A fever is a body temperature that is higher than normal. Your child's normal body temperature varies with his age, general health, activity level, the time of day and how much clothing he is wearing. Everyone's temperature tends to be lower early in the morning and higher between late afternoon and early evening. Body temperature also will be slightly higher with strenuous exercise.

Most pediatricians consider any thermometer reading above 100.4 degrees Fahrenheit (38 degrees Celsius) a sign of a fever. This number may vary depending on the method used for taking your child's temperature. If you call your pediatrician, say which method you used.

If your child has a fever, it is probably a sign that her body is fighting an infection. When your child becomes ill because of a virus or bacteria, her body may respond by increasing body temperature. It is important to remember that, except in the case of heat stroke, fever itself is not an illness — only a symptom of one. Fever itself also is not a sign that your child needs an antibiotic.

Many conditions, such as an ear infection, a common cold, the flu, a urinary tract infection or pneumonia, may cause a child to develop a fever. In some cases, medication, injury, poison or an extreme level of overactivity may produce a fever. An environment that is too hot may result in heat stroke, a potentially dangerous rise in body temperature. It is important to look for the cause of the fever.

Fevers are generally harmless and help your child fight infection. They can be considered a good sign that your child's immune system is working and the body is trying to rid itself of the infection.

If your child has a fever, her heart and breathing rates naturally will speed up. You may notice that your child feels warm. She may appear flushed or perspire more than usual. Her body also will require more fluids.

Some children feel fine when they have a fever. However, most will have symptoms of the illness that is causing the fever. Your child may have an earache, a sore throat, a rash or a stomachache. These signs can provide important clues as to the cause of your child's fever.

Source: American Academy of Pediatrics

The appendix is a narrow, finger-shaped, hollow structure attached to the large intestine. While it serves no purpose in humans, it can cause serious problems when it becomes inflamed. Because of its location, this can happen quite easily. For example, a piece of food or stool can get trapped inside, causing the appendix to swell, become infected and painfully inflamed. This inflammation, called appendicitis, is most common in youngsters over the age of six, but can occur in younger children as well. Once infected, the appendix must be removed. Otherwise it may burst, allowing the infection to spread within the abdomen.

Because this problem is potentially life-threatening, it's important to know the symptoms of appendicitis so you can call your pediatrician at the first sign of trouble. In order of appearance, the symptoms are:

• Abdominal Pain: This usually is the child's first complaint. Almost always, the pain is felt first around the umbilicus (belly button). After several hours as the infection worsens, the pain may intensify in the lower right side. Sometimes, if the appendix is not located in the usual position, the discomfort may occur elsewhere in the abdomen or in the back, or there may be urinary symptoms such as increased frequency or burning. Even when the appendix lies in its normal position and the pain is in the right lower abdomen, it also may irritate one of the muscles that leads toward the leg, causing the child to limp or walk bent over.
• Vomiting: After several hours of pain, vomiting may occur. It is important to remember that stomachache comes before the vomiting with appendicitis, not after. Abdominal pain that follows vomiting is commonly seen in viral illnesses such as the flu.
• Loss of appetite: The absence of hunger occurs shortly after the onset of the pain.
• Fever: There may be a low-grade fever (100-101 degrees Fahrenheit; 38-38.5 degrees Celsius).

Unfortunately, the symptoms associated with appendicitis sometimes may be hidden by preceding viral or bacterial infections. Diarrhea, nausea, vomiting, and fever may appear before the typical pain of appendicitis, making the diagnosis much more difficult. Also, your child's discomfort may suddenly vanish, thus persuading you that all is well. Unfortunately, this disappearance of pain also could mean that the appendix has just broken open. Although the pain may leave for several hours, this is exactly when appendicitis becomes dangerous. The infection will spread to the rest of the abdomen, causing your child to become much more ill, develop a higher fever, and require hospitalization for surgery and intravenous antibiotics. Recovery may take much longer, and there may be more complications than with appendicitis diagnosed and treated earlier.

Detecting the signs of appendicitis is not always easy. This is particularly the case in a child under the age of three, who cannot tell you where it hurts or that the pain is moving to the right side. Therefore, it's better to act sooner rather than later if you have any suspicion that your child's pain or discomfort seems "different," more severe than usual, or out of the ordinary. While most children with abdominal pain don't have appendicitis, only a physician should diagnose this serious problem.

If the abdominal pain persists for more than an hour or two, and if your child also has nausea, vomiting, loss of appetite, and fever, notify your pediatrician immediately. If the doctor is not certain the problem is appendicitis, she may decide to observe your child closely for several hours, either in or out of the hospital. During this time, she will have performed additional laboratory or X-ray examinations to see if more conclusive signs develop. If there is a strong probability that appendicitis is present, surgery usually will be done as soon as possible.

In almost all cases, the treatment of appendicitis is surgical removal of the appendix. In rare instances, the tissue covering the intestines may enclose the appendix, thus containing the infection. This makes it more difficult to remove the appendix without spreading the infection, so antibiotics may be used, either alone or combined with drainage of the infection by a small tube. Because inflammation can recur even after the initial infection is gone, the appendix usually is removed later on.

Source: American Academy of Pediatrics

Overview of Vomiting
Most vomiting is caused by gastroenteritis, a viral infection of the gastrointestinal tract. Thankfully, these infections are usually short-lived and are more disruptive than damaging. Your most important intervention may be your bedside manner - vomiting is frightening for young children and exhausting for children of all ages. Supplement the following time-tested routines with plenty of reassurance.

• Rest the stomach. This may be easier said than done with a small child, who doesn't understand what's happening and is longing for a big drink of water. Try to wait a few hours, then offer small sips of water, ice chips, or a cold, wet washcloth to suck.
• If sips of water are not tolerated, you may wish to consult your doctor about an over-the-counter nausea medication. If your doctor approves, ask about the correct dose for your child.
• If sips of water are tolerated, slowly increase the amount of liquids you give your child. Then you can try other clear liquids. Milk and milk products should be avoided.
• Introduce foods gradually. Wait for your child to say she's hungry, then start with dry toast or crackers.
• Your school-age child will probably tell you when she is ready to eat heavier food, and you can generally trust her judgment and give her what she asks for. With a younger child, stick with bland, starchy foods like potatoes and rice until you're sure she's out of the woods.

When should you call the Doctor?

The greatest risk of vomiting due to gastroenteritis is dehydration. Call your doctor if your child has diarrhea, refuses fluids, is not urinating, cries without tears, has a dry mouth, or seems confused. You should also call if vomiting persists more than two days, which increases the risk of dehydration.

The following symptoms may indicate a condition more serious than gastroenteritis and require immediate medical attention:

• projectile vomiting in an infant
• vomiting accompanied by fever
• repeated vomiting of green or yellow bile
• stomach feels hard and bloated in between vomiting episodes
• vomit resembles coffee grounds
• vomiting blood
• vomiting follows head injury
• vomiting during recovery from a viral infection

Source: American Medical Association

Understanding Anemia

Our blood contains several different types of cells. The ones we have the most of are the red blood cells. These cells absorb oxygen in the lungs and distribute it throughout the body. They contain hemoglobin, a red pigment that carries oxygen to the tissues and carries away the waste material, carbon dioxide. When there is a decreased amount of hemoglobin available in the red blood cells, making the blood less able to carry the amount of oxygen necessary for all the cells in the body to function and grow, the condition is called anemia.

Anemia may occur for any of the following reasons:

• Production of red blood cells slows down.
• Too many red blood cells are destroyed.
• Not enough hemoglobin within the red blood cells are present.

Young children most commonly become anemic when they fail to get enough iron in their diet. Iron is necessary for the production of hemoglobin. This iron deficiency causes a decrease in the amount of hemoglobin in the red blood cells. A young infant may get iron-deficiency anemia if he starts drinking cow's milk too early, particularly if he is not given an iron supplement or food with iron. The deficiency occurs because cow's milk contains very little iron and the small amount present is poorly absorbed through the intestines into the body. In addition, cow's milk given to an infant under six months of age can cause irritation of the bowel and small amounts of blood loss. This results in a decrease in the number of red blood cells, which can cause anemia.

Other nutritional deficiencies, such as lack of folic acid, can cause anemia, but this is very rare. It is probably most often seen in children fed goat's milk, which contains very little folic acid.

Anemia at any age can be caused by excessive blood loss. In rare cases, the blood does not clot properly, and a newborn infant may bleed heavily from his circumcision or minor injury, and become anemic. Because vitamin K promotes blood clotting and is often lacking in newborns, an injection of this vitamin generally is given right after birth.

Sometimes the red cells are prone to being easily destroyed. This is called hemolytic anemia, and can result from disturbances on the surface of the red cells or other abnormalities in or outside the cells. Certain enzyme deficiencies also can alter the function of the red blood cells, increasing their susceptibility to destruction.

A severe condition involving an abnormal structure of hemoglobin, seen most often in children of black African heritage, is called sickle-cell anemia. This disorder can be very severe and is associated with frequent "crises" and often repeated hospitalizations. Children with sickle-cell anemia may have unexplained fever or swelling of the hands and feet as infants, and they are extremely susceptible to infection. If there is a history of sickle-cell anemia in your family, make sure your child is tested for it.

Source: American Academy of Pediatrics

Most children should continue to eat a normal diet including formula or milk while they have mild diarrhea. Breastfeeding should continue. If your baby seems bloated or gassy after drinking cow's milk or formula, call your pediatrician to discuss a temporary change in diet. Special fluids are not usually necessary for children with mild illness.

Children with moderate diarrhea can be cared for easily at home with close supervision, special fluids, and your pediatrician's advice. Your pediatrician will recommend the amount and length of time that special fluids should be used. Later, a normal diet can be resumed. Some children are not able to tolerate cow's milk when they have diarrhea and it may be temporarily removed from the diet by your pediatrician. Breastfeeding should continue.

Special fluids have been designed to replace water and salts lost during diarrhea. These are extremely helpful for the home management of mild to moderately severe illness. Do not try to prepare these special fluids yourself. It is too easy to get confused by some of these complex recipes. You could accidentally make a bad fluid for your baby. Use a fluid that is made by one of the reputable manufacturers. The three most widely available products that you will find in nearly every pharmacy are:

• Pedialyte (Ross Laboratories)
• Infalyte (Mead Johnson Nutritionals)
• ReVital (PTS Labs)

Other brands of special fluids are available and equally effective. Many drug stores have their own generic brands of special fluids. Ask the pharmacist for assistance.

If a child is not vomiting, these fluids can be used in very generous amounts until the child starts making normal amounts of urine again.

If your child develops severe diarrhea, he may require IV fluids in the emergency department for several hours to correct dehydration. Usually hospitalization is not necessary. Immediately seek your pediatrician's advice for the appropriate care if symptoms of severe illness occur.

