TPG Medical Advice

Nothing but Breastmilk or Formula before Four Months of Age This is a pretty firm and widely accepted rule, and unless you have been specifically advised by your Pediatrician to give your baby something else before s/he is four months old, don’t! Begin Solids between Four and Six Months of Age There have been studies showing that if you wait until your child is six months old to introduce solids s/he is less likely to develop food allergies. And then there have been studies to show that waiting may make your child more likely to have food allergies. Obviously very confusing and unclear. So – in our office we recommend that you base when to start solids on your child’s interest and readiness. Your child should be able to hold his/her head up and sit with support before beginning solids. If you have a baby between 4-6 months of age who is intent on watching and trying to grab food when you eat and who is consistently interested, then it’s time to start. If your child shows little/no interest you should wait until 6 months. Even if your child shows little interest at 6 months it’s time to begin because it sometimes takes time to get used to the texture of food and the process of eating. The General Progression –If you choose to feed using the baby-led weaning guidelines then these guidelines are irrelevant to you aside from the types of foods to introduce. Please clearly follow the guidelines outlined by the baby-led weaning movement. You will begin to feed your baby a very watery food once a day and by the time s/he is 8-9 months old you will be feeding him/her chunky and chopped table foods three times a day. You will follow your baby’s lead here. If thicker foods don’t cause gagging, move forward. If your baby loves having solids early on then offer them. Every child is different, and this path follows a basic progression but is not set in stone. You can jump from “stage 1” foods to “stage 3” foods if your child handles the thicker foods well. Think flexible. Making Your Own Food If you choose you can make your own baby food at home. You should buy organic fruits and vegetables only, steam them and put them into a food processor until you reach your desired consistency. Do not add salt, sugar, lemon juice, broth, cream, oil or anything else to the foods when starting out. There are books and online guidelines to help advise and support you with the making and storage of homemade food. Where to Start – Step One The easiest place to start is with a rice cereal. If your child is very constipated with rice cereal you may consider switching to a barley cereal. These cereals are widely available and are meant to be mixed with breastmilk or formula. They are iron fortified which is an added benefit to breastfed babies. It is a good idea to begin cereal once a day – mixed to a very watery consistency and fed to your baby on a spoon. Initially it’s a complete mess. In order to feed from a breast or bottle your baby needs to thrust his/her tongue. In order to eat off of a spoon the opposite motion is necessary. So, don’t be surprised if you put a spoonful in, and out it comes. It’s a learning curve for everyone. Step Two Once your baby has been on a cereal for a couple of weeks and seems to get the idea of eating you can introduce vegetables and peanut butter (new guidelines do show that regular early introduction of peanut products decrease the chance of developing a peanut allergy). Start with a single new food every 4-5 days so that if your child has a reaction to a food you will immediately know which food is the offending one. If you have introduced carrots, peas and green beans, and then after introducing sweet potatoes you notice a rash or vomiting, stop the sweet potatoes and discuss if/when to re-introduce them with your Pediatrician at your next visit. Step Three Fruit. We usually recommend introducing fruit after vegetables because there are some children who, once they’ve had the sweetness of fruit, are not interested in the veggies. But there is no other reason to start fruit after vegetables so if you want to you can definitely swap steps two and three. Step Four Proteins. Once you’ve made your way thru the veggies, peanut butter and fruit move on to the proteins- eggs, chicken, fish, meat. From 4-6 until 8-9 months of Age During this time you will explore the grains, peanut products, fruits, vegetables and proteins with your child. By the time your child is 8-9 months of age s/he will be eating three times a day in addition to having breastmilk or formula, in general, from 3-5 times a day. During this period it is also a good idea to introduce a sippy cup with water to your child. A straw or regular cup are fine as well. Begin with water (less messy) and if your child does well feel free to replace bottles with the cups between 9-12 months of age. No juice! Watch for sugar – the less the better. Use plain and not flavored yogurts. And try to keep any added salt to a minimum—if you are making a meal avoid the salt and then add to your portion at the table, rather than cooking with it whenever possible. 