Bay Area Parent

Ask the Pediatrician

Specialists from UCSF Children's Hospital answer questions from Bay Area Parent magazine readers.

Foods and Allergies
Staying Healthy At Daycare
Crossed Eyes
Combating Cavities
Tylenol Usage
School Vaccines
Early Toilet Training
Flu Shot Timing
Hepatitis A Vaccine
Halloween Safety
West Nile Warning
The Macaroni Diet
Shy Kindergartner
Allergy Testing
Asthma and Activities?
Chicken Pox Vaccine
Allergy Remedies

Foods and Allergies

Q. I've heard food allergies are very common in young children. True?

A. Most parents have heard stories about young children who are fed new foods and suffer allergic reactions. The good news is that those reactions are not very common, occurring in an estimated 2 to 5 percent of infants under 1 year of age. Though the risk is small, parents and physicians should not be lulled into a false sense of security regarding the potential severity of adverse food reactions. This is especially true of children who come from families in which asthma, eczema or food allergies are known to occur.

Studies have shown that infants who are breastfed exclusively for at least six months are at a reduced risk of developing food allergies. Yet even among children who were breastfed, the prophylactic effect of breast milk eventually diminishes in families with a history of allergies. Most of the research suggests that by 7 or 8 years old, the children at high risk still develop allergic disease.

Any food can potentially cause a reaction but there are several common offenders, including peanuts, milk, soy, eggs, chocolate, tomatoes, shellfish and citrus foods, as well as foods derived from them. In infants, intolerance to milk or soy protein can cause a variety of reactions, ranging from mild skin rashes to bloody stools to rare but severe anaphylactic reactions, characterized by hives, wheezing, rapid pulse and other symptoms. While these reactions can be worrisome, most subside when the milk or soy protein is removed from the diet. More than 90 percent of babies with the protein intolerance will outgrow it by 1 to 3 years of age.

Reintroducing products into the diet, however, should be done with physician guidance. To be safe, it's always wise to offer new foods to kids slowly, one at a time. Generally, parents should wait about a week to see whether a new food causes a reaction before introducing others into the diet.

Staying Healthy At Daycare

Q. My son attends daycare. What can I do to prevent him from getting sick from other kids?

A. As many parents know, when children enter daycare for the first time they are at heightened risk of contracting colds and other viral infections from their peers. But daycare providers can take several steps to limit the spread of colds and other diseases. Parents should also be aware of what procedures the provider has in place and when to keep a sick child home. The following practices are recommended by the American Academy of Pediatrics:

• Establish and follow set procedures for managing both child and employee illnesses, such as when a sick child or employee should remain or be sent home.
• Routine hand washing by daycare providers is a must.
• Diaper-changing areas should be located away from food-preparation areas and surfaces should be sanitized between each use or covered with sanitary cloths that are discarded after use.
• Toilet areas and toilet-training equipment must be kept sanitary.
• Sleeping equipment, such as cots and blankets, should be used by only one child at a time and sanitized before use by other children.
• Infant toys should be cleaned before use by another child and disinfected daily, especially those that tend to be placed in a child's mouth.

Parents should insist that daycare providers follow these practices. You can also help keep everyone well by teaching kids healthy habits at home:

• Teach toddlers to cover their mouths when sneezing or coughing, ideally using their upper arms rather than their hands. If a child sneezes into a hand and doesn't wash it in a timely manner, he can still pass along the germs by touching other children or open surfaces in the daycare.
• Keep children's immunizations current. Cases of measles and pertussis (whooping cough) still occur in this country. Other immunizations can help decrease your child's risk of contracting ailments like pneumonia, ear infections and meningitis.
• If possible, continue breastfeeding. There are numerous immune system benefits of breastfeeding for your child. Antibodies in the breast milk can help decrease the likelihood of infections in kids.

Crossed Eyes

Q. My baby is crossed eye. Will he outgrow this without any treatment?

A. Crossed eyes, also known as strabismus—a condition that prevents children from simultaneously aligning both eyes—usually does not go away on its own and requires treatment. Affecting about five percent of children, strabismus typically develops when a baby is around 6 months old or between ages 3 and 5. Parents shouldn't worry if babies 2 months old and under cross their eyes intermittently. But babies 2 months and up with persistently crossed eyes should be evaluated by an ophthalmologist. Strabismus isn't normally associated with underlying problems of the brain or eye.