While this illness runs its course, here are some general do's and don'ts that you should keep in mind:

DO:

• Watch for signs of dehydration which occur when a child loses too much fluid and becomes dried out. Symptoms of dehydration include a decrease in urination, no tears when baby cries, high fever, dry mouth, weight loss, extreme thirst, listlessness, and sunken eyes.
• Keep your pediatrician informed if there is any significant change in how your child is behaving.
• Report if your child has blood in his stool.
• Report if your child develops a high fever (more than 102ºF or 39ºC).
• Continue to feed your child if she is not vomiting. You may have to give your child smaller amounts of food than normal or give your child foods that do not further upset his or her stomach.
• Use diarrhea replacement fluids that are specifically made for diarrhea if your child is thirsty.

DON'T:

• Try to make special salt and fluid combinations at home unless your pediatrician instructs you and you have the proper instruments.
• Prevent the child from eating if she is hungry.
• Use boiled milk or other salty broth and soups.
• Use "anti-diarrhea" medicines unless prescribed by your pediatrician.

Source: American Academy of Pediatrics

The flu spreads very easily, especially in preschool and school-age children. Adults are then easily exposed and can get the disease. The virus is usually transmitted just as symptoms begin or in the first several days of the illness.

The flu is spread from person to person in various ways:

• Direct hand-to-hand contact
• Indirect contact - for example if your child touches an infected surface like a toy or a doorknob and then puts her hand to her own eyes, nose, or mouth.
• By virus droplets being passed through the air for example, from coughing or sneezing.

You can take steps to reduce your families chances of catching the flu. Good hygiene is the best way to prevent the flu from spreading to other family members. If your child has the flu, the following will help prevent its spread:

• Teach your child to cover her mouth and nose when coughing or sneezing. If your child is old enough, teach her how to blow her nose properly.
• Use facial tissues for runny noses and to catch sneezes. Throw them away in the trash after each use.
• Avoid kissing your child on or around the mouth or face, though she will need plenty of hugs while she is sick.
• Make sure everyone washes their hands before and after coming in close contact with someone with the flu.
• Wash dishes and utensils in hot, soapy water or in the dishwasher.
• Do not let children share pacifiers, cups, utensils, washcloths, or towels. Never share toothbrushes.
• Use disposable paper cups in the bathroom and kitchen.
• Disinfect. Viruses can live for more than 30 minutes on doorknobs, toilet handles, countertops, even on toys. Use a disinfectant or soap and hot water to keep these areas clean.
• Do not smoke around your child. Children who are exposed to tobacco smoke cough and wheeze more and have a harder time getting over the flu.

Source: American Academy of Pediatrics

In years past, it was very common for children to have their tonsils and the adenoid taken out. Today, doctors know much more about tonsils and the adenoid and are more careful about recommending removal.

The tonsils are oval-shaped, pink masses of tissue on both sides of the throat. Tonsils can be different sizes for different children. They can be large or small. There is no "normal" size. You can usually see the tonsils by looking at the back of the mouth with a flashlight. Pressing on the tongue may help, but this makes many children gag. Instead, ask your child to open her mouth wide and say, "aaahhh." This will usually cause the tongue to flatten just enough to see the back of the throat more clearly. The uvula, a fleshy lobe that hangs down in the back of the mouth, should not be mistaken for the tonsils.  

The most common illness associated with the tonsils is tonsillitis. This is an inflammation of the tonsils usually due to infection. There are several signs of tonsillitis, including:

• Red and swollen tonsils.
• White or yellow coating over the tonsils.
• A "throaty" voice.
• Sore throat.
• Uncomfortable or painful swallowing.
• Swollen lymph nodes ("glands") in the neck.
• Fever.

The adenoid is often referred to as "adenoids." This is incorrect because the adenoid is actually a single mass of tissue. The adenoid is similar to the tonsils and is located in the very upper part of the throat, above the uvula and behind the nose. This area is called the nasopharynx. The adenoid can be seen only with special mirrors or instruments passed through the nose.

It is not always easy to tell when your child's adenoid is enlarged. Some children are born with a larger adenoid. Others may have temporary enlargement of their adenoid due to colds or other infections. This is especially common among young children. Constant swelling or enlargement can cause other health problems such as ear and sinus infections. Some signs of adenoid enlargement are:

• Breathing through the mouth instead of the nose most of the time.
• Nose sounds "blocked" when the child talks.
• Noisy breathing during the day.
• Snoring at night.

Both the tonsils and the adenoid may be enlarged if your child has the above symptoms along with any of the following:

• Breathing stops for a short period of time at night during snoring or loud breathing ( this is called "sleep apnea").
• Choking or gasping during sleep.
• Difficulty swallowing, especially solid foods.
• A constant "throaty voice," even when there is no tonsillitis.

Both the tonsils and the adenoid are part of your body's defense against infections. Since similar tissues in other parts of the body do the same job, removal of the tonsils or the adenoid does not harm the body's ability to fight infection.

Source: American Academy of Pediatrics

Croup is an inflammation of the voice box (larynx) and windpipe (trachea). When a child has croup, the airway just below the vocal cords becomes swollen and narrow. This makes breathing noisy and difficult.

Some children get croup often, such as whenever they have a respiratory illness. Children are most likely to get croup between 6 months and 3 years of age. After age 3, it is not as common because the windpipe is larger, so swelling is less likely to get in the way of breathing. Croup can occur at any time of the year, but it is more common between October and March.

There are two different types of croup:

• Spasmodic croup is usually caused by a mild upper respiratory infection or allergy. It is often frightening because it comes on suddenly in the middle of the night. Your child may go to bed with a mild cold and wake up in a few hours, gasping for breath. He will also be hoarse and have a cough that sounds like a seal barking. Most children with spasmodic croup do not have a fever. This type of croup can reoccur.
• Viral croup results from a viral infection in the voice box and windpipe. This kind of croup often starts with a cold that slowly develops into a barking cough. As your child's airway swells and she secretes more fluid, it becomes harder for her to breathe. Her breathing will also get noisier, and it may make a coarse musical sound each time she breathes in. This condition is called stridor. Most children with viral croup have a low fever, but some have temperatures up to 104°F.

As your child's effort to breathe increases, he may stop eating and drinking. He also may become too tired to cough, although you will hear the stridor more with each breath. The danger with croup accompanied by stridor is that the airway will keep swelling. If this happens, it may reach a point where your child cannot breathe at all.

Stridor is common with mild croup, especially when a child is crying or moving actively. But if a child has stridor while resting, it can be a sign of severe croup.

Treating Croup

If your child wakes up in the middle of the night with croup, take her into the bathroom. Close the door and turn the shower on the hottest setting to let the bathroom steam up. Sit in the steamy bathroom with your child. Within 15 to 20 minutes, the warm, moist air should help her breathing. (She will still have the barking cough, though.)

For the rest of that night and 2 to 3 nights after, try to use a cold-water vaporizer or humidifier in your child's room. Sometimes another attack of croup will occur the same night or the next. If it does, repeat the steam treatment in the bathroom. Steam almost always works. If it does not, take your child outdoors for a few minutes. Inhaling moist, cool night air may loosen up the air passages so that he can breathe more freely. If that does not help, consult your pediatrician about other options. If your child's breathing becomes a serious struggle, call for emergency medical services. (In most areas, dial 911.)

Never try to open your child's airway with your finger. Breathing is being blocked by swollen tissue out of your reach, so you cannot clear it away. Besides, putting your finger in your child's throat will only upset her. This can make her breathing even more difficult. For the same reasons, do not force your child to throw up. If she does happen to vomit, hold her head down and then quickly sit her back up once she is finished.

Your pediatrician will ask if your child's breathing is better after the steam treatment. If it is not, your pediatrician may prescribe a steroid medication to reduce swelling in the throat or shorten the illness. Although it has not been firmly proven that this works, treatment with a steroid for 5 days or less should do no harm.

Antibiotics, which treat bacteria, are not helpful for croup because the problem is almost always caused by a virus or allergy. Cough syrups are of little use too, because they do not affect the larynx or trachea, where the infection is located. These also may get in the way of your child coughing up the mucus from the infection.

If you suspect your child has croup, call your pediatrician—even if it is the middle of the night. Also, listen closely to your child's breathing. Call for emergency medical services immediately if he:

• makes a whistling sound that gets louder with each breath.
• cannot speak for lack of breath.
• seems to be struggling to get a breath.
• seems very pale or has a bluish mouth or fingernails.
• has stridor when resting.
• drools or has extreme difficulty swallowing saliva.

In the most serious cases, your child will not be getting enough oxygen into her blood. If this happens, she may need to go into the hospital. There she may be put in a plastic tent, called a croup tent, to receive oxygen. She may also be fed through a vein and take medication by inhaling it. Sometimes a tube is inserted through the nose or mouth into the windpipe to bypass the swelling in the larynx and trachea. Your child may be hoarse for a while after the tube is removed, but this usually does not last. Luckily, these severe cases of croup do not occur very often.

Source: American Academy of Pediatrics

In children over 1 year of age, type A influenza can be treated with antiviral agents if given in the first day or two of the illness. This can speed recovery. Under some circumstances, antiviral agents can be taken before exposure to the flu and can prevent illness. This is particularly important for children with other health problems who have not been immunized. Antibiotics can be used to fight bacterial infections but have no effect on viruses, including the influenza viruses. Extra bed rest, extra fluids, and light, easy-to-digest meals can also help your child feel better.

If your child is uncomfortable because of fever, acetaminophen or ibuprofen in proper doses for age and weight will help him feel better. Ibuprofen is approved for use in children 6 months of age and older; however, it should never be given to children who are dehydrated or who are vomiting continuously.

Do not give aspirin to your child for the flu. An increased risk of developing Reye's syndrome (an illness that can seriously affect the liver and the brain) is associated with aspirin use during bouts of the flu and many other diseases caused by viruses.

Do not give your child over-the-counter cough or cold medicines without checking with your pediatrician.

An older child with the flu usually does not need to see the pediatrician unless the condition becomes more serious. If your child is 3 months of age or younger, however, call your pediatrician if she has a fever. For a child older than 3 months of age who has been exposed to the flu, call your pediatrician if your child experiences any of the following:

• Difficulty breathing
• Blue lips or nails
• A cough that just will not go away (for more than 1 week)
• Pain in the ear
• Persistent or new onset of fever after 3-4 days of illness

Your pediatrician may want to see your child or ask you to watch your child closely and report back if he does not improve each day.

There are safe and effective vaccines to protect against the flu. However, they are mainly recommended for children with health problems that make it risky for them to get the flu. This includes children with the following:

• Heart disease
• Lung disease, including asthma
• Immune problems, including HIV infection
• Blood diseases
• Cancer
• Diabetes
• Chronic renal and metabolic diseases
• Long-term aspirin therapy such as with rheumatoid arthritis

Children 6 months or older with these health problems should get a flu shot each fall, as should everyone in their household.

