of ground beef, pork, veal, and lamb should reach 160°F. All poultry (including ground) should reach a minimum of 165 °F. NEVER partially grill meat or poultry and finish cooking later. Eggs should not be runny For all of you "older kids" who will be baking this holiday season, watch out for the batter (I am a notorious offender.), Even one lick from raw food containing a contaminated egg can get you ill. ____________________________________________ Myth: Freezing food kills harmful bacteria that can cause food poisoning. Fact: bacteria can survive freezing temperatures. When food is thawed, bacteria can still be present and can begin to multiply. Cooking food to the proper internal temperature is the best way to make sure any bacteria is killed. Myth: vegetarians don't need to worry about food poisoning. Fact: Fruits and vegetables are an important part of a healthy diet, but like other foods they may carry a risk of foodborne illness. Always rinse produce well under running tap water. Never eat the pre-washed 'ready to eat' greens if they are past their freshness date or if they appear slimy. Myth: Plastic or glass cutting boards don't hold harmful bacteria on their surfaces like wooden cutting boards do . Fact: Any type of cutting board can hold harmful bacteria on its surface. Regardless of the type of cutting board you use, it should be washed and sanitized after each use. Solid plastic, tempered glass, sealed granite, and hardwood cutting boards are dishwasher safe. However, wood laminates don't hold up well in the dishwasher. Once cutting boards of any type become excessively worn or develop hard-to-clean grooves, they should be discarded. Myth: Locally-grown, organic foods will never give you food poisoning. Fact: Any food, whether organic or conventional, could become unsafe with illness-causing foodborne bacteria at any point during the chain from the farm to the table. Consumers in their homes can take action to keep their families safe. That is why it is important to reduce your risk of foodborne illness by practicing the four steps: Clean, Separate, Cook, and Chill. Some excellent resources for food safety tips can be found at: www.foodsafety.gov  This site keeps track of any food recalls www.Stilltasty.com This is as great site for seeing how long food will last. I used it just this week to figure out if an open can of chickpeas was still good. (After a week, the answer was no) www.fightbac.org   This site has loads of kid friendly activities Breastmilk storage guide http://www.eggsafety.org Enjoy your Thanksgiving! Grandma Fuffy’s apple chocolate chip cake Beat together 3 eggs 1 3/4 cups sugar 1 cup oil (can make some of it apple sauce) sift together 2 ¼ cups flour (can substitute cup for cup Gluten free flour) ½ teaspoon salt 1 teaspoon baking soda                             ¼ teaspoon baking powder Mix together wet and dry ingredients Add ½ cup of chopped nuts ( optional) ½ cup chocolate chips ( sometimes more seem to find their way into the bowl) 4 cups peeled and diced apples ( about 4 apples) this is the only pain in the butt part of this recipe, otherwise it is so easy cook in ungreased 9X13 pan in 350 oven if you use only oil it is about an hour, if you use some applesauce it is done more quickly, use a toothpick to check the center ******************************************************************* Cranberry Puree (8 servings) 1 pound of fresh cranberries 2 cups of sugar 3/8 cup of Marsala wine ½ cup of Grand Marnier 1/8 cup of Angostura Bitters Cook cranberries and sugar in heavy medium saucepan over medium heat until cranberries are very soft, stirring frequently, about 20 minutes. Puree mixture in blender with half of Marsala wine. (The original recipe says that you should strain this mixture into a medium bowl, pressing to extract as much fruit as possible, although I don’t bother with this step as I think the texture with the seed and fruit bits is more interesting.) Whisk in remaining Marsala wine, Grand Marnier, & bitters. Cover and refrigerate overnight. (Can be prepared up to 5 days ahead.) Serve well chilled. (The amounts of alcohol can be decreased but not by more than ½ of what is called for; the less liquids added, the more jelly-like the puree.)   Don't eat this cranberry sauce and drive!!