Treatment depends on the age of onset. In the first year, it's likely that corrective surgery will be needed. In older children the condition is often corrected with a combination of glasses and an eye patch that covers the dominant eye so the vision in the weaker eye improves. The patch should be worn daily for two to six hours a day, for two to six months. Only about 30 percent of older children require surgery.

When strabismus is detected and treated early, the combination of surgery, glasses and patch therapy can have a success rate as high as 90 percent. But even after surgery, the child will need to continue to wear the glasses and use patching, as vision isn't stable until 8 years of age. At that stage, the patch would only be worn for about a half-hour a day.

Combating Cavities

Q. Besides brushing teeth, how else can tooth decay be prevented in my child?

A. In addition to toothpaste and dental floss, there's another tool you can use to combat tooth decay in your child. Fluoride varnish is a treatment that is applied directly to a child's teeth to protect them from cavities. A recent UCSF study found that application of the varnish, combined with educating parents about children's oral health, can significantly diminish the risk of tooth decay in both school-aged kids with permanent teeth and younger children who still have baby teeth. Preventing damage to teeth is key to avoiding uncomfortable dental visits, including the numerous fillings and extractions, all at increased cost to families.

Fluoride varnish is a resin that contains concentrated fluoride. It is recommended that children receive a varnish application during their first dental visit at age 1 or earlier if they get their first teeth before age 1. The varnish should then be reapplied every six months. If your child is at a high risk of developing tooth decay, already has cavities or early signs of dental problems, applying the varnish even more frequently is recommended. Application takes five to 10 minutes, depending on the age of your child and the number of teeth. There are no side effects from applying the varnish and the treatment is typically covered by dental insurance.

Tylenol Usage

Q. Is it safe to give my child acetaminophen (Tylenol)? If so, what is the appropriate dose?

A. In appropriate doses, acetaminophen (Tylenol) is one of the safest and most effective over-the-counter remedies for your child's aches and fevers. But sometimes parents accidentally give children too much of the medicine, which can damage the liver. Rarely, children end up in the hospital and a few even need liver transplants. This may occur when parents give their child acetaminophen in combination with a cold remedy that also contains the drug, which is more than a child's liver can handle.

Consider the following points when giving your child medications containing acetaminophen, such as Tylenol and cold remedies:

• Even with warning labels, children's doses are not easy to decipher, especially since different formulations (tablets, liquid, drops) may contain very different amounts of acetaminophen.
• Dosing depends on the child's size and other factors, such as whether they are stressed by a virus or taking the medication on an empty stomach, which may increase the drug's potency.
• Use children's formulations if possible and carefully read the recommendations on the label to determine the maximum dose in 24 hours. Look for the amount of acetaminophen in each product, then add them up to determine the total dose your child is receiving per day. Call your pediatrician if your child needs more than 24 hours of treatment and be sure to tell the doctor about symptoms and amounts of acetaminophen.
• Symptoms of an accidental acetaminophen overdose include nausea, vomiting, lack of appetite and abdominal pain. If some symptoms subside but abdominal pain and tenderness continue, and especially if the symptoms return after a few days, ask your doctor to check your child for signs of liver damage.

School Vaccines

Q. What kinds of vaccines should my child have and how often?

A. Every parent knows that keeping kids' immunizations up-to-date is as important a back-to-school ritual as the obligatory set of new clothes and lunch boxes. Immunizations protect children from life-threatening illnesses, like pneumonia, polio and influenza.

The childhood inoculation schedule is recommended by the American Academy of Pediatrics (AAP), in consultation with the Advisory Committee on Immunization Practices of the CDC and the American Academy of Family Physicians.

Recommendations for different age groups include:

• Preschool children: Kids ages 2 to 4 should have received four doses each of DTaP (diphtheria, tetanus and acellular pertussis), PCV (pneumococcal conjugate vaccine) and Hib (hemophilus influenza). They also should have received three doses each of IPV (inactivated polio vaccine), hepatitis B, and one dose each of the MMR (measles, mumps and rubella) and varicella (chicken pox) vaccines. The number of shots may vary depending on the combination of vaccines your health care provider uses.
• 4 to 6 year olds: Children entering kindergarten should receive any immunizations that they’ve missed or receive a booster — a supplementary dose — of DTaP, IPV and MMR. Consult your provider.
• Pre-adolescents and teens: Adolescents 11 years old and up should receive boosters of DTaP and MMR, as well as the MCV4 (meningococcal conjugate vaccine). Those who never received the varicella vaccine or who have not had the illness should also get that shot.