For children under 9 years of age, the vaccine requires two injections, given 1 month apart the first year it is given. After that, only one dose is needed. The best time to get the flu vaccine is in late October to early November — before the flu season starts — but vaccination should begin earlier for those needing two shots.

Since the strains of flu are different every year, a new flu vaccine is developed each year as well. The vaccine is made from killed flu viruses and helps the immune system fight the flu. Most children are immune within 2 weeks of getting the vaccine. Side effects are almost always minor and include soreness at the site of the injection and a low-grade fever.

Scientists are working on the development of a nasal spray flu vaccine. This will be a painless and effective way to protect children from the flu.

Important note: Even though there are few side effects to the vaccine, production of the vaccine involves the use of eggs. If your child has had a serious allergic reaction to eggs or egg products, he should be skin tested before getting the vaccine. If skin testing confirms hypersensitivity, the vaccine usually should not be given.

Source: American Academy of Pediatrics

Viral and Bacterial Sore Throats

The terms sore throat, strep throat, and tonsillitis are often used interchangeably, but they don't necessarily mean the same thing.

Tonsillitis refers to tonsils that are inflamed. When your child has a sore throat or strep throat, the tonsils may be inflamed or the inflammation may affect the surrounding part of the throat but not the tonsils. Infectious mononucleosis also can produce a sore throat, often with marked tonsillitis.

In infants, toddlers, and preschoolers, the most frequent cause of sore throats is a viral infection. No specific treatment is required when a virus is responsible, and your child should get better over a three- to five-day period. Often, children who have sore throats due to viruses also have a cold at the same time. They may develop a mild fever, too, but they generally aren't very sick.

One particular virus (called Coxsackie), seen most often during the summer and fall, may cause the child to have a somewhat higher fever, more difficulty swallowing, and a sicker overall feeling. If your child has a Coxsackie infection, she also may have one or more blisters in her throat, which your pediatrician will look for during the examination.

Strep throat is caused by a bacterium called Streptococcus pyogenes. To some extent, the symptoms of strep throat may depend on the child's age. Infants may have only a low fever and a thickened, bloody nasal discharge. Toddlers (ages one to three) also may have a thickened, bloody nasal discharge with a fever. Such children are usually quite cranky and have no appetite and often swollen glands in the neck. Children over three years of age with strep are often more ill; they may have an extremely painful throat, fever over 102 degrees Fahrenheit (38.9 degrees Celsius), swollen glands in the neck, and pus on the tonsils. It's important to be able to distinguish a strep throat from a viral sore throat because strep infections must be treated with antibiotics.

Any time your child has a sore throat that persists (one that doesn't go away after her first drink of juice in the morning), whether or not it is accompanied by fever, headache, stomachache, or extreme fatigue, you should call your pediatrician. That call should be made even more urgently if your child seems extremely ill, or if he has difficulty breathing or extreme trouble swallowing (causing him to drool). This may indicate a more serious infection.

The pediatrician will examine your child and may perform a throat culture to determine the nature of the infection. To do this, he will touch the back of your child's throat and tonsils with a cotton-tipped applicator and then smear the tip onto a special culture dish that allows the strep bacteria to grow if they are present. The culture dish usually is examined 24 hours later for the presence of the bacteria.

Most pediatric offices now are doing quick-result strep tests that provide findings within minutes. However, when these tests are negative, their results still need to be confirmed with a 24-hour culture. If the result of the culture is still negative, the infection usually is presumed to be due to a virus. In that case, antibiotics will not help and should not be prescribed.

If your child's strep test is positive, your pediatrician will prescribe an antibiotic to be taken by mouth or by injection. If your child is given the oral medication, it's very important that she take it for the full 10-day course, as prescribed, even if the symptoms get better or go away.

If your child's strep throat is not treated with antibiotics or if she doesn't complete the treatment, the infection may worsen or spread to other parts of her body, causing more serious problems such as ear and sinus infections. If left untreated, a strep infection also can lead to rheumatic fever, a disease that affects the joints and the heart.

Source: American Academy of Pediatrics

Anemia causes a mild paleness of the skin, usually most apparent as a decreased pinkness of the lips, the lining of the eyelids (conjunctiva) and the nail beds (pink part of the nails). Anemic children may be irritable, mildly weak or tire easily. Those with severe anemia may have shortness of breath, rapid heart rate, and swelling of the hands and feet. If the anemia continues, it may interfere with normal growth. A newborn with hemolytic anemia may become jaundiced (turn yellow), although many newborns are mildly jaundiced and don't become anemic. If your child shows any of these symptoms, or if you suspect he is not getting enough iron in his diet, consult your pediatrician. A simple blood count can diagnose anemia in most cases.

Some children are not anemic but still are deficient in iron. These youngsters may have decreased appetite, be irritable, fussy and inattentive, which may result in delays in their development or poor school performance. These problems will reverse when the children are given iron. Other signs of iron deficiency that may be unrelated to anemia include a tendency to eat weird things, such as ice, dirt, clay and cornstarch. This behavior is called pica. It is not harmful unless the material eaten is toxic (such as lead). Usually the behavior improves after the anemia is treated and as the child becomes older, although it may persist longer in children who are developmentally delayed.

Because there are so many different types of anemia, it is very important to identify the cause before any treatment is begun. Do not attempt to treat your child with vitamins, iron, or other nutrients or over-the-counter medications unless it is at your physician's direction. This is important because such treatment may mask the real reason for the problem and thus delay the diagnosis.

If the anemia is due to lack of iron, your child will be given an iron-containing medication. This comes in a drop form for infants, and liquid or tablet forms for older children. Your pediatrician will determine how long your child should take the iron by checking his blood at regular intervals. Do not stop giving the medication until the physician tells you it is no longer needed.

Following are a few tips concerning iron medication:

• It is best not to give iron with milk because milk blocks the absorption.
• Vitamin C increases iron absorption, so you might want to follow the dose of iron with a glass of orange juice.
• Since liquid iron tends to turn the teeth a grayish-black color, have your child swallow it rapidly and then rinse his mouth with water. You may want to brush your child's teeth after every dose of iron. Although tooth-staining by iron is unattractive, it is not permanent.
• Iron medications cause the stools to become a dark black color. Don't be worried by this change.
• Safety precautions: Iron medications are extremely poisonous if taken in excessive amounts. (Iron is one of the most common causes of poisoning in children under age 5.) Keep this and all medication out of reach of small children.

Iron-deficiency anemia and other nutritional anemias can be prevented easily by making sure your child is eating a well-balanced diet and by following these precautions:

• Do not give your infant cow's milk until he is older than 1 year old.
• If your child is breastfed, give him iron-fortified foods such as cereal when solid foods are introduced. Before then, he will absorb enough iron from breast milk. If you choose to solely breastfeed beyond four months, an iron supplement is recommended. However, the introduction of iron-poor solid foods will decrease the amount of iron your baby absorbs from the milk.
• If your baby is formula-fed, give him formula with added iron.
• Make sure your older child has a well-balanced diet and eats foods that contain iron. Many grains and cereals are iron-fortified (check labels to be sure). Other good sources of iron include egg yolks, green and yellow vegetables, yellow fruits, red meat, potatoes, tomatoes, molasses and raisins. Also, to increase the iron content of your entire family's diet, use the fruit pulp in juices and cook potatoes with the skins on.

Source: American Academy of Pediatrics

Chickenpox is one of the most common childhood diseases. It is usually mild and not life-threatening to healthy children. Anyone can get chickenpox at any age, but it occurs most frequently in children from ages 6 to 10.

The most obvious sign of chickenpox is a skin rash that develops on your child's scalp and body, then spreads to his face, arms, and legs over a period of 3 to 4 days. The rash forms between 250 to 500 itchy blisters that dry up into scabs 2 to 4 days later. School-age children often get a mild fever for 1 or 2 days before the rash appears. Other symptoms of chickenpox are:

• coughing
• fussiness
• loss of appetite
• headaches

Chickenpox can easily be spread in any of the following ways:

• by direct contact with an infected person, usually through fluid from broken blisters
• through the air when an infected person coughs or sneezes
• through direct contact with lesions (sores) from a person with shingles

A person with chickenpox is contagious from 1 to 2 days before the rash starts and for up to 5 days after the rash appears. Your child will have to stay home from child care or school until she is no longer contagious. An adult or child who has never had chickenpox is at risk of getting it and may not show symptoms for 10 to 21 days after being exposed to the virus. Within households, 80% to 90% of at-risk persons will develop chickenpox if they are exposed to a family member who has it.

Once someone has had chickenpox, the virus stays in the body of the infected person permanently. Later in life, the virus can reappear and cause shingles. Shingles can occur at any age, but usually occur after a person is 50 years old. About 10% to 20% of all people who have had chickenpox develop shingles. People with shingles typically feel numbness and itching or severe pain in the skin areas where the affected nerve roots are. Within 3 to 4 days, clusters of blister-like sores develop and last for 2 to 3 weeks.

Chickenpox can occur at any time of the year, but the peak times are in the winter and early spring, especially in moderate climates. Before the vaccine became available, there were about 4 million cases of chickenpox in the United States each year.

Treating Chickenpox
You may remember how itchy chickenpox was when you were a child. If your child scratches the blisters before they are able to heal, they can become infected, turn into small sores, and possibly leave scars. Discourage your child from scratching and keep his fingernails trimmed short just in case.

Oatmeal baths can help relieve itching and acetaminophen may help reduce your child's fever. Acetaminophen is a substitute for aspirin. Do not give your child aspirin or salicylate (a compound found in aspirin). They have been associated with Reye's syndrome, a disease that affects the liver and brain. If your child's fever lasts longer than 4 days, rises above 102° F after the third day of having chickenpox, or your child becomes dehydrated, call your pediatrician. Also let your pediatrician know if the rash gets very red, warm, or tender. It may mean your child has an infection and needs other treatment.

The drug acyclovir can help make a case of chickenpox less severe. Acyclovir is most often used for patients who are at risk of developing severe chickenpox, such as adolescents; children with certain skin or lung diseases; and children taking other prescribed medications, such as steroids. To be effective, acyclovir must be given within the first 24 hours of the onset of the chickenpox rash. You may want to discuss the use of acyclovir with your pediatrician.

Most healthy children who get chickenpox won't have any complications from the disease. However, each year in the United States, about 9,000 people are hospitalized for chickenpox and about 90 people die from the disease.

The most common complication from chickenpox is a bacterial infection of the skin. The next most common problems are pneumonia and encephalitis, an infection of the brain. The following groups of people are at higher risk of developing these problems:

• people who have weak immune systems or low resistance to disease
• infants under 1 year of age
• adolescents and adults
• newborns whose mothers had chickenpox around the time of delivery
• premature infants whose mothers have not had chickenpox
• children with eczema and other skin conditions
• children receiving therapy with salicylate (a compound found in aspirin)

When an adult gets chickenpox, the disease is usually more severe, often developing into pneumonia. Adults are almost 10 times more likely to be hospitalized for chickenpox than children under 14 years of age, and adults are more than 20 times more likely to die from the disease. If a pregnant woman gets chickenpox, her unborn baby may have complications.