9 Months The tables have now turned and instead of a list of what you CAN give your child, it’s a short list of what you cannot introduce. The only food your child cannot have (aside from any s/he has proven to be allergic to) is honey. Keep the pieces small to avoid choking. Avoid foods that are too hard to mash– if you cannot smash the food between your fingers then your child cannot mash it between his/her gums. So no raw carrots or hot dogs. Avoid honey- raw or cooked- until 1 year of age. There is a toxin often present in honey – botulism – that the body is unable to handle before a year. Unless your Pediatrician has recommended juice as a treatment for constipation you should not give your child juice. Juice is a drink that will fill your child with empty calories and teach him/her to avoid water and milk. As your child gets older you may offer it at playdates or birthday parties, but you should always think of juice as a dessert and avoid incorporating it into your daily routine. One year of Age At this point your child will be drinking from a cup and will be eating the foods that you eat at the table. Amazingly. You can now introduce honey. Milk If your child has been on formula you can switch to whole milk—in a cup. There is no need to slowly transition to whole milk slowly unless your child doesn’t like it, in which case you can mix the formula with whole milk to allow your child to get used to the flavor. If your child is breastfed and you will continue to breastfeed you can introduce whole milk at meal times or snack times but there is no need to stop breastfeeding. If your child does not like milk or rejects it that is fine. Your child does not need to drink milk or milk products again after a year of age- calcium can be found in many foods. Allergies If you feel that your child is reacting to a certain food you should stop the food and discuss it with your Pediatrician during regular office hours, or at your next scheduled visit. If your child shows mild signs of an allergic reaction – hives or a mild rash – you should give your child a dose of diphenhydramine/Benadryl (see medication dosing page) and contact your Pediatrician. If your child has swelling of the lips or tongue or difficulty breathing you should go directly to the Emergency Room. If you can manage to quickly give a dose of diphenhydramine without slowing down in your movement to the emergency room, do so. Remember that these are mostly guidelines to help you with beginning to feed your child solids. There is a lot of flexibility and there are very few absolute rules. Beginning foods is an exciting time for all of you so try to relax and enjoy yourselves. -Monique Araya, MD, FAAP The medical information on this Web site is provided for educational purposes only. The information provided in this site, or through linkages to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call consultation or the advice of your physician or other healthcare provider. If you believe you have a medical emergency you should call 911 or your physician immediately. If you have any questions regarding your health or a medical condition, you should promptly consult your physician.

Prevention  Mint – Mint tea, peppermints. Mint is a natural anti-nausea agent. Ginger – Ginger snaps, ginger tea. (not ginger ale – it does not actually have ginger in it) Ginger is one of the best natural anti-nausea remedies available Crackers – Saltines, Club crackers – something simple and plain to calm the stomach. Watch the horizon On a boat keep eyes focused on where the sky meets the water. In a car have your child in the middle of the back row where s/he can see through the front window easily. Avoid reading in the car Seabands – Wristbands that have a plastic/metal button to put pressure on an acupressure anti-nausea pressure point on each wrist. Breath through the mouth (not nose) Queasy Pops – lollipops Cold packs to forehead and back of neck. Medications for prevention - Benadryl OR Dramamine Benadryl 30-60 minutes before departure (this may cause drowsiness) (see medication dosing page). Do not take with Dramamine. Dramamine – Do not use in children less than 2 years of age. Side effects include dizziness, drowsiness and blurred vision. Take 30-60 minutes prior to departure. Do not take with Benadryl Dramanine Tablets: Adults and children 12 years of age and over: 50 to 100 mg (1-2 tablets) every 4-6 hours Children 6-11 years of age: 25 to 50 mg (1/2 to 1 tablet) every 8-12 hours Children 2-5 years of age: 12.5 to 25 mg (1/4 – 1/2 tablet) every 8-12 hours Dramamine Liquid (12.5mg/5ml) Children 6-11 years of age: 10-15 mL (2-3 tsp) every 8-12 hours Children 2 to under 6 years of age: 5-7.5 mL (1- 1 1/2 tsp) every 8-12 hours And just in case this all fails, bring wet wipes, Ziploc bags, a change of clothes for everyone (two changes for your motion sick child), bottles of water and lots of patience. -Monique Araya, MD, FAAP The medical information on this Web site is provided for educational purposes only. The information provided in this site, or through linkages to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call consultation or the advice of your physician or other healthcare provider. If you believe you have a medical emergency you should call 911 or your physician immediately. If you have any questions regarding your health or a medical condition, you should promptly consult your physician.