Early Toilet Training

Q. I've heard that toilet training is easier before age 2. True?

A. The easiest period to start toilet training is when the child is developmentally ready. Although parents may be eager to reach this milestone for the family, there is no deadline or correct age. In the United States, the majority of children are ready to start toilet training between 18 and 36 months of age. However the best time will be different for every child.

It helps for parents to be aware of the cues that suggest when a child is ready to start toilet training. According to the American Academy of Pediatrics, it's time to begin when:

• Your child can walk to the bathroom and sit down on the toilet by himself.
• Your child shows an interest in toilet training. He may follow you to the bathroom, ask about the toilet, and feel comfortable sitting on a potty chair or toilet.
• Your child acknowledges and can indicate that he needs to urinate or defecate.
• Your child is able to manipulate his clothes, that is, to pull pants and underwear down and up.

Starting toilet training too soon has several possible disadvantages. The overall toilet training may take longer - you may start earlier, but it will take a longer period of time to complete the process. Regression and accidents are also more likely. While sitting on the toilet, a younger child may be easily distracted and need more supervision.

Flu Shot Timing

Q. When should my child get the flu shot? Does she really need it?

A. Your child should get the vaccine if she's between 6 months and 2 years old. The Centers for Disease Control and Prevention (CDC) also recommend the flu shot every year for children of any age who have a chronic heart condition, a lung condition like asthma, chronic kidney disease or an immune deficiency.

The vaccine is necessary to prevent the disease and associated complications, such as severe pneumonia. The flu is a seasonal illness triggered by different strains of the influenza virus. The flu shot is made of inactivated copies of three flu virus strains that are anticipated for the coming season. Since the strains change from season to season, a different flu vaccine is offered each year.

After receiving the shot, it takes the body about two weeks to generate antibodies. Since the typical flu season in U.S. peaks between December and March, it's not too late to get a vaccination in the months in between. Next year you can plan with you pediatrician for the optimal time for the shot - from October through November.

Hepatitis A Vaccine

Q. My son's pediatrician recommends a Hepatitis A shot. Is it really necessary?

A. Yes. The Hepatitis A vaccine will protect your son's health and help prevent the virus from spreading in daycare, preschool and other settings where it's hard to completely prevent fecal-oral contact. Hepatitis A can spread before it is detected. Children are most likely to pass the virus (which only has a mild affect in the youngest kids) to others in the two weeks before any symptoms appear.

There's good reason for your child to avoid inadvertently bringing the virus home. Unvaccinated older children and adults are more likely to get seriously ill if they are infected. Symptoms such as liver damage and related jaundice (yellow color in the skin and eyes), abdominal pain and nausea can be severe enough to force family members to miss work or school. In the worst cases, the illness can last for weeks or months.

More than 100,000 Americans are infected with Hepatitis A each year. While most do not show symptoms, almost half of children ages 6 to 14, and as many as 80 percent of infected people 15 and older, suffer from jaundice as a result. Though rare, approximately 100 people infected with Hepatitis A each year develop fulminant liver failure, which can be fatal. Adults of all ages are susceptible to severe effects, and even children sometimes suffer liver failure from Hepatitis A.

To avoid infection, wash hands frequently since Hepatitis A can be transmitted via contaminated food or water. A recent outbreak in Pennsylvania began with a shipment of green onions. Outbreaks caused by improper food handling in restaurants are rare, but when they occur hundreds of people can be affected.

Such incidents will continue as long as many Americans go unvaccinated. In most regions there is not sufficient "community immunity" to prevent the disease from spreading. That's why, on Oct. 27 this year, the CDC's Advisory Committee on Immunization Practices recommended vaccinations to safeguard all U.S. children, beginning as part of the regular vaccination schedule between ages 1 and 2.

For those concerned about vaccines, the Hepatitis A vaccine has been found to be one of the safest available. The most common side effect is pain at injection site. While some parents worry about giving their children vaccines, you can rest assured that there is a high standard of safety and safety-monitoring for vaccines. Two shots of the Hepatitis A vaccine from your pediatrician will give your child an immunity that should last at least seven years, perhaps as long as 20 years.