Source: American Academy of Pediatrics

Diarrhea is the passage of watery stools. Diarrhea is caused by one of several diarrhea-causing viruses and usually gets better by itself within a week.

A child with viral diarrhea has a fever and often starts the illness with some vomiting. Shortly after these symptoms appear, the child develops diarrhea. Often children with viral diarrhea "feel bad," but do not act ill.

You should call your pediatrician if your child is less than 6 months of age or has any of the following:

• Blood in stool
• Frequent vomiting
• Abdominal pain
• Urinates less frequently (wets fewer than six diapers per day)
• No tears when crying
• Loss of appetite for liquids
• High fever
• Frequent diarrhea
• Dry, sticky mouth
• Weight loss
• Extreme thirst

It is not necessary to call your pediatrician if your child continues to look well even though there may be:

• Frequent or large stools
• Lots of intestinal gas
• Green or yellow stools

Most of the time mild diarrhea lasts from three to six days. Occasionally a child will have loose stools for several days longer. As long as the child acts well and is taking adequate fluids and food, loose stools are not a great concern.

Source: American Academy of Pediatrics

What is it?

Conjunctivitis, commonly known as "pinkeye," is an irritation of the conjunctiva. The conjunctiva is the moist, delicate membrane that lines the inside of the eyelids and covers the whites of the eyes. Conjunctivitis can be caused by a bacterial or viral infection, or it can be the result of an allergic reaction or chemical irritation of the eye.

In newborns, conjunctivitis that develops in the first two days of life can be caused by irritation from silver nitrate eyedrops. This irritation is not an eye infection - silver nitrate eyedrops are given at birth to prevent eye infections. Silver nitrate conjunctivitis usually begins within six hours to 12 hours after birth and resolves within two days.

Silver nitrate eyedrops are used in newborn babies because of possible exposure to bacteria during birth. Bacteria from the mother's vagina may pass into the infant's eyes during birth and cause bacterial conjunctivitis. In this case, the most common are the sexually transmitted bacteria Chlamydia trachomatis and Neisseria gonorrhoeae (the bacteria that cause gonorrhea). Both of these bacteria can cause symptoms of conjunctivitis in infants within the first two weeks of life, and both can cause serious eye damage. Herpes simplex virus from a mother's vagina can also pass to an infant during delivery. Besides causing viral conjunctivitis, herpes simplex virus can cause serious complications, including encephalitis (inflammation of the brain).

Many types of chemicals can irritate the conjunctiva and cause conjunctivitis. Spray perfumes, deodorants, household cleaners, smog, and industrial pollutants are some of the causes of chemical conjunctivitis.

Conjunctivitis can also be an allergic reaction. Allergic conjunctivitis can be due to something in the air, such as pollen or dust; something put into the eye, such as contact lens solutions; or something that a child has touched and then accidentally transferred to the eye.

Many types of bacteria and viruses can cause conjunctivitis in children. The most common bacterial cause of conjunctivitis is Haemophilus influenzae. Bacteria can pass from person to person through contact with infected body fluids and can also spread on a child's hands if she rubs or wipes her infected eyes.

Viral conjunctivitis can be caused by a number of different viruses, and it usually spreads through contact with contaminated tears or nasal fluids. Viral conjunctivitis can also be part of a broader group of symptoms when a child has one of the viral childhood infections, such as measles.

What are the symptoms?

All types of conjunctivitis cause redness of the eye (a "bloodshot" appearance), usually with itchiness or irritation.

In allergic conjunctivitis, the conjunctiva usually appears swollen and red. The eyes are also very watery, and itching is usually severe. In chemical conjunctivitis, depending on the chemical irritant, there can be severe eye irritation and pain.

In bacterial conjunctivitis, in addition to redness and itching of the eyes, there is usually a thick, sticky, yellowish discharge. The discharge may accumulate into crusts on the child's eyelids and may make the eyelids stick together after the child has been sleeping. In viral conjunctivitis, the eye discharge is usually clear and watery.

How is it treated?

Doctors can often determine the type of conjunctivitis by taking a careful history of when and how the child's eye symptoms began and by examining the child's eyes to look for specific signs, such as swelling or discharge.

Some cases of chemical conjunctivitis can be medical emergencies that require immediate action to prevent eye damage. If a chemical has gotten into your child's eye, flush the eye gently with cool, running water for at least 15 minutes. After covering the injured eye with a clean pad, take the child to the nearest hospital emergency department immediately. For some chemicals, flushing the eye alone may be sufficient to prevent eye damage, but it is important to follow up with your doctor.

If your child has allergic conjunctivitis, your doctor may treat her irritated eyes with decongestants or with eyedrops containing antihistamines. Cold compresses may also help relieve irritation. In some cases, your child may need to be referred to an ophthalmologist (eye doctor), who may prescribe stronger eye medications.

Bacterial conjunctivitis is treated with antibiotics, usually given as either eyedrops or as an ointment. With certain types of bacteria, oral antibiotics may be given. If you are caring for a child with bacterial conjunctivitis, it is important to give these medications for as many days as your doctor has prescribed, even if eye symptoms clear several days before the end of the treatment. This will prevent your child's conjunctivitis from coming back. If your child's eyelids are very sticky with yellowish discharge, you can use a clean cotton ball soaked in warm water to gently wipe the eyelids. Ask your doctor when your child can return to school.

Viral conjunctivitis cannot be treated with antibiotics effectively, but it usually clears on its own after a few days. As with bacterial conjunctivitis, viral conjunctivitis is contagious, so follow your doctor's advice about when your child can return to school.

How long does it last?

How long chemical conjunctivitis will last depends on the particular chemical irritant causing the problem and how it is treated. Simply flushing out the irritant with water can treat some types of chemical conjunctivitis; other types can cause severe or permanent eye damage.

Allergic conjunctivitis can sometimes be cured simply by eliminating exposure to the allergen. For example, reactions to a contact lens solution might be avoided by switching to a brand that doesn't include the irritating chemical. On the other hand, allergic conjunctivitis caused by seasonal allergies to pollen can last a whole season and return every year.

Bacterial conjunctivitis clears after a few days of antibiotic treatment, and there is rarely any permanent damage to the eye. (Eye infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae need immediate medical attention to prevent permanent eye problems.) Viral conjunctivitis usually goes away on its own in a few days without further problems.

How can conjunctivitis be prevented?

Since there are multiple causes of conjunctivitis, there is no single way to prevent it. You can help prevent chemical conjunctivitis by keeping all chemicals, including perfumes and deodorants, safely out of your young child's reach. If your older child is working with chemicals at home or at school, make sure that she wears safety goggles to protect her eyes.

If your child has seasonal allergies, ask your doctor about ways to manage her symptoms. If your child's symptoms are severe, your doctor may suggest that your child be treated by an allergy specialist or an ophthalmologist.

To help prevent bacterial and viral conjunctivitis, remind your child to wash her hands frequently, especially if her school has an outbreak of "pinkeye." To prevent conjunctivitis from spreading among family members, make sure that an infected child never shares washcloths, towels, or pillowcases with anyone else. Wash these items well in hot water and detergent after your child uses them.

Conjunctivitis that occurs as part of other childhood viruses, especially measles, can be prevented by immunizing your child against these illnesses.

Pregnant women should ask their obstetricians to check that they have no active sexually transmitted diseases that might infect their infants, either before birth or during delivery.

When should the doctor be called?

Chemical conjunctivitis may be a medical emergency, depending on the chemical involved. If your child has gotten a chemical in her eyes, flush the area gently with cool, running water for at least 15 minutes. Then call your doctor or, if the irritation looks severe, take your child to the nearest hospital emergency department. Since most products containing dangerous chemicals are required to have emergency first-aid instructions on their labels, check the product's package for first-aid information, or call your local poison control center.

For other forms of conjunctivitis, call your doctor if your child has any of the following symptoms: eyes that are unusually red, itchy, or watery; eyes that look puffy or swollen; a thick, sticky, yellowish discharge from the eyes; or eyelids that look crusty or stick together when your child awakens.

Source: American Academy of Pediatrics

Ear Infections and Your Child

Next to the common cold, an ear infection is the most common childhood illness. In fact, most children have at least one ear infection by the time they are 3 years old. Most of the time, ear infections clear up without causing any lasting problems.

In order to understand how ear infections occur, it’s helpful to know how our ears work. The ear has three parts — the outer ear, middle ear and inner ear. A small tube (eustachian tube) connects the middle ear to the back of the nose. When a child has a cold, nose or throat infection, or allergy, the eustachian tube can become blocked, causing a buildup of fluid in the middle ear. If bacteria or a virus infects this fluid, it can cause swelling and pain in the ear. This type of ear infection is called acute otitis media.

Often after the symptoms of acute otitis media clear up, fluid remains in the ear. Acute otitis media then develops into another kind of ear problem called otitis media with effusion (middle ear fluid). This condition is harder to detect than acute otitis media because except for the fluid and usually some mild hearing loss, there are often no other noticeable symptoms. This fluid may last several months and, in most cases, disappears on its own. Hearing then returns to normal.

Your child may have many symptoms during an ear infection. Talk with your pediatrician about the best way to treat your child’s symptoms.

• Pain. The most common symptom of an ear infection is pain. Older children can tell you that their ears hurt. Younger children may only seem irritable and cry. You may notice this more during feedings because sucking and swallowing may cause painful pressure changes in the middle ear.
• Loss of appetite. Your child may have less of an appetite because of the ear pain.
• Trouble sleeping. Your child may have trouble sleeping because of the ear pain.
• Fever. Your child may have a temperature ranging from 100°F (normal) to 104°F.
• Ear drainage. You might notice yellow or white fluid, possibly blood-tinged, draining from your child’s ear. The fluid may have a foul odor and will look different from normal earwax (which is orange-yellow or reddish-brown). Pain and pressure often decrease after this drainage begins, but this doesn’t always mean that the infection is going away. If this happens it’s not an emergency, but your child will need to see your pediatrician.
• Trouble hearing. During and after an ear infection, your child may have trouble hearing for several weeks. This occurs because the fluid behind the eardrum gets in the way of sound transmission. This is usually temporary and clears up after the fluid from the middle ear drains away.

Source: American Academy of Pediatrics

Middle Ear Fluid and Your Child

The middle ear is the space, usually filled with air, behind the eardrum. When a child has middle ear fluid (otitis media with effusion), it means that a watery or mucous-like fluid has collected in the middle ear. Otitis media means middle ear inflammation, and effusion means fluid.