First Aid Kit/Supplies  Sterile gauze – few sizes Adhesive cloth tape Non-stick wound pads Band-aids in different sizes Triple antibiotic ointment (ex: Neosporin) Ace bandage(s) Finger splints (small and large) Hydrogen Peroxide Hydrocortisone cream (0.5%-face and/or 1%-everywhere else) Calamine lotion Thermometer Alcohol wipe pads Tweezers Tylenol/Acetaminophen (see medication dosing page) Motrin/Advil/Ibuprofen (see medication dosing page) Benadryl/Diphenhydramine (see medication dosing page) If you have a highly allergic child for whom an epi or epi-jr. pen has been prescribed, keep an extra pen in your kit. Medication dosing chart First aid instruction booklet Flashlight and extra batteries Blanket Duct Tape Instant ice packs -Monique Araya, MD, FAAP The medical information on this Web site is provided for educational purposes only. The information provided in this site, or through linkages to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call consultation or the advice of your physician or other healthcare provider. If you believe you have a medical emergency you should call 911 or your physician immediately. If you have any questions regarding your health or a medical condition, you should promptly consult your physician.

Natural Cough Treatments The easiest and safest way to treat cough during a cold is to use a humidifier or vaporizer in your child’s room. Keeping the air moist soothes the throat and minimizes post-nasal drip. Steam. There is nothing better. Go into the smallest bathroom in your house, put the shower on its hottest setting, and create your own steam room. Sit in the room (not in the steamy water) with your child to help clear the secretions and calm the cough. Decongest. Nasal saline (salt water) helps to loosen and clear mucus in the nose and also helps to delay the return of the mucus. Squeeze two to three drops of the nasal saline into each nostril and then have your child blow his/her nose (use the bulb syringe to suction mucus out of the noses of smaller children/infants). In older and cooperative children you can use a saline flushing system, such as the neti pot, to clear out the nasal passages. If your child is over 12 months of age you can try to prop him/her up on a pillow for sleep. If your child is less than 12 months of age and seems to keep his/her head at one end of the crib at night you can place a phone book under each of the two front legs of the crib so that the head of the bed is higher than the foot. Like a pillow, but safer for little ones. If your child is over 12 months of age you can use a teaspoon of honey – pure raw honey on a teaspoon- as needed. It soothes the throat and in recent studies has been shown to work as well as over the counter cough suppressants at calming the cough. This is only safe in children over a year of age. DO NOT EVER GIVE HONEY OR CORN SYRUP TO A CHILD LESS THAN ONE YEAR OF AGE. There is little scientific evidence regarding the use of herbal supplements in the treatment of cough and cold, but the doses for the ones most commonly discussed are: Ecinacea – one of the following forms taken 3x/day for 7-10 days  1/2 gram dried root or herb, as tea OR 1 mL of standardized tincture extract OR 3 mL of expressed juice (succus) OR 100 mg of standardized, powdered extract containing 4% phenolics OR 1 mL of Tincture (1:5) (approx 25 drops) OR 0.25 mL of Stabilized fresh extract (approx 5 drops) Zinc – once a day 1 - 3 years: 3 mg 4 - 8 years: 5 mg 9 - 13 years: 8 mg 14 - 18 years: 11 mg 14 - 18 years: 9 mg Vitamin C – once a day Children 1 - 3 years: 15 mg Children 4 - 8 years: 25 mg Children 9 - 13 years: 45 mg Adolescent girls 14 - 18 years: 65 mg Adolescent boys 14 - 18 years: 75 mg Medications for Suppressing a Cough Caused by a Cold Every physician seems to have a different perspective regarding the use of over the counter medications. We tend to agree on a couple of points – They are unsafe to use in children under a year of age. If your child is over 5 years of age, they are safe if used as directed. There is no definitive proof that they are effective. There are a few main ingredients in most cough and cold preparations. Look for the things you need, and don’t give your child medicines they don’t need. It is usually best to stay away from combinations of fever/pain control with cough and cold medicines. If your child has a fever you want to be accurate about the dosing (see medication dosing guidelines) and you lose this accuracy with combination medications. The main goals/ingredients of cough medicines are as follows: Guaifenesin – expectorant used to help loosen and bring up mucus Dextromethorphan – cough suppressant Diphenhydramine – anti-histamine used to calm the airways and body during an allergic reaction. Causes drowsiness as a side effect in most children (beware – it causes the opposite in some) so it is in most ‘nighttime’ cough preparations to make your child drowsy. Phenylephrine – a decongestant. It has replaced pseudoephedrine in most over the counter cough and cold preparations due to misuse of pseudoephedrine by the general population Pseudoephedrine – a decongestant. Often more effective than phenylephrine. Available without a prescription but kept behind the pharmacy counter to prevent abuse. If your child is/has any of the following, contact and/or see your physician: Your child is less than 2 months old Difficulty breathing as described above Drowsy, listless Bluish discoloration around mouth or fingers Fever lasts more than 3-5 days Cough that lasts more than 2 1/2 – 3 weeks If you feel that something is just not right – remember, no one knows your child like you do! -Monique Araya, MD, FAAP The medical information on this Web site is provided for educational purposes only. The information provided in this site, or through linkages to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call consultation or the advice of your physician or other healthcare provider. If you believe you have a medical emergency you should call 911 or your physician immediately. If you have any questions regarding your health or a medical condition, you should promptly consult your physician.