RSV 2022/When to worry/Symptomatic Treatment

 

November is typically the start of RSV season but it came early this year. Every year, severe RSV disease is the number one reason babies under 12 months old have to be admitted to hospitals in the US. But this season has been a doozy so far. There are so many cases that nationwide some children's hospitals are having trouble finding room for all the sick kids.If you want to track the numbers for your location, click here   This post will review What is RSV When do you need to worry? Symptomatic treatment How is it spread and what is the exposure period? Tips to prevent Testing FAQ (including daycare, siblings and nursing moms)       What is RSV disease?   Respiratory syncytial (sin-SI-shul) virus, or RSV, is NOT new. It is a common, seasonal virus that is often simply referred to as an especially bad cold. Nearly all children will get their first RSV infection by age 2. Like most viruses, it ranges in its severity from case to case. Let me repeat - I am sorry to say, but your child is likely to get this! No need to freak out…Keep reading.   RSV often settles in the bronchioles. These are the little airways in the lungs that lead to the microscopic alveoli, the place where oxygen is pulled into the blood. The virus causes these little airways to get clogged with mucus, making it difficult for air to pass. This is part of why the virus is so much worse for younger kids. Their smaller airway gets clogged more easily. Some studies show that somewhere between 25-40% of young infants with the RSV virus will have bronchiolitis or pneumonia. That is a scary statistic, but to balance it out, here is some reassuring data: in the US, 99.4% of kids under 5, and 98.5% of kids under 6 months will not need to be hospitalized with RSV. By far, the majority of cases can be safely managed at home.   You know the wretched colds that knock you flat? Not only do you have a runny nose, sniffling and sneezing, but you also have a harsh, deep cough and fever. That might well be RSV. I actually can almost diagnose it just by hearing the distinctive cough. It is deep, wet and sounds like it hurts.    RSV can come on slowly, unlike the flu that usually has a sudden ‘hit by a truck’ onset. Generally the first signs are runny nose and decreased appetite. The cough comes along a few days later. It is also common to have mild to moderate fevers that can come and go for several days. The symptoms are usually at their peak at the 3-5 day mark, but often last 8 days total. It is common for the cough to linger for several weeks.   Unfortunately RSV is not one of those viruses that is ‘one and done’. Sadly it takes multiple exposures before you develop immunity. Adults don’t get as seriously ill, but they still get it and are in for a miserable week. Most folks get RSV about 8 times until they finally seem to be not as vulnerable! It spikes again in older folks when the immunity tends to wane. It can sweep through retirement communities, so be cautious for the older adults in your life as well.   So how do you know if you need to worry? Severe RSV disease symptoms usually include some abnormal breathing but there are some specific things to watch out for.   As Dr. Ted says, “Respiratory distress looks like your kid ran a baby marathon. It’s not subtle” We worry when: The skin is sucking in between or under the ribs with inspiration. These are called retractions. The nostrils might be flaring out, and the baby’s head might be bobbing up and down. The belly might be pulling in and out dramatically with breaths. They might be gasping or grunting There might be a bluish color around the mouth or fingernails There might be coughing or wheezing that feels constant  The rate of breathing is fast. Breaths per minute vary by age. Try counting breaths when your kid is calm. It is fine to do it while they are sleeping. Count for 30 seconds and multiply by 2 See the chart at the bottom of the post for a list of respiratory rates/age.   Check out the Tik Tok that Dr. Ted and I did. Seeing what labored breathing actually looks like is worth 1000 words (if someone had told me a few years ago that I would be doing TikToks, I would not have believed them.)     If you are reading this and your child is actually one of the few kids who is not coughing and doesn’t have a fever, I strongly recommend making note of what their normal breathing looks like before they get sick. Lift their shirt and get a baseline assessment.    Labored breathing is usually pretty obvious, but hydration is another big concern that sometimes gets missed. Warning signs include Dry mouth with cracked lips Crying without tears Urinating less often (smaller diapers are okay) A dehydrated kid is almost never playing happily. They usually seem pretty droopy.   