Halloween Safety

Q. My child is going trick-or-treating for the first time this year. How can I make sure it's safe and fun?

A. Your child can enjoy the thrill of being spooked--without the danger--if you plan ahead. You'll probably accompany your child all the way, but even older trick-or-treaters need some adult supervision.

First, choose a costume that is flame resistant and comfortable. Find a mask that is easy to see and breathe through, or use non-toxic face paints, glues and glitters. Since it will be dark outside, carry flashlights and wear reflective tape on costumes and goodie bags. Choose a familiar neighborhood and start with households your child already visits often. If friends plan to be dressed up to receive trick-or-treaters, ask them to remove their masks so your child will see familiar faces at the door.

To prevent your child from eating treats before you've checked them, make it a firm rule that goodies must be saved until the end of the night. Then inspect all treats. Throw out unwrapped candies, and only keep homemade treats if they were given by someone you know. Fruit is okay if it is washed and cut open before eating. Commercially produced candy should also be safe as long as the packaging is not torn, loose or punctured. The California Poison Control Center says that poisonings due to deliberate tampering with Halloween candies are extremely rare. But a good rule of thumb is: when in doubt, throw it out.

West Nile Warning

Q. From the news, it sounds like West Nile Virus has come to the Bay Area. What can we do to protect our kids?

A. While there were more than 800 cases last year in California, we don't yet know the scope of the problem this year because infections tend to occur in the summer and early fall when mosquitoes are most prevalent. However, it is important to keep in mind that the frequency and severity of the illness increases with age, and that last year, less than 4 percent of cases were in children 18 years of age or younger. Most serious cases are in the elderly and those with underlying medical problems.

You can minimize the risk of mild or severe WNV infection. The mosquitoes, which carry WNV, tend to be most active at dawn or dusk, so avoid the outdoors at those times. You and your children can also wear mosquito repellents and/or lightweight, long sleeves and long pants to minimize insect exposure. Around your home, all stagnant water should be removed or drained (because these serve as breeding grounds for mosquitoes) and screens should be installed on any windows which are regularly opened. To get more information on repellents, prevention strategies and local resources, visit the California State Department of Public Health Web site at http://westnile.ca.gov/prevention.htm.

The Macaroni Diet

Q. My three year old only wants to eat macaroni and cheese for every meal. How can I encourage her to try other foods?

A. It's normal for a young child to go on a single-food jag like this. I recommend the Rule of 15, which is based on the idea that you might need to introduce a child to a new food 15 times before she accepts it. Make it appealing-dot peas like polka dots in the macaroni one time and circle them around the pasta the next. But don't comment if you have to throw away the peas. Hopefully, she'll try the peas one day and like them. If she doesn't, introduce another new food 15 times and come back to peas later.

The secret to promoting a lifetime of healthy eating in your child is to consistently offer a balanced diet and to avoid letting mealtimes turn into food battles. Don't push food on your child or bribe her to eat it. Although it may not seem so to anxious parents, children start out with an instinct for what they need to eat and when they're done. If you offer healthy foods consistently, including calcium-rich foods like milk or cheese plus iron-rich foods like meat or iron-fortified cereal, over time your child will learn to enjoy them. If you're still concerned about nutritional deficiencies, talk to your child's doctor about using multivitamins.

Shy Kindergartner

Q. My five year old has always been a little shy. I am worried about how he will adjust to kindergarten.

A. It's normal for a child to feel shy, especially going into a new environment. You can build your son's confidence by helping him feel familiar with kindergarten and reassuring him that you'll be there at the end of the session or day.

Before the school year starts, take him to meet his teacher, see his classroom and play in the playground. If you can contact other parents, arrange short play dates. Read to your child from a children's book about the first day of school, and learn the classroom schedule from the teacher so you can "play school," including snack and nap times, at home.

On the first day of school, bring reminders from home, such as a favorite toy or family photos. A change of clothes in his locker is another reminder that school is a safe, familiar place. Take time to show him on the clock where the little hand will point when you come to take him home.

As friends and teachers at school become familiar, he should become less shy. However, if shyness significantly affects your child's life, talk with his pediatrician about whether he would benefit from a referral to a therapist or child psychiatrist.