Cause of Diaper Rash Both urine and stool are acidic and can cause skin breakdown, especially when you consider how sensitive a baby’s skin is. No matter how vigilant you are about changing diapers there will be times when the urine or stool sits up against your baby’s skin. Add this to the fact that there is a covering (the diaper) rubbing the stool and/or urine and holding it close to the skin, and you can see why diaper rash, at least occasionally, is inevitable. Once the skin is broken down there is the opportunity for bacteria and/or yeast to further complicate matters. -A contact rash will be red irritated skin that might have blisters and skin breakdown with raw-looking areas and possibly bleeding. If your child has diarrhea, or you have a newborn who has many liquid-y stools a day, then you should be ready to change diapers at least every 2 hours. You may want to use either a zinc based cream or an ointment (Vaseline) on the diaper area for every change as prevention. If your child has been sick recently or is on antibiotics leading to diarrhea you may want to give him/her acidophilus to minimize and shorten the duration of diarrhea. Treatment Keep the area dry and open as much as possible – leave your baby on a blanket without a diaper so that the area can air out. Let your toddler wear loose fitting cotton bottoms without diapers whenever you can. Ointment – A&D, Vaseline, Aquaphor – these are all examples of ointments that will soothe the irritated area and provide a barrier when more stool/urine arrives. Zinc based creams – Zinc helps the irritated broken skin to heal. If your child has a very irritated and raw diaper area you can mix up your own concoction using: Maalox, Zinc cream & an ointment. Take a bit of each and mix together in a container until the consistency is right for spreading on the area. Leave this container on your changing table and apply to the diaper area at every diaper change until the rash is gone. Allergies If you notice that your baby/toddler has a flare in diaper rash after certain foods it is possible that s/he is allergic to this food. Some foods are acidic (tomatoes, citrus fruit) and are more likely to produce acidic stools-- this is different from allergies. If you notice a pattern speak with your doctor about this. Yeast If your child’s diaper rash is spreading into the folds of the groin (an area that usually does not touch the urine/stool) or is raised with clear borders you may be dealing with a yeast infection. You can apply clotrimazole cream (available over the counter) 3-4 times a day, over which you should still use the zinc and ointment, to help get rid of the yeast. Bacteria If the rash becomes blister-y or oozes a clear/yellowish liquid, it is likely infected. You should contact your doctor during regular office hours to discuss the possible need for a prescription ointment. If your baby seems to have very sensitive skin you may want to use a zinc based cream or an ointment at every diaper change. This will help prevent diaper rash from starting. Remember that keeping the area dry is key to both prevention and healing. And keep in mind that murphy’s law seems to dictate that as soon as you walk out of the room and your child falls asleep s/he will poop. Which l

Pull pants down (and up) Show pride in accomplishments Tells you when s/he has a dirty diaper Has regular bowel movements – around the same times daily Can follow simple instructions Knows how to clean up toys and put them in their places Is dry for up to 2-3 hours at a time during the daytime Has words for urine and stool  Are you ready? If you are going through any big life changes: a new baby is arriving in less than a month (or just arrived), you are moving, there is an imminent separation/divorce, or you are changing caregivers – then hold off on potty training for a while. It would be ideal if potty training could happen 2-3 months away from a major life change. Can you put aside three days where you do not go out or make plans so that you can dedicate the time for potty training? If you have more than one child at home it would be ideal if two adults were available for those 3 consecutive days, or for some of the time to give you a breather. The Potty It is great when your child can use the big potty with just a seat on top so that you don’t have any clean-up, but this is not the way to start. Big toilets are scary for children and if they cannot get on and off easily and without fear you will not have success potty training. Start with a potty that is stable and low to the ground. Don’t get one that sings and lights up or it becomes a toy-- not something to sit upon to go to the bathroom. Children in the 15-24 month age range love imitating what adults do (they can jabber on your cell phone though I’m sure you didn’t walk them through the steps) and, given a potty that looks like a potty, they know what to do. The Quick and Easy Method Summed up in one word: Naked. Second important word: Outside . If possible. Outside allows you to have a relaxed attitude about accidents, which prevents the pressure and anxiety that can accompany potty training gone wrong. And outside is fun for children. The different/adventure factor. If