It is normal for the appetite to be pretty off. I don’t even worry if kids lose a bit of weight from a week of pathetic eating. They will gain it back when they are recovered. However if they are not drinking adequately, they may need to get checked to see if they need to get an IV for some hydration and nourishment. Having an elevated fever is a symptom that often gets the parents the most worried. In general my attitude is that fevers are part of the package and can usually be managed with fever reducing meds or a tepid bath. If the fever is higher than 103 and not responding to medication or it is lasting longer than 5 days, then I would want to have your kid checked. This could be a sign that the RSV has turned into an ear infection and/or pneumonia. Bottom line - If your child is having trouble breathing, or significant trouble feeding, they may need to be hospitalized for a night or two for fluids, oxygen and observation.    Treatment   For mild cases, time tends to be the great healer. Your medical team can simply suggest the same symptomatic treatment and supportive care that we would do for any bad cold and cough.  Treat the fever as needed     If you need some tips and trick getting the medicine in check out this post   If your child is having trouble eating because of all the congestion, try doing some clearing about ten minutes before a feeding.    To clear the nose, squirt some saline, xlear nose spray or breast milk in each nostril. Next step is to suck it back out with either a Nose Frida/ aspirator or the Neil Med Naspira. I think these products are easier to use than the standard bulb aspirators. Some parents swear by the Oogie bear. This is a safe little scoop that can safely get into the nostril and remove the more stubborn boogers.     It is also helpful to keep their heads elevated. They may be more comfortable on a bit of an incline. Try to raise the mattress a bit. You can do this by putting a towel underneath or place thin books under two of the legs of the crib. For older kids, add an extra pillow. The American Academy of Pediatrics guidelines specify not to raise the head more than 10% when they are sleeping and you are not keeping an eye on them. If they’re napping but you’re in the room keeping an eye on them, you can raise the bed to 30% for easier breathing.   Let them sit in a steamy bathroom, and use a humidifier at night. Increase fluids during the day.   Warm fluids are great. For kids older than a year, honey is terrific. I especially like the manuka honey. Have a little tea party, invite the teddy bears. Boys can have tea parties, too. This can also be a good way to encourage them to drink.   If your little one is having a rough time your doctor may do a one-time trial of a nebulizer or inhaler to see if it helps. Some children may be prescribed steroids.   According to our local pediatric acupuncturist, Dr. Den, at The Acupuncture Den, the actual symptoms are more important than any official western medicine diagnosis. Whether or not it is RSV, a common cold or even teething, if seen in the office early on, a treatment can help the body to heal itself more easily and will also help with symptom relief (non-needle treatment options are available!)   If you don't manage to stop it in its tracks quickly enough, traditional Chinese medicine can still be very helpful as the infection runs its course. Dr. Den keeps high quality pediatric herbal tinctures stocked in her office, and encourages the families in her practice to keep a bottle or two on hand, as they are most effective when used at the first signs of trouble. While some of the tinctures are highly specific, others can be used more generally (when you know your child is getting sick but you’re not sure yet what’s going on). In terms of the common cold, the flu, and RSV, the two tinctures Dr. Den recommends to keep in your medicine cabinet are CQ Jr (perfect for the first signs of illness) and Lung Qi Jr. (if it starts to move into the chest).   For more information about pediatric acupuncture (or grown-up acupuncture!) and/or herbal medicine, please reach out to Dr. Den. She’d love to hear from you!   How is it spread and what is the exposure period? This is NOT spread the same way as COVID which easily spreads through the air. RSV spreads through heavy droplets. An infected person coughs or sneezes You get virus droplets from a cough or sneeze in your eyes, nose, or mouth You have direct contact with the virus, like kissing the face of a child with RSV You touch a surface that has the virus on it, like a doorknob, and then touch your face before washing your hands. According to the CDC, people infected with RSV are usually contagious for 3 to 8 days and may become contagious a day or two before they start showing signs of illness. However, some infants, and people with weakened immune systems, can continue to spread the virus even after they stop showing symptoms, for as long as 4 weeks.   Prevention There is no vaccine for RSV yet, although there is a promising one in the works that may be given to pregnant women. It looks like it may give infants several months of protection. It will be exciting to see how that is progressing   What we do have already is a medication called Synagis. Alas this is only approved for very high risk children who are very premature or have significant heart or lung issues. Most doctors are on top of this and would have informed you if you are eligible, but If you think your child might be a candidate, reach out to your doctor.   Since most of our children don’t fit the guidelines to get Synagis, please take precautions to prevent the spread of this nasty virus, especially for babies younger than 6 months.   