Middle ear fluid is not the same as an ear infection. An ear infection occurs when middle ear fluid is infected with viruses, bacteria or both, often during a cold. Children with middle ear fluid have no signs or symptoms of infection. Most children don’t have fever or severe pain, but may have mild discomfort or trouble hearing. About 90 percent of children get middle ear fluid at some time before age 5.

There is no one cause for middle ear fluid. Often your pediatrician may not know the cause. Middle ear fluid could be caused by:

• A past ear infection
• A cold or flu
• Blockage of the eustachian tube (a small tube that connects the middle ear to the back of the nose)

You can help your pediatrician find the cause of your child’s middle ear fluid. Just write down your child’s name, pediatrician’s name and number, date and type of ear problem or infection, treatment, and results. These clues and can lead to a cause of the fluid.

Many healthy children with middle ear fluid have little or no problems. They often get better on their own. Often middle ear fluid is found at a regular checkup. Ear discomfort, if present, is usually mild. Your child may be irritable, rub his ears or have trouble sleeping. Other symptoms include hearing loss, changes in behavior, loss of balance, clumsiness and repeated ear infections. You may notice your child sitting closer to the TV or turning the sound up louder than usual. Sometimes it may seem like your child isn’t paying attention to you.

Some children with middle ear fluid are at risk for delays in speaking or may have problems with learning or schoolwork. Children at risk may include those with:

• Permanent hearing loss not caused by middle ear fluid
• Speech and language delays or disorders
• Developmental delay of social and communication skills disorders (for example, autism-spectrum disorders)
• Syndromes that affect cognitive, speech and language delays (for example, Down syndrome)
• Craniofacial disorders that affect cognitive, speech and language delays (for example, cleft palate)
• Blindness or visual loss that can’t be corrected

If your child is at risk and has ongoing middle ear fluid, her hearing, speech and language should be checked out right away.

Some risk factors for ear infections and middle ear fluid can be avoided, some can’t. Studies have found that children who live with smokers, attend group child care, or use pacifiers have more ear infections. Because some children who have middle ear infections later get middle ear fluid, you may want to:

• Keep your child away from tobacco smoke.
• Keep your child away from children who are sick.
• Throw away pacifiers or limit to daytime use (if your child is older than 1 year).

Since there are limited symptoms associated with middle ear fluid, there are two tests that can determine whether fluid exists: a pneumatic otoscope and tympanometry.

A pneumatic otoscope is the best test for middle ear fluid. With this tool, the pediatrician looks at the eardrum. Tympanometry is another test for middle ear fluid. Tympanometry shows how well the eardrum moves. An eardrum with fluid behind it doesn’t move as well as a normal eardrum. Your child must sit still for both tests; the tests are painless. Because these tests don’t check hearing level, a hearing test may be given, if needed. Hearing tests measure how well your child hears. Although hearing tests don’t test for middle ear fluid, they can measure if the fluid is affecting your child’s hearing level. The type of hearing test given depends on your child’s age and ability to listen.

Source: American Academy of Pediatrics

Regular checkups at your pediatrician's office or local health clinic are an important way to keep children healthy.

By making sure that your child gets immunized on time, you can provide the best available defense against many dangerous childhood diseases. Immunizations protect children against:

• hepatitis B
• polio
• measles
• mumps
• rubella (German measles)
• pertussis (whooping cough)
• diphtheria
• tetanus (lockjaw)
• Haemophilus influenzae
• type B
• chickenpox.

All of these immunizations need to be given before children are 2 years old in order for them to be protected during their most vulnerable period. Are your child's immunizations up-to-date?

Remember to keep track of your child's immunizations -- it's the only way you can be sure your child is up-to-date. Also, check with your pediatrician or health clinic at each visit to find out if your child needs any booster shots or if any new vaccines have been recommended since this schedule was prepared.

If you don't have a pediatrician, call your local health department. Public health clinics usually have supplies of vaccine and may give shots free.

Source: American Academy of Pediatrics

It's important to know that there is no true cure for acne. If untreated, it can last for many years, although acne usually clears up as you get older. The following treatments, however, generally can keep acne under control.

1. Use topical benzoyl peroxide lotion or gel
Benzoyl peroxide helps kill skin bacteria, unplug the oil ducts and heal acne pimples. It is the most effective acne treatment you can get without a doctor's prescription. Many brands are available in different levels of strength (2.5 percent, 5 percent or 10 percent). Read the labels or ask your pediatrician or pharmacist about it.

• Start slowly with a 2.5 percent or 5 percent lotion or gel once a day. After a week, increase use to twice a day (morning and night) if your skin isn't too red or isn't peeling.
• Apply a thin film to the entire area where pimples may occur. Don't just dab it on current blemishes. Avoid the delicate skin around the eyes, mouth and corner of the nose.
• If your acne isn't better after four to six weeks, you may increase to a 10 percent strength lotion or gel. Start with one application each day and increase to two daily applications if your skin tolerates it.

2. If you don't see results, consult your pediatrician
Your doctor can prescribe stronger treatments, if needed, and will teach you how to use them properly. Three kinds of medications may be recommended:

• TRETINOIN (RETIN-A) CREAM OR GEL helps unplug oil ducts but must be used exactly as directed. Be aware that exposure to the sun (or tanning parlors) can cause increased redness in some people who are using the medication.
• TOPICAL ANTIBIOTIC SOLUTIONS may be used in addition to other medications for a type of acne called pustular acne.
• ORAL ANTIBIOTIC PILLS may be used in addition to creams, lotions or gels if your acne doesn't respond to topical treatments alone.

3. What about the "miracle drug" Accutane?
Isotretinoin (Accutane) is a very strong chemical taken in pill form. It is used only for severe cystic acne that hasn't responded to any other treatment. Accutane must NEVER be taken just before or during pregnancy. There is a danger of severe or even fatal deformities to unborn babies whose mothers have taken Accutane while pregnant or who become pregnant soon after taking Accutane. You should never have unprotected sexual intercourse while taking Accutane. Patients who take Accutane must be carefully supervised by a doctor knowledgeable about its usage, such as a pediatric dermatologist or other expert on treating acne. Your pediatrician may require a negative pregnancy test and a signed consent form before prescribing Accutane to females.

If you are experiencing acne problems, remember that your pediatrician can help you. And as you begin treatment, keep these helpful tips in mind:

• Be patient. It takes three to six weeks to see any improvement. Give each treatment enough time to work.
• Be faithful. Follow your program every day. Don't stop and start each time your skin changes. Remember, sometimes your skin may appear to worsen early in the program before you begin to see improvement.
• Follow directions. Not using the treatment as directed is the most common reason the treatment fails.
• Don't use medication prescribed for someone else. This holds true for all medications, especially Accutane. Doctors prescribe medication specifically for particular patients. What's good for a friend may be harmful for you. Never take Accutane that's prescribed for another person.
• Don't overdo it. Too much scrubbing makes skin worse. Too much benzoyl peroxide or Retin-A cream makes your face red and scaly. Too much oral antibiotic may cause side effects.

A Word About ... Acne and Birth Control Pills

In 1996, the Food and Drug Administration (FDA) approved a low-dose birth control pill to be used as an effective treatment for acne in women over 15 years of age. Research has shown that certain birth control pills lower the levels of hormones that cause acne.

However, taking birth control pills along with other medications for the prevention of acne may reduce the effectiveness of both medications. If you are taking birth control pills, talk to your pediatrician about their effect on acne.

Finally, many people don't understand acne and may say hurtful things about it. Although acne may bother you, keep in mind it's only temporary. With present-day treatment, it usually can be controlled.

Source: American Academy of Pedicatrics

You and Your Pediatrician

Pediatricians: Child Health Experts

Children have different health care needs than adults - both medical and emotional. In choosing a pediatrician, you can know that your child is being treated by an expert in children's health. Pediatricians are trained to prevent and manage health problems in infants, children, teens, and young adults. Older patients trust their pediatrician, because they have known one another for many years.

Training

To become trained in pediatrics, a doctor must take special courses for 3 or more years after medical school. This is called residency. After residency, a doctor usually takes a long, detailed test given by the American Board of Pediatrics. After passing the test, the doctor is a board-certified pediatrician. He or she gets a certificate that you may see displayed at the office. The doctor can then become a Fellow (or member) of the American Academy of Pediatrics (FAAP). All of this background prepares your pediatrician to manage your child's total health care needs, including:

• Growth and development
• Illnesses
• Nutrition
• Immunizations
• Injuries
• Physical Fitness

Your pediatrician will also work with you on other issues, such as:

• Behavior
• Emotional or family problems
• Learning and other school problems
• Preventing and dealing with drug abuse
• Puberty and other teen issues

Pediatricians also work with teachers and other adults in child care centers, schools, and after-school programs. If your child has a very special or complex problem, your pediatrician can refer him or her to another specialist for further help, if needed.

As your child grows

Your pediatrician can continue to be an important resource not only for illness or injury care, but for all sorts of health advice, including:

• Exercise
• Nutrition
• Being too thin or too heavy
• Emotional and behavioral problems
• Helping children cope with issues like divorce and death
• School or learning problems
• Family problems

Your pediatrician can respond to your teen's special needs and can offer advice and counseling on:

• Body changes during puberty
• Menstruation
• Growth and hygiene
• Coping and being happy with oneself and with others
• Substance abuse
• Dating and sexual issues
• Eating disorders
• Acne
• Birth control
• Violence and related problems
• Gang problems

When to call the pediatrician

You should always feel free to call your pediatrician's office, either during office hours for routine questions or at any time for an emergency. Call right away if you are worried about your child. Sometimes a parent feels there is a problem before symptoms actually show up. Always call and get proper medical advice. Realize, though, that sometimes your pediatrician may not be able to answer your questions without seeing your child first. When you are not sure whether to call, trust your instincts. Follow these suggestions to be sure the phone is beneficial for both you and your pediatrician.

Make the most of the phone. Your pediatrician may prefer that you call with general questions during office hours. Some offices even have special "phone-in" times. Before you call, have a pen and paper ready to write down any instructions and questions. You could easily forget some details, especially when you are worried about your child. Be ready to gather information about your child's health.

• Take your child's temperature. If your child has a fever, write down the temperature, the time you took it, and how (orally, rectally, ancillary).
• Remind the doctor about past medical problems. Do not expect your pediatrician to always remember your child's medical condition. He or she cares for many children each day and may not remember that your child has asthma, seizures, or some other condition.
• Be sure to mention medications. If your child is taking prescription medication or a nonprescription drug, tell your pediatrician.
• Keep immunization records at hand. These are especially helpful if your child has an injury that may require a tetanus shot or if pertussis (whooping cough) is in your community.

If possible, have your child near the phone when you call your pediatrician. An older child may be able to tell you where it hurts, and you will not have to go to another room for an answer about a rash, fever, or cut.