you do not have a safe, enclosed outdoor space there are tips for indoor training below. The key to quick potty training is letting your child feel the urge to go to the bathroom and then see the natural evolution of this. The ideal is choosing warm weather days and spending those days outside. If the weather is cold and you can’t wait for it to warm up go with the indoor training and set the house thermometer at a balmy level. As soon as your child awakens in the morning go outside into the backyard without clothing on bottom- so bottom-half naked. Have a picnic breakfast and be prepared for a day of outdoor fun. Lots of water and drinks to promote lots of urine. High fiber foods (fruit, fruit, fruit) to promote soft stools. Sand play, water play, bubbles, gardening – all while bottom half naked. Be sure to sunscreen those little bottoms (& fronts). If you notice your child going to the bathroom, or making a face as if it’s coming, give him/her options: Do you want to go on the grass, in the bushes, pee on the tree (a big hit with the little boys) or on the potty? And let him/her choose. If s/he chooses the potty feel free to do a happy dance (the sillier the better…and the more likely to produce a repeat performance) or give a little reward – a sticker, a penny, or if you’d like a tiny treat (tiny – one smartie or m&m). If your child at this point is anxious offer the pull-ups you have conveniently kept hidden outside. Allow him/her to go in a pull-up by the potty and then remove the pull-up for more outdoor naked play. Have a picnic lunch outdoors. At naptime go inside, put a pull-up on your child, and take a break. When nap is over remove the pull-up and head back outside for more outdoor play, books, and a picnic dinner. Continue to encourage sitting on the potty. When the nighttime ritual time begins go inside for bath, etc, and bring the potty in, too. It’s great to get into the habit of sitting on the potty before bath and before bed. Keep a few special books in the bathroom for potty sitting time. Put on a diaper/pull up for bedtime. Begin again the next morning. Kids love being naked, and love being outside, and if your child has shown signs of readiness s/he will likely be 75% potty trained using this method in 3 days. Indoor variation- most is the same as above, only the location is different. Choose an area of your house, if possible, that has no carpeting or upholstered furniture and set this area up as your playground for a few days. This will allow you to relax about accidents and clean up with little fuss. If your child has an accident, calmly clean it up and in a fun/nice way let him/her know that maybe next time s/he can try the potty. The Three Days Are Over, Now What? After the three day training period, when you move inside, allow your child to choose his/her underwear, or to remain naked inside. And keep a pile of pull-ups in the bathroom. If your child wants to go to the bathroom & put a pull up on instead of sitting on the potty, but only wears the pull up in the bathroom and it is removed before playtime resumes, you’re really just about there. Don’t look at this as a negative – your child is aware of the need to go pee/poop, is able to hold it in while making his/her way to the bathroom, goes in an appropriate place, and can leave it behind when done! Keep the special books in the bathroom and consider a star chart for success at using the potty. There does not need to be an end reward – stickers alone often do the job perfectly! Get into the habit of having your child sit on the potty upon awakening, 10-15 minutes after meals, before nap & bedtime, and before getting into the car. Remember that naptime and bedtime dryness may not follow closely behind daytime dryness. Don’t toss out those diapers until you have weeks of dryness at naptime and/or bedtime. Side notes: You will need to help your children wipe until they are probably three or four years old. Longer for those who have soft bowel movements. Boys potty train sitting down (unless in the garden watering the bushes and trees). Flushing of bowel movements can be scary for small children. Allow them to choose if they want to flush or if they want you to do it after they leave the bathroom. Potty training done with punishment and negative/forceful energy can have long lasting negative effects on a child. Do not: Punish your child for accidents Create anger and anxiety around the potty training Force your child to use the potty – have other options as described above. If your child is not having 70+% success by the end of the third day period then you may want to stop potty training for a couple of months before you re-try. It’s possible you misread the signs of readiness initially. And if it is not working you cannot force it. Better to just give it a rest for a while and then come at it with fresh positive energy when you are all ready again. Potty training is an opportunity for your child to learn a new skill and feel proud about it. If you see it in a positive way your child will see it as a fun adventure. Celebrate the successes, overlook the mistakes. And soon you will be able to sit back and really enjoy no longer having to change those poopy diapers!