Wash your hands before touching your child. Make sure others wash up too. Clean toys, crib rails, and any other surfaces your baby might touch. Try to keep your baby away from crowds.  Avoid anyone with a cold or fever. Snotty nosed toddlers are the biggest carriers. See suggestions below for dealing with this circumstance. Don't let anyone smoke near your baby. Tobacco smoke exposure can increase the risk of severe RSV disease.   If your child is unfortunate enough to get a nasty case of RSV, it may take a few weeks for the lungs to calm down. Many of them have an extra tough winter season. Every new cold seems to re-trigger the wheeze.    With any cold or illness, your best bet is to pay attention to the first sign of illness. Here is my blog post with my list of things you can do to boost and protect your immune system.   Testing There is a rapid test (a swab to the nose) that many offices can do to see if it is RSV or not. Usually they will test for flu and covid while they are at it. Believe it or not, some unfortunate kids can have more than one of those at the same time! Unless your child is looking really sick, it might not be worth an actual office visit to get an official diagnosis since it doesn't necessarily change the approach. Since RSV is a virus, the treatments are usually simply those listed above. Antibiotics would not be appropriate unless it progresses to a secondary infection.   Frequently asked questions   When can my little one go back to school? Keeping your child home because they have a mild runny nose or lingering cough is not reasonable. However, kids with fevers and/or copious mucus should stay home.   I am nursing, do I need to stop? Can I still be around the baby? Nursing moms who test positive should still continue to nurse their babies. This includes newborns. Just wear a mask and do thorough and frequent hand washing. (and I am so sorry if you are dealing with this.)   Do I need to keep my kids apart from each other? Sigh, this is SO hard. It is almost impossible to quarantine family members. If there is an infant in the house, I would try hard to keep toddlers who have been exposed at least 6 feet apart (sneezing distance) from the baby. No kissing or hugging. Put them in charge of the ‘magic soap’ otherwise known as hand sanitizer. Tell them to make sure that anyone who is having direct contact with their new baby needs to use the magic soap first. Maybe furnish them with a new baby doll that they can cuddle with instead.

What is the best cup option for your child? Spoil alert, it is NOT a standard sippy cup

 

What is the best cup option for your child?

Since I know that my posts get a little chatty (understatement) Here is a TL/DR: Sippy cups aren't the best choice for oral development. If you've been using sippy cups, it's nothing to freak out about. There are a lot of alternative cups, including many that almost match the convenience and ease of the sippy cup. There is nothing simple about parenting. Even something that seems pretty basic can get a barrage of opinions. This includes sippy cups. Sippy cups, really? Here’s the scoop. To understand why sippy cups have come under fire recently, here is a bit of physiology. Bear with me. Baby’s mouths have some unique characteristics that help them safely feed and swallow. There is typically not a lot of open space in their little mouths. The tongue takes up most of the room. The palate is flexible and moveable at birth but will harden over time. The development and shape of the palate are significantly influenced by the placement of the baby’s tongue at rest and during feeding. Not only is the mouth a little different, but the normal infant’s swallow includes a tongue thrust that is necessary for latching and sucking As the babies and their mouths grow, the initial swallow and tongue pattern should change. The development of a more mature sucking pattern is vital in overall tongue positioning. With this more mature swallow, the tongue rises higher in the mouth and can do wave-like motions that are needed for dealing with more textured foods. With proper swallowing patterns, the tongue naturally rests on the roof of the mouth. That helps the palate to widen. It is all connected; the wider palate impacts the nasal septum which can help facilitate the much preferred nose breathing. If the early tongue thrust pattern persists, the tongue doesn't elevate, Instead it tends to rest forward in the mouth. This can impact speech and language development. In extreme cases, kids can end up with high narrow palates and lower, more forward jaws. Those kids can in turn end up being mouth breathers with an increase in drooling issues. (If you haven’t read the book Breath, I highly recommend it. It explains why nose breathing is so important.) Why does this all matter?  