Routine and emergency calls Routine calls include questions about medicines, minor illnesses, injuries, behavior, or parenting advice. You will usually not need urgent care for a simple cold or cough, mild diarrhea, constipation, temper tantrums, or sleep problems. For these cases you may just need proper medical advice.

However, if your child has any of the following, call to find out if he or she needs to be seen right away:

• Vomiting and diarrhea that last for more than a few hours in a child of any age
• Rash, especially if there is also a fever
• Any cough or cold that does not get better in several days, or a cold that gets worse and has a fever
• Cuts that might need stitches
• Limping or is not able to move an arm or leg
• Ear pain or drainage from an ear
• Sore throat or problems swallowing
• Sharp or persistent pains in the abdomen or stomach
• Any fever in a baby younger than 3 to 4 months of age
• Fever and vomiting at the same time
• Not eating for more than a day

Emergency calls require your pediatrician's prompt attention. But it is best to know what to do before a problem occurs. Plan to learn basic first aid, including CPR (cardiopulmonary resuscitation). During a scheduled checkup, ask your pediatrician what to do and where to go should your child ever need emergency medical care.

Call your pediatrician immediately if your infant or child has:

• Bleeding that cannot be stopped
• Poisoning
• Seizures
• Any trouble breathing
• High fever
• Head injury with loss of consciousness, vomiting, or poor skin color
• Blood in the urine
• Bloody diarrhea or diarrhea that will not go away
• Sudden lack of energy or is not able to move

Source: American Academy of Pediatrics

Girls are not the only ones who go through changes during puberty. Puberty for boys usually starts with a growth spurt at about 10 to 16 years of age. You may notice that you grow out of your clothes or shoes a lot faster than you used to. Don't worry, just as with girls, your hormones will balance out and your body will catch up.

How will my body change?

Following are some other changes you will notice during puberty:

Body size:
Arms, legs, hands, and feet may grow faster than the rest of your body. Until the rest of your body catches up, you may feel a little clumsy.

Body shape:
You will get taller and your shoulders will get broader. You will gain a lot of weight. During this time, many boys experience swelling under their nipples. This may cause them to worry that they are growing breasts. If you experience this, don't worry. It is common among boys your age and is a temporary condition. If you are worried about it, talk to your pediatrician.

During puberty, your muscles will also get bigger. Try not to rush this part of your growth. You may have friends who work out with weights and equipment to build up muscles, and you may want to begin this type of training yourself - often before your body is ready for it. If you are interested in these activities, talk to your pediatrician about a safe time for you to begin weight training.

Voice:
Your voice will get deeper. This may start with voice cracking. As you continue to grow, the cracking will stop and your voice will stay at the lower range.

Hair:
Hair will appear under your arms, on your legs and face, and above your penis. Chest hair may appear during puberty or years after, although not all men have chest hair. Some men shave the hair on their faces. There is no medical reason to shave, it is simply a personal choice. If you decide to shave, be sure to use shaving cream and a clean razor made for men. It is a good idea to use your own personal razor or electric shaver and not to share one with your family or friends.

Skin:
Skin may get more oily and you may notice you perspire more. This is because your glands are growing too. It is important to wash every day to keep your skin clean and to use a deodorant or antiperspirant to keep odor and wetness under control. Despite your best efforts to keep your face clean, you still may get pimples. This is called acne and is normal during this time when your hormone levels are high. Almost all teenage boys get acne at one time or another. Whether your case is mild or severe, there are things you can do to keep it under control. For more information on controlling acne, talk to your pediatrician.

Penis:
Your penis and testes will get larger. You may have erections more often due to an increase in sex hormones. Erections occur when the penis gets stiff and hard - sometimes for no reason. This is normal. Even though you may feel embarrassed, try to remember that most people will not even notice your erection unless you draw attention to it. Many boys become concerned about their penis size; a boy may compare his own penis size with that of his friends. It is important to remember that the size of a man's penis has nothing to do with his manliness or sexual functioning.

Your body will also begin to produce sperm during puberty. This means that during an erection, you may also experience ejaculation. This occurs when semen (made up of sperm and other fluids) is released through the penis. This could happen while you are sleeping. You might wake up to find your sheets or pajamas are wet. This is called a nocturnal emission or "wet dream." This is normal and will stop as you get older.

Source: American Academy of Pediatrics

The lungs of an infant do not function as efficiently as the lungs of an older child. As a result, a severe episode of asthma in an infant can quickly result in lung failure.

Things to be aware of

• Asthma is sometimes more difficult to diagnose in young infants compared to older children. Many "nonasthma" diseases can mimic asthma.
• Over one-third of children with asthma will have symptoms under 1 year of age, and more than half will have had symptoms by 2 years of age.
• Even in infants, there are many medicines available to treat asthma.

What to do

• Follow the appointment schedule for checking on your infant's asthma. Your physician will want to see your baby regularly, even if your baby is not having symptoms.
• If your infant has asthma symptoms, act quickly. Follow the asthma action plan that you and your physician developed for handling symptoms.
• Watch your infant closely for signs to seek emergency care. These signs include:

o                                Breathing rate increases (to over 40 breaths per minute while the infant is sleeping). Count the number of breaths in 15 seconds and multiply by 4.

o                                Suckling or feeding stops, or becomes difficult.

o                                Skin between your infant's ribs is pulled tight.

o                                Chest gets bigger.

o                                Coloring changes (pale or red face; fingernails turn blue).

o                                Cry changes in quality - becomes softer and shorter.

o                                Nostrils open wider (nasal flaring).

o                                Grunting.

Be prepared. Do not wait until the last minute to learn how to handle an emergency. Have an asthma action plan that includes how you'll get to your physician or hospital and who will watch your other children.

Concerns about medications

• Many of the same medicines used for older children and adults can be safely used in infants.
• Most asthma medications have no long-term effects, that is, their use during infancy will not cause problems when your child is older or becomes an adult.

Source: American Medical Association

An allergy happens when the human body's natural defense system (immune system) overreacts to an otherwise harmless substance (like pollen). Allergies can appear in several different ways:

Asthma is when airways swell and air passages in the lungs become narrow. This may be triggered by an allergic reaction, although nonallergic triggers can be involved.

Allergic rhinitis is an allergic reaction mainly in the nasal passages. It can occur in one or more "seasons" (seasonal allergic rhinitis or "hay fever") or all year long (perennial allergic rhinitis).

Eczema (atopic dermatitis) is a chronic, itchy rash, most commonly found in young children. It may be aggravated by certain allergies.

Hives (urticaria) are itchy welts that may be due to allergies, viral infections or unknown causes. Certain foods, viral infections and medications are most likely to cause hives.

Contact dermatitis can be just a skin irritation or an allergic reaction. The allergic type is an itchy skin rash caused by touching, rubbing, or coming into contact with things like poison ivy, chemicals or household detergents.

Food allergy is an allergic reaction to food that can range from stomachache or skin rash to a serious respiratory and medical emergency.

You probably know a child who has asthma or allergies. Perhaps it is your own child. Asthma, hay fever, hives and eczema are familiar words for most of us. In fact, in the United States, more than 35 million adults and children have these allergy-related problems.

So how can you tell whether your child has allergies or just another cold? Allergy symptoms differ from cold symptoms. Allergies usually appear for longer periods of time and including the following:

• An itch, runny nose with thin, clear nasal discharge and/or a stuffy nose
• Itchy, watery eyes
• Repeated attacks of sneezing and itching of the nose, eyes or skin that last for weeks or months
• No fever
• Often seasonal (spring, summer, fall before frost)

On the other hand, cold symptoms usually last for a shorter period of time. Colds are often marked by the following:

• Stuffy nose
• Nasal discharge that is usually clear initially but can turn colored and thick
• A duration of three to 10 days, with or without fever
• Occasional sneezing
• Absence of itching

There are many good medicines to treat allergies and asthma. Some, like antihistamines, are available over-the-counter. They may help relieve many of the symptoms of hay fever and eczema, especially itching, sneezing and runny nose. Other kinds of medications must be prescribed by your pediatrician.

Both allergy and asthma medicines may have side effects. Some antihistamines may cause sleepiness, sometimes interfering with mental tasks. Decongestants (like pseudoephedrine) and oral asthma medications (like albuterol) may make your child irritable. Before using any medication, you should talk to your pediatrician and carefully read the warnings listed on the label. If any of these medicines fail to relieve the symptoms, or if side effects interfere with rest, school or play, you should call your pediatrician. Your child may need a different medication or dose.

In some cases, avoiding the cause of the allergy or using medicines may not control allergic symptoms. If this happens, your pediatrician may recommend that you see a pediatric allergist, a doctor who specializes in hay fever, asthma, eczema and other allergy-related diseases. The allergist will most likely:

• Look for unsuspected triggers for your child's allergic disease
• Suggest ways to avoid the cause of your child's allergic symptoms
• Give you a specific medication plan to follow

Allergy shots may be recommended. These shots contain small but gradually increasing amounts of the substances to which your child is allergic. This binds the antibodies that cause the allergic symptoms so your child is less sensitive to these substances. Allergy shots are not effective for food allergies. Staying away from the substance that causes trouble is best. Only a small number of children require allergy shots.

No matter what treatment you use, you can help your child live a happy, healthy life by working closely with your pediatrician to prevent problems and by using recommended medications. Your pediatrician also can tell you about simple environmental precautions to take and help you decide if your child needs to see an allergy specialist.

Source: American Academy of Pediatrics

The causes of allergies are not fully understood. Your child can get allergies from coming into contact with allergens. Allergens can be inhaled, eaten, injected (from stings or medicine), or they can come into contact with the skin. Some of the more common allergens are:

• pollens
• molds
• house dust mites
• animal dander and saliva (cat, dog, horse, rabbit)
• chemicals used in industry
• some foods and medicines
• venom from insect stings

The tendency to have allergies is often passed on in families. For example, if you as a parent have an allergy problem, there is a higher than normal chance that your child also will have allergies. This risk increases if both parents are allergic.

Pet Allergy

More than 70 percent of U.S. households have a dog or cat. Pets provide companionship, security and a sense of comfort. Children often learn responsibility and lessons about life and death from pets.

However, people with allergies should be cautious in deciding what type of pet they can safely bring into their home. Pet exposure may cause sneezing and wheezing. An estimated 10 percent of the population may be allergic to animals. A higher rate of 20 percent to 30 percent of individuals with asthma have pet allergies.

Pets can cause problems to allergic patients in several ways. Their dander, or skin flakes, as well as their saliva and urine, can cause an allergic reaction. The animal hair is not considered to be a very significant allergen. However, the hair or fur can collect pollen, dust, mold and other allergens.

What Are the Most Common Pets?

The most common household pets are dogs, cats, birds, hamsters, rabbits, mice, gerbils, rats and guinea pigs. Larger animals such as horses, goats, cows, chickens, ducks and geese, even though kept outdoors, can also cause problems as pets.