Every person’s body makes a hormone called anti-diuretic hormone (ADH) at night. This hormone helps the body concentrate urine – it pulls water out of the bladder so that the bladder does not become overly full while sleeping. This is why urine is darker – more concentrated – first thing in the morning. If the body is not making enough of the ADH then the bladder becomes very full very quickly, and if your child is a deep sleeper (most young children are) then s/he will not feel the bladder fullness and will wet a diaper, a pull-up or the bed. As your child gets older his/her body will make more ADH and will also become more sensitive to the stretching of the bladder walls – s/he will produce less urine at night and will become more aware of a full bladder so will get up and use the toilet when necessary. Remember – nighttime wetting is out of your child’s control. If you become angry or frustrated, or choose to punish your child you will only cause anxiety and upset and will not have any effect on the bedwetting itself. Imagine punishing your child for falling when learning to ride a bike – this is almost equivalent. If changing sheets and bedding is tiresome and frustrating for you then talk to your child about wearing pull-ups to bed until his/her body is ready for nighttime underwear. Or consider layering the bed: waterproof mattress pad, fitted sheet, then another waterproof mattress pad with a fitted sheet – so if the fitted sheet and mattress pad are wet in the middle of the night you simply need to pull off the top layer and have your child change PJ’s in the middle of the night – quicker and easier than having to entirely make the bed up again. When should you expect your child to stay dry through the night? Nighttime wetting is normal under five years of age. From the ages of five to six, if your child is not feeling badly about the bedwetting, it is still considered normal. Approximately 10-15% of 5-year olds wet the bed. Approximately 2-5% of 10 years old wet the bed. This is something that time alone will cure. For most children over the age of six bedwetting can be embarrassing and there are ways to try to eradicate it more quickly. Behavioral Techniques for older children who are interested in trying: Talk about any plan to prevent bedwetting before beginning it, and make sure that your child is on board. Limit fluids in the two hours prior to bedtime. Have your child go to the bathroom right before bedtime. Use a reward/star chart to congratulate your child for dry nights. Awakening: wake your child up right before you go to bed and walk with him/her to the bathroom to use the toilet. After 5-7 days try to awaken your child with your voice only – no touch. After one week begin using a bedwetting alarm (described below). Within 4-6 months of using a bedwetting alarm 70-90% of children no longer have bedwetting. After your child has been dry for at least 3-4 weeks you can stop using the alarm to see how things go. Bedwetting Alarms The way the alarms work is they have a sensor that is attached to underwear. The sensor triggers the alarm as soon as a drop of moisture comes into contact with it. Your child will need to get out of bed, turn off the alarm, go to the bathroom to finish urinating, and then will need to change any wet bedding and underwear, dry and reattach the sensor, reset the alarm and go back to sleep. It is time and labor intensive so if your child is not ready to do the work then the alarm won’t work! Medicinal Intervention Anti-diuretic hormone is available by prescription in both pill and intranasal forms. For children who have tried behavioral techniques alone without success, or for those who have a sleepover/week at camp planned and are anxious about accidents, it can provide a layer of help and reassurance. Because part of the issue in bedwetting is the lower than expected level of ADH being produced by the body, replacing it allows the body to produce less urine and helps to prevent bedwetting. If bedwetting alarms alone have not worked, using an alarm with ADH is often the next step. It can take 4-6 months before bed-wetting will cease, and if not used with an alarm the bedwetting often returns when ADH is stopped. If you think that your child may be a candidate for ADH treatment you should schedule an appointment to discuss this with your Pediatrician during regular office hours. When to see a doctor If your child has been dry at night for more than 3-6 months and then suddenly begins having nighttime wetting you should talk to your child’s Pediatrician for guidance. If your child has daytime wetting, urgency about using the bathroom, fever, pain with urination, or is using the bathroom very frequently s/he may have a urinary tract infection and testing of the urine is a good first step. Call if you feel that something is just not right – remember, no one knows your child like you do! -Monique Araya, MD, FAAP The medical information on this Web site is provided for educational purposes only. The information provided in this site, or through linkages to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call consultation or the advice of your physician or other healthcare provider. If you believe you have a medical emergency you should call 911 or your physician immediately. If you have any questions regarding your health or a medical condition, you should promptly consult your physician.