Frequent drinking from a sippy cup can change tooth and jaw development and makes it easier for tongue thrust swallowing patterns to persist! Studies have shown that children who use sippy cups during their early years have an increase in malocclusions (poor bite alignment) and cross-bites. Chronic pacifier use can have the same effect, so ideally the ‘pacifier fairy’ comes and makes those disappear by 18 months. Of course not all kids who drink from sippy cups have problems, but if we can avoid the possibility in the first place by offering alternatives, it seems like a good choice. Before I go on, if your child has been relying on a sippy cup for most of their drinking, please don’t beat yourself up. You can’t manage the past. It isn’t too late to make changes. I don’t usually routinely offer water until kids are starting to experiment with solid foods. Let them drink their milk from the breast or bottle, but move on to a cup for their water. How much water depends on your individual child. As long as they are peeing and pooping well, I don’t focus on an exact amount.  A note about hydration - For young infants under 4 months, they are likely getting adequate liquid just from their milk intake. Of course, factors such as extreme weather or illness can impact the hydration level so in some cases they might need some extra fluid. The best way to tell if your little one is getting enough to drink is to look at their urine. If it is darker and less frequent than normal it is time to offer water or pedialyte. Intro to a cup: I asked Jody Vaynshtok, one of my favorite speech therapists, and a consultant at Oath Care for her expert opinion on how to make this progression. Jody likes to start with an open cup like the EzPz - the cup is the perfect size for little hands, weighted to help with little ones learning motor movements, and silicone, so they can add pressure (or even bite) and it won’t cause any problems.  Open cups are an important skill. Try to find opportunities where you just don’t care about the mess. They need to learn this. Of course there are times when you would rather not have everything in your orbit get spilled on. This is where straw cups come in. Sucking from a straw is another good skill for your little one to master.  For this, a great option is the Honey Bear which is a soft squeezy bear with a straw. When you squeeze, this pushes liquid through the bear and up into the straw - that’s when they take over to swallow. The straw can be cut down over time so that it gets shorter and shorter as the child learns the (tough) motor pattern of sucking up liquids and swallowing. Jody calls this a transition cup, so once they master the swallow with a straw you can move onto other cups with straws. We used the Honey Bear with my grandson Elliot and the learning curve was very quick. If you don’t have a transition cup, here is a method that can help you teach your early eater how to use a straw There are several pop-up straw cups on the market that don’t leak. Once your little one masters it, go ahead and cut the straws so that they are pretty short. This ensures that the tongue can still elevate. Jody’s Cup recommendations EzPz: great for starting with an open cup - they also have a version with a straw that’s fantastic for training little ones to use a straw. Cup and straw: functional and cute is always fun to have in the house! These cups have silicone straws so you won’t be worried about them walking around with it and potentially hurting themselves. They can also double as an open cup. 360 cup: if you are afraid of the mess that an open cup can make this can be a good alternative - my only caveat is that some kids become frustrated by the cups slow pour and a pattern of adding pressure to the top of the cup to release the liquid needs to be learned.  All this natural learning is taking place within the first several years. By the time kids are over three, they hopefully have the correct swallow pattern.  Remember that our only concern is for the formative years when kids are learning to swallow correctly. If you have a favorite cup that isn’t sanctioned, just put it away for a little while. Also, if you continue to use a sippy cup occasionally, for instance in the car, I have no trouble with that. As long as most of the drinking is with the preferred cups, you should be just fine. These are Jody’s favorites for kids over the age of 3. We are assuming that by that age they have developed the mature swallow pattern. Camelbak: their designs and so cute, and the ease of use lures you in, but for little ones the soft spout is very similar to a bottle nipple and may continue the immature swallow pattern. Soft sippy cups: this is just a bottle in disguise. Although it may be easy for your little one to use there is no differentiation between this top and a bottle top. There are plenty of knockoffs on the market. When you buy a cup, make sure it is made from safe BPA free plastic. Mama Ellie liked using stainless steel shot glasses. They were a good size and there are no plastic concerns. Note about bottles Prolonged bottle use will have the same impact as the sippy cup. The American Academy of Pediatrics suggests that babies get rid of the bottle between 12-15 months. If your child is one of the ones who will only drink milk out of the bottle and doesn’t want it in a cup (that’s a thing, I don’t know why) I don’t worry about them using the bottle for a couple extra months. If your little one does stay with the bottle for some extra time, here is a gentle reminder: Please don’t let your child have a bottle in the crib. One benefit of transitioning to a cup is eliminating that habit!