The number of pets in the United States is estimated at more than 100 million. This large number also increases the likelihood of accidental exposure to animals by the allergic patient when visiting homes, farms, etc.

Both feathers and the droppings from birds, another common pet, can increase the allergen exposure. The allergic patient should not use feather pillows or down comforters. If a feather pillow is used, it should be encased in plastic. An encasing with a zipper is recommended, so none of the feathers can escape.

Bird droppings can be a source of bacteria, dust, fungi and mold. This also applies to the droppings of other caged pets, such as gerbils, hamsters and mice.

What Do Allergists Recommend?

The best types of pets for an allergic patient are pets that don't have hair or fur, shed dander, or produce excrement that creates allergic problems. Tropical fish are ideal, but very large aquariums could add to the humidity in a room, which could result in an increase of molds and house dust mites.

A frequent misconception is that short-haired animals cause fewer problems. It is the dander (skin scales) that causes the most significant allergic reactions - not the length or amount of hair on the pet. As stated previously, allergens are also found in the pet's saliva and urine. In addition, dogs have been reported to cause acute symptoms of allergic conjunctivitis, or inflammation of the eye, and hay fever after running through fields and then coming back into contact with their owners.

Those pets that are known to cause significant allergic reactions should be removed from the home of the allergic patient to avoid possible progression of symptoms. A "trial" removal of a pet for a few days or even weeks may be of little value since an average of 20 weeks is required for allergen levels to reach levels found in homes without pets.

Can Pet Allergies Be Managed?

If the family is unwilling to remove the pet, it should at least be kept out of the patient's bedroom and, if possible, outdoors. Allergic individuals should not pet, hug or kiss their pets because of the allergens on the animal's fur or saliva.

Indoor pets should be restricted to as few rooms in the home as possible. Isolating the pet to one room, however, will not limit the allergens to that room. Air currents from forced-air heating and air-conditioning will spread the allergens throughout the house. Homes with forced-air heating and/or air conditioning may be fitted with a central air cleaner. This may remove significant amounts of pet allergens from the home. The air cleaner should be used at least four hours per day.

The use of heating and air-conditioning filters and HEPA (High Efficiency Particulate Arresting) filters as well as vacuuming carpets, cleaning walls and washing the pet with water are all ways of reducing exposure to the pet allergen. Vacuum cleaners with HEPA filters are now available. However, in a patient with severe symptoms resulting from animal dander exposure, a HEPA filter is not an effective solution.

Litter boxes should be placed in an area unconnected to the air supply for the rest of the home, and should be avoided by the allergic patient.

Some allergic patients may have severe reactions, such as wheezing and shortness of breath, after exposure to certain pets. Also, a chronic, slowly progressive feeling of shortness of breath, loss of energy and feeling of fatigue can result from long-term exposure to birds and their droppings. This type of disease is known as hypersensitivity pneumonitis and can result in severe disability. In the event of these severe cases, removal of the offending animal is mandatory.

How Are Pet Allergies Diagnosed?

The avid pet owner may claim that exposure to his or her pet does not cause their allergy symptoms. This, however, should be viewed skeptically, since pet ownership is an emotionally charged subject. Also, many allergic pet owners are rarely away from their pets, so an accurate reporting of pet-related symptoms may not be possible.

Skin tests or special allergy blood tests are helpful for diagnosing allergy to animals, but are not always accurate. To gain confirmation about a pet's significance as an allergen, the pet should be removed from the home for several weeks and a thorough cleaning done to remove the hair and dander. It should be understood that it can take weeks of meticulous cleaning to remove all the animal hair and dander before a change in the allergic patient is noted.

Are Allergy Shots Effective for Pet Allergies?

Allergy shots (immunotherapy) may be indicated for cat or dog allergies, particularly when the animal cannot be avoided - as might be the case when the patient is a small animal veterinarian. They are typically given for at least three years. They decrease symptoms of asthma and allergy. Usually after about six months of weekly injections allergy symptoms improve and less medication is required

Allergy shots are most effective and safe when administered under the supervision of an allergist-immunologist. The response is highly individual and depends on environmental avoidance as well as the initial sensitivity of the individual

What Can I Do When Visiting People With Pets if I Am Allergic?

The approach to visiting households with pets for an allergic individual is to take appropriate precautions including administration of medications prior to visitation. Your allergist-immunologist can provide information on medications for your animal allergy, such as antihistamines, nasal sprays, decongestants or appropriate asthma medications.

For patients who have severe symptoms on animal dander exposure, the pet should removed from the house at least day before the visit, and the host household should be cleansed of animal allergen to the extent practical.

Source: American College of Allergy, Asthma, and Immunology

Many types of food can cause allergic reactions in middle childhood. The most common of these are cow's milk and other dairy products, egg whites, poultry, seafood, wheat, nuts, soy and chocolate.

Allergies are caused by antibodies that the body's immune system produces, which react to a component of a particular food and then release chemicals that cause allergic symptoms like a runny nose, sneezing, coughing and itching. Children may also experience stomach pain, bloating, cramping, diarrhea, skin rashes and swelling. Although these reactions can occur almost immediately after consuming these foods, they may be delayed for hours or sometimes even days.

Diagnosing food allergies is not easy. Identical symptoms may be caused by other disorders, and pinpointing the offending food can be difficult. Your pediatrician may refer your child to an allergist, who has several diagnostic options. The allergist might suggest an elimination diet, a procedure in which suspicious foods are removed from the diet for a period of time and symptoms are closely monitored to see if they subside. After several weeks the foods are reintroduced one by one, and allergic responses are again evaluated to determine which food, if any, is really the cause of the problem.

Your doctor might also use skin and blood tests. He or she might prick the skin on your child's back or arm, and then introduce a liquid extract of the suspicious food to see if a response - swelling and itchiness, for example - takes place. However, while the validity of this test is widely accepted in diagnosing airborne allergies, there is controversy about its reliability in detecting food allergies.

Some doctors also use the RAST test, in which a sample of your child's blood is mixed with food extracts. Then the blood is evaluated to determine whether antibodies to that food are present. The reliability of this test may vary from laboratory to laboratory.

Once an offending food has been identified, your doctor will probably recommend that it be removed from your child's diet. This means not only eliminating eggs, for example, but also all products that contain them. As a result, you may have to become more diligent reading labels in the supermarket. A child allergic to wheat gluten, for instance, may have to avoid most grains, including cookies, pies, cakes, and pasta, as well as processed cheese, salad dressings and many other foods. The situation becomes even more challenging if your child is allergic to several food items.

Ask your doctor to suggest alternatives to the foods to which your child is allergic. Can egg substitutes be used for a youngster allergic to eggs? When a child is allergic to milk, should she eat additional protein-rich foods (legumes, chicken, fish, meat) and calcium-rich items (sardines, broccoli, spinach)? Can other products be consumed in place of cow's milk? If your child is allergic to wheat, can you cook with corn flour or rice flour instead?

Source: American Academy of Pediatrics

Good social skills are necessary for success, security, and adjustment in life, whether in the home, the classroom, the playground or the community. When a child is able to interact well with others, she will develop and maintain resiliency when encountering stress and will be better able to compensate for shortcomings or failures in other parts of life. On the other hand, inadequate or inappropriate social skills-and the peer rejection that they may cause-can contribute to social, behavioral, emotional and academic problems.

What are social skills? They are the verbal and nonverbal behaviors that occur during everyday social interactions. Some are innate; most are learned. Usually, children learn their social skills at home, with friends in the community, at school or in places of worship. However, as these institutions change, the development of these skills is being affected. The American family structure, for instance, is in transition. More than ever before, mothers are working, and many children live in households with a single parent or as part of a stepfamily. No matter how the family is structured, it is not immune to marital, financial or health-related stresses, which can interfere with a family's time together. Yet families are the primary place in which children learn social skills.

America's schools are also changing. The diversity of students is increasing, and schools are being called upon to respond to an ever-widening range of individual abilities and needs. School personnel, who are having to cope with budget changes, redistribution of funds, and increasing class size, have new and increasing responsibilities, including the need to attend to the complex emotional and social needs of children. As schools stretch limited resources to address the academic needs of their students, the development of social skills may not get all the attention it deserves.

Furthermore, children increasingly spend more time outside the family in a variety of peer-group organizations, such as day care and preschool and after-school programs. As a result, time spent with other children is on the rise, increasing both the opportunity to learn and the need for good social skills.

Does Your Child Have Problems with Social Skills?

To help you understand how your child relates to others, talk to her teachers, coaches and even friends (in a confidential, discreet manner). What are her strengths? What are her difficulties? Do the difficulties appear to be isolated incidents, related to a specific difficult situation or stress? Or are they long-term problems, repeated patterns that are leaving her unpopular and unhappy? If they tend to fall into the latter category, you'll need to take some action. Try to pinpoint the components of social interactions that create the most problems for your child - for instance, does she have trouble reaching out and "breaking the ice," even with just simple statements such as "How are you today?"

If you suspect that your child has difficulties with social interactions, the following questions might help pinpoint the problem.

Does your child have difficulty:

• Entering and joining a group?
• Keeping a friend?
• Dealing with teasing and provocation?
• Effectively managing major conflicts?
• Successfully participating in group activities?
• Responding to failure or disappointment?
• Responding to success?
• Meeting the expectations of peers, parents and teachers?
• Considering other people's feelings?

Source: American Academy of Pediatrics

Whether on the school playground or in the neighborhood park, children in the middle years sometimes find themselves the target of bullies. When that happens, these bullies can not only frighten a youngster, shaking his confidence and spoiling his play, but they can also cause bodily injury.

Avoiding a bully is one reason your child may be reluctant to go to school. Perhaps he is being forced to relinquish his lunch money to this bully. Or he might be fearful of physical harm. If you suspect a problem like this, you need to take action to ensure your child's safety and well-being. Here are some strategies he can adopt with your help, and which will help make him safer:

• Tell your child not to react to the bully, particularly by giving in to demands. A bully relishes intimidating others and likes nothing better than to see his victim cry or become visibly upset in other ways. Getting that response reinforces the bullying behavior. Your child should try to keep his composure and simply walk away.
• If your child's attempts at disregarding a bully's taunts aren't effective, he should become assertive with his harasser. While standing tall and looking his tormentor in the eyes, he should clearly and loudly make a statement like, "Stop doing that now. If you keep on, I'm going to report you to the principal." Or, "I'll talk to you, but I'm not going to fight. So put your fists down now." Sometimes, a strong statement will defuse the situation, and the bully will try to find another, weaker target. Drawing the attention of peers to the bullying situation can embarrass the bully. If your child isn't used to reacting assertively, help him rehearse what he will say if he is confronted.
• Encourage your child to form strong friendships. A youngster who has loyal friends is less likely to be singled out by a bully, or at least he'll have some allies if he does become a target of harassment.
• Talk to your son's teacher or to the principal of his school if the situation with the bully persists. You might be reluctant to intervene, perhaps because your child is embarrassed to have you do so, or because you believe he needs to learn to deal with these situations on his own. On the other hand, you don't want your child's self-confidence to weaken, or his physical well-being to be jeopardized. Your youngster deserves to attend school in a safe environment, even if it means both you and the school staff need to become involved.