General House : Stairs- baby gates Small pieces of toys, broken/sharp toys, tools, plastic bags, balloons- Injury and Choking hazards Basement door – out of reach lock Baby walker with wheels- dangerous and should be discarded. Cleaners and dangerous liquids/powders – in high lockable cabinets Hot water heater for the house set at or below 120 degrees Farenheit. Do not keep firearms in the house. If there are firearms in the house keep them locked up and lock the bullets up separately. Toy Box should not have a heavy, hinged lid. Tables’ edges- padding. Houseplants out of reach. Try to avoid poisonous houseplants. Listing of poisonous plants: http://www.poison.org/prevent/plants.asp Television, Bookcases, Heavy items - anchored and secured. Outlets- plug protectors. Cords – out of reach. Fireplace – gate around the area to prevent burns. Drapes and blind cords out of reach- strangulation risk. Matches and lighters out of reach. Kitchen : Sharp knives in high cabinets and out of reach Chairs and step-stools away from cabinets and oven/stove Cleaning products – keep in original containers in high &/or locked cabinets Vitamins and Medicines in high locked cabinets. When cooking use back burners and keep handles of pots pointing away from access Toaster and electrical appliances- out of reach and unplugged if not in use. Outlets- plug protectors. Cords – out of reach. High chair- Working straps- between legs and around waist; Sturdy. Fire Extinguisher within easy adult reach.  Bathroom : Medications, creams, makeup in high locked cabinet. Medications in original containers with childproof caps. Hair dryer, flat iron, curling irons, electrical appliances – unplugged and out of reach when not in use. Close supervision if in use. Outlets- plug protectors. Cords – out of reach. Child locks on cabinets Doorknob cover to prevent unsupervised bathroom access to little ones. Remind family members to close the toilet seat and close the bathroom door when exiting. Non skid bath strips/mat in tub. No unsupervised bathtub time for young children. Non skid bath mats in bathroom. Bedrooms Drapes and blind cords out of reach- strangulation risk. Working smoke detector and carbon monoxide detector Outlets- plug protectors. Cords- out of reach. Child’s bedroom Drapes and blind cords out of reach- strangulation risk. Working smoke detector and carbon monoxide detector Outlets- plug protectors. Cords- out of reach. Carpet or non-skid rug beneath the crib and changing table. Changing table: Safety belt. All changing supplies in easy reach of adult. No baby powder (risk of lung injury). Never leave a baby unattended on a changing table. Crib: No broken parts or pieces. No high posts or areas on which clothing can become hooked. No plastic material in or around the crib. Slots less than 2 3/8 inches apart. All hardware for the crib is in place and secured. Not placed near a window. Mattress should be firm and flat and should fit snugly- no gaps between it and the crib. No bumpers, pillows, blankets, stuffed animals or toys in the crib. By the time a baby is 4 months old the hanging toys, decorations and crib gyms should be removed. As the baby is able to pull up the mattress should be placed at the lowest possible level (deep into the crib). Window guards on windows. Night lights- if in use should be ‘cool’, not near any bedding or drapery, and out of reach. OUTSIDE YOUR HOME Yard Remove any poisonous plants. HYPERLINK "http://www.poison.org/prevent/plants.asp" http://www.poison.org/prevent/plants.asp Playset: Soft seats for swings. Sturdy. All hardware in place and secured. Capped nuts and bolts. Energy absorbing material beneath playset- wood chips, bark, sand, rubber. Face away from sun to prevent metal surfaces from burning children- and check temperature before children use playset. Check playset regularly for loose parts and to ensure the base underneath (wood chips, etc) are deep enough and sufficient. No playing on playset with dangling drawstrings. Supervision of children on a playset. Lawn tools locked up. Power mower should stop if handle is not being held. Young children (under 12) should not handle a power mower. All stones and toys should be cleared before lawn is mowed. Mower should wear glasses/goggles and closed toe shoes. Pool Fence completely surrounding pool with a self closing and locking gate. Fence should be at least 4 feet high. Gate latch should be out of reach of small children. Keep life preservers and a phone near the pool in case of emergency. Never leave a child alone in or near a pool. Pool cover should completely cover pool with no gaps. -Monique Araya, MD, FAAP The medical information on this Web site is provided for educational purposes only. The information provided in this site, or through linkages to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call consultation or the advice of your physician or other healthcare provider. If you believe you have a medical emergency you should call 911 or your physician immediately. If you have any questions regarding your health or a medical condition, you should promptly consult your physician.