Allergy Testing

Q. My 4-year-old has mild allergies. Should I have him tested by an allergist?

A. Allergy testing is an effective way of identifying what your child is allergic to (dust, pets or other triggers) so that the offending substances can be removed from his environment or lessened. Decreasing his exposure to allergens will not only improve his symptoms but it can also minimize the amount of allergy medications he needs to take.

An evaluation of allergies by an allergist usually includes three steps: discussing the details of the allergies (triggers, frequency, severity); a physical examination; and allergy testing, which involves pricking the child's skin with a small device to test for different substances that might provoke his symptoms.

You should consider having your child evaluated by an allergist if his symptoms are not well controlled, if you would like to decrease the amount of medication he uses, or if you would simply like to identify those triggers that cause his allergies so they can be removed from his environment. For a referral to an allergist, talk to your child's pediatrician or family doctor.

Asthma and Activities?

Q. My 9-year-old daughter has asthma caused by allergies to grass and trees. Can she safely play the flute and sing in school?

A. The goal of treating your child's asthma is to ensure that she has no limitations in any activities. This goal can usually be achieved through a combination of three strategies: avoiding substances that she is allergic to (allergens); the use of medications; and if needed, allergen immunotherapy, i.e. allergy shots.

Your daughter should certainly participate in any activities that interest her, including sports, flute playing or singing. If, however, during these activities she feels short of breath, coughs frequently or needs to rest sooner than other children, her asthma needs to be under better control. If those problems occur, discuss the situation with her pediatrician or an allergist (see above question and answer).

For many children with asthma, symptoms worsen during certain times of the year when they are exposed to pollens or other allergens. When symptoms increase, you can help your daughter manage them by staying indoors, closing windows and turning on an air conditioner. If that doesn't work, your child may need to increase the use of asthma medications under the guidance of her doctor.

Chicken Pox Vaccine

Q. My friend's daughter has chicken pox. When I was young, the mothers in the neighborhood brought children over to play with the child who got chicken pox, so we'd all get infected early. Is that a good alternative to the vaccine?

A. No. It's better for your child to get the varicella (chicken pox) vaccine, which is about 85-percent effective in preventing moderate to severe infection. Though many people consider chicken pox a childhood "rite of passage", in the pre-vaccine era, many children developed serious complications affecting their skin, bones, joints or brains. Before the vaccine was licensed in 1995, there were also approximately 100 deaths a year from chicken pox; half of those deaths were in children. By 2002, when vaccine use had increased, deaths were less than 10 per year. Even children who don't have complications can have high fever, severe itching and trouble sleeping.

The vaccine is safe and will keep your child playing and going to school. That is why the American Academy of Pediatrics and the Centers for Disease Control and Prevention both recommend that all children 12 to 15 months of age (and any older children who have not yet had chicken pox) be vaccinated. The most common side effects are a sore arm, low-grade fever and mild rash, which typically subside on their own.

Allergy Remedies

Q. Many children with seasonal allergies are having severe symptoms this year. Can you suggest a home remedy?

A. One effective technique is a saline nasal wash. This ancient remedy clears away mucus and rinses out pollen accumulated in the nasal cavity. If your doctor has prescribed a nasal spray, using the saline wash first will allow the medicine to work more effectively. The technique takes getting used to - a toddler is not likely to tolerate it, while older children may be willing to do it once or twice a day.

Look for a nasal wash product in your drug store. Or do it yourself: Use a clean rubber bulb, such as a rubber ear syringe. Dissolve one-quarter teaspoon of salt into one-half cup (4 ounces) of lukewarm water. Fill the bulb, have your child lean forward over the sink, and gently squeeze the solution into one nostril. Some of it will flow out into the basin and some into the mouth. Ask your child to gently blow his nose, and then wash out the other nostril and blow the nose again. Be sure to regularly sanitize the suction bulb with rubbing alcohol or by placing it in boiling water.

The advice in Ask the Pediatrician is general and cannot take the place of the advice of a health care practitioner.

Send your questions to: Ask the Pediatrician, Bay Area Parent, 1660 S. Amphlett Blvd., Ste. 335, San Mateo, CA 94402. Or email bapeditor@parenthood.com. Letters will not be answered individually.