If your child is learning many languages it is possible that the initial language milestones will be delayed. This is normal, and certainly not, on its own, a reason to limit exposure to multiple languages or to be concerned. To the contrary, having many languages is an asset and helps a child master each language better. Many people believe that children should be walking at one year of age. Fifty percent of children walk at or before one year of age, fifty percent walk after one year. So if your child is not walking at one year of age it is not in any way a cause for concern.  2 Months: Smiling Cooing Looking toward noises and faces Follows movement with eyes Picks head up Pushes up with arms. 4 Months: Laughs Copies sounds Different cries for hunger, pain, tired Reaches for objects Hands to mouth Rolls from front to back Holds head steady Rolls from back to side Scoots on back Flexes hips and reaches for legs 6 Months: Recognizes close family members Makes sounds for happy or sad/upset Consonant sounds, including raspberries Tries to get things that are out of reach Transfer things from one hand to another Rolls from back to front Scoots on belly Sits with support and momentarily without support Explores objects with mouth, including Opens mouth for food Smile at self in mirror. 9 Months: Upset when caregivers are out of sight (separation anxiety) Wary of strangers. Babbles (“ma”, “da”, “ba” sounds but you can tell your friends that they’re actually calling for you) Explores cause and effect Pushes Balls Likes to watch things fall –drops things over and over. Plays peek-a-boo Immature pincer grasp (picks things up with the index finger and thumb). Points at things Gets to seated position on own Sits without support Combat crawl and/or mature crawl Pulls to stand Shakes musical toys (maracas, bells) 12 Months: Strong attachment to primary caregivers-cries when they leave Waves goodbye Shakes head for “no” Has favorite toys and people Says mama and dada- non-specific Bangs things together Finds hidden things Dumps out containers of things Drink from cup Knocks down towers of blocks Follows simple instructions Stands alone Cruises along furniture Takes steps Feeds self finger foods 18 Months: Begins pretend/imaginative play Imitation of adult activities and words Short lived temper tantrums Scribbles Points to a body part Able to say a few words Shakes head (and says) “no” Pulls off socks and shoes Tries to undress self Runs Climbs up and down stairs Shows interest in eating with utensils 24 Months: Likes being around other children Might begin to play with other children, especially older ones Asserting independence Wants to do things by him/herself Tantrums (not always so short lived!) Many words Able to put 2-3 words together in short sentences Follows simple instructions Knows names of people and body parts Follows two step instructions Plays make believe games Builds towers from blocks Kicks balls Runs and climbs Draws lines and circles. While it can help to detect big developmental delays early, give your child time to develop. You can use various activities to promote developmental growth but every child develops at a different pace and may excel in one area over another. Remember when going through the milestones that these do not take your child and your life circumstances into account. If you have any concerns then make a note of them and discuss them with your child’s pediatrician. -Monique Araya, MD, FAAP The medical information on this Web site is provided for educational purposes only. The information provided in this site, or through linkages to other sites, is not a substitute for medical or professional care, and you should not use the information in place of a visit, call consultation or the advice of your physician or other healthcare provider. If you believe you have a medical emergency you should call 911 or your physician immediately. If you have any questions regarding your health or a medical condition, you should promptly consult your physician.