Let the principal or teacher talk to the bully when he or she sees the inappropriate behavior taking place on the school grounds. This is generally a more effective approach than having you speak with the child or his parents.

Source: American Academy of Pediatrics

Almost all children have times when their behavior veers out of control. They may speed about in constant motion, make noise nonstop, refuse to wait their turn, and crash into everything around them. At other times they may drift as if in a daydream, failing to pay attention or finish what they start.

However, for some children, these kinds of behaviors are more than an occasional problem. Children with attention-deficit/hyperactivity disorder (ADHD), have behavior problems that are so frequent and severe that they interfere with their ability to live normal lives.

These children often have trouble getting along with siblings and other children at school, at home and in other settings. Those who have trouble paying attention usually have trouble learning. An impulsive nature may put them in actual physical danger. Because children with ADHD have difficulty controlling this behavior, they may be labeled "bad kids" or "space cadets."

ADHD is a condition of the brain that makes it difficult for children to control their behavior. It is one of the most common chronic conditions of childhood. It affects 4 percent to 12 percent of school-aged children. About three times more boys than girls are diagnosed with ADHD.

Left untreated, more severe forms of ADHD can lead to serious, lifelong problems such as poor grades in school, run-ins with the law, failed relationships, and the inability to keep a job.

But effective treatment is available. If your child has ADHD, your pediatrician can offer a long-term treatment plan to help your child lead a happy and healthy life. As a parent, you have a very important role in this treatment.

For information on ordering the complete booklet, "Understanding ADHD" from the American Academy of Pediatrics, click here.

Source: American Academy of Pediatrics

There are few areas that raise more concern among parents than their child's behavior. While their pediatrician may be able to prescribe an antibiotic to cure a sore throat or an ear infection, solutions for childhood behavior problems are not nearly as clear-cut, nor is there a consensus on the best approach to discipline.

By definition, behavior is simply verbal and nonverbal communication. It is the conduct, actions, and words that children employ - a signal with which they express their thoughts, feelings, needs and impulses. It is judged as to whether it meets social, cultural, developmental and age-appropriate standards. Behavior can be positive or negative, impulsive or planned, predictable or unpredictable, consistent or inconsistent and it can elicit a wide range of positive or negative responses from others.

Through her behavior, your child may be trying to communicate messages like: "That's too difficult for me. . . . I'm afraid of failure. . . . I'm afraid of disappointing you. . . . I'm bored. . . . I'm tired. . . . I'm afraid of being rejected. . . . I want you to play with me. . . . I need you. . . . I want to please you. . . . I love you. . . . I want you to pay attention to me."

Attention, of course, is one of the most important things that children desire and seek from their parents. The attention they most want is the message that they are loved, valued, accepted and respected. Children will go to great extremes for the feeling that unconditional love is there for them.

Children will do whatever it takes to get recognition and to have their needs met. They quickly learn which kinds of behavior get their parents to respond to them and meet their needs, and if positive behavior doesn't work, they will turn to the negative. Even if their misbehavior gets them a negative reaction (such as being scolded), any recognition is better than none, in the eyes of children.

Behavior, then, does not occur in isolation. It is a form of communication, a way to express needs and feelings, and is influenced by a child's desires, temperament, and ability to adapt, as well as by her mother's and father's parenting style, family situation, and various stresses and transitions - from a minor illness to starting a new school year.

You and Your Child's Discipline

During the school-age years, children are developing rapidly, and in many ways they are trying to understand the world around them, face new demands, deal with success and failure, and communicate with their siblings, parents and increasingly with their peers. In many cases these changes can lead to problems. Just as the middle years offer endless opportunities for children to learn and to meet new challenges, so, too, they provide an equal number of chances for them to make mistakes, to achieve and succeed, and to question or challenge parental values, rules and attitudes. Proper parental discipline is a way to teach children what behavior is appropriate in which circumstance, or how to interact in a socially acceptable manner.

Here, discipline does not imply punishment or scolding. It means "to educate." Proper discipline teaches children to live in a safe, civilized and harmonious manner with themselves and others. There are some essential elements to disciplining well, including correctly understanding the child's needs and abilities (going beyond the concrete, actual behavior), communicating effectively, and using positive and negative reinforcement appropriately.

Three Types of Behavior

Some parents find it helpful to consider three general kinds of behavior:

• Some kinds of behavior are wanted and approved. They might include doing homework, being polite and doing chores. These actions receive compliments freely and easily.
• Other behavior is not sanctioned but is tolerated under certain conditions, such as during times of illness (of a parent or a child) or stress (a move, for instance, or the birth of a new sibling). These kinds of behavior might include not doing chores, regressive behavior (such as baby talk) or being excessively self-centered.
• Still other kinds of behavior cannot and should not be tolerated or reinforced. They include actions that are harmful to the physical, emotional, or social well-being of the child, the family members and others. They may interfere with the child's intellectual development. They may be forbidden by law, ethics, religion or social mores. They might include very aggressive or destructive behavior, overt racism or prejudice, stealing, truancy, smoking or substance abuse, school failure or an intense sibling rivalry.

Source: American Academy of Pediatrics

In a research study, fifth- and sixth-graders were asked about the life events that had made them (or would make them) worried or feel bad. Here are the circumstances most commonly mentioned, with the most frequent ones listed first.

• Feeling sick
• Having nothing to do
• Not having enough money to spend
• Feeling pressure to get good grades
• Feeling left out of a group of peers
• Not spending enough time with parents
• Not having homework done
• Not being good enough at sports
• Not being able to dress as desired
• Experiencing body changes
• Being late for school
• Being smaller than other children of the same age
• Having parents argue in front of them
• Not getting along with teachers
• Being overweight or bigger than other children of the same age
• Moving
• Changing schools
• Arguing with parents about rules in the family
• The separation of parents
• Being pressured to try something they didn't really want to (e.g., smoking)

Signs of Overload

Although stress is a part of life and growing up, you need to intervene when you sense that it is undermining your child's physical or psychological well-being. Here are some clues that stress may be having too negative an effect.

• Your child develops physical symptoms like headaches and stomach pains.
• He seems restless, tired and agitated.
• He appears depressed and is uncommunicative about how he feels.
• He gets irritable, negative and shows little excitement or pleasure in his activities.
• He seems less interested in an activity that was once extremely important to him and prefers to stay at home.
• His grades at school begin to fall, and he has less interest than usual in attending classes and doing homework.
• He exhibits antisocial behavior such as lying and stealing, forgets or refuses to do his chores and seems much more dependent on you than in the past.

Are You Pushing Your Child Too Hard?

Much of the stress in your child's life comes from outside the family and may be beyond your control. Yet many youngsters may feel pressure because their parents, with the best of intentions, are overscheduling them with music lessons, sports activities, computer courses and art classes.

At first glance it might seem advantageous to expose your child to as many educational, cultural and athletic experiences as possible. For some parents, this seems to be a way to give him a little edge over his peers in our very competitive society. But experts believe that when children are driven to be overachievers - when nearly the entire day is structured for them - it can have negative effects. Many children find it stressful to race from activity to activity without any time to relax, to play, to "hang out" and just "be a kid."

Finding a Balance

You and your child together need to find a balance between structured and unstructured activities. Don't worry about his becoming bored; he can actually benefit from some unplanned time, when he can use his imagination and pursue interests of his own. As for his structured activities, limit them to those he truly enjoys, and in which he is able to succeed, gain new skills or see improvement. Solicit your child's suggestions and opinions before making any plans for him.

Once your child has become engaged in activities, be supportive (but not pushy), offering praise and showing your interest by attending his baseball games and piano recitals. Sometimes, your child may complain about losing interest in an organized program, or of feeling anxiety about his inability to perform as well as his peers or teammates. Explore the reasons for and realities of his complaints. There may be problems to resolve together, or it may be time to discontinue the current activity. As a parent, keep in mind that in these middle years your youngster is still very much a child. Particularly as children approach adolescence, they often feel pressure to be more grown-up. Parents and peers alike may encourage more adult actions or dress. Help your youngster enjoy his childhood without unnecessary stressors like these. As he matures, let him set his own pace of discovery. Talk with him about issues like individuality and peer pressure.

Helping your Child Cope with Stress

Together, you and your child should evaluate the situations or activities that are producing problems. Clarify the problems together, and identify a number of possible solutions. Look at the influences that might be adding to the difficulty your child is having in adjusting to or managing the situation, and find ways in which she can change them.

If your youngster seems to have too little free time, help her modify her schedule so she can relax and play. She will probably increase her creativity and devise her own forms of recreation. Encourage her to use her imagination and skills to create play and pleasure. Remember, your job is not to keep her entertained; in fact, most children enjoy playtime free of the frenetic pace and the tension that usually accompany formal overscheduling.

You may also wish to protect 10 to 15 minutes of time each day to devote solely to your child in an activity that she chooses and directs. This can promote family closeness while offering some stress-free time.

Talking with your Child about Stress

When your child is facing a lot of stress, she may benefit from your help in figuring out how best to cope. Take the time to talk with her about the pressures she is feeling and the anxiety in her life. School-age children often find it difficult to sit down and discuss these matters. But let her know that you are interested and care, and that you would like to help. Approach each situation as a problem to be solved.

You may need to put yourself in your child's place and imagine what she may be feeling. Talk about some of her behavior and displays of emotion you have noticed recently, which suggest to you that she may be struggling with some issues. Gradually, your efforts may help her put her feelings into words.

Help your child understand her own temperament. Use some guiding statements about observations that you have made about her. Say things like "I know you react pretty strongly to stress.'' Or, "You seem to prefer to take your time making decisions.'' This can help foster insight and help your child cope.

Examining the Issues

If you feel you need additional help in the area of stress management, discuss this issue with your child's pediatrician, who can talk to you and your child and help the family develop less stressful avenues for your youngster to pursue. In some cases, when your child is coping especially poorly and the stress is interfering with her day-to-day functioning, the doctor might refer you to a professional counselor.

You also may need to examine your own life. Children under stress often have parents under stress, and some of the resulting anxiety is transferred from parent to child. If you are undergoing a personal crisis - a divorce, for example - or have filled your child's day with activities because you yourself are overcommitted, it may be time to make changes in your own life, easing the personal stress that might have an indirect impact on your child as well.

Source: American Academy of Pediatrics

To help you determine if your child has low self-esteem, watch for the following signals. They could be everyday responses to how your child relates to the world around him, or they might occur only occasionally in specific situations. When they become a repeated pattern of behavior, you need to become sensitive to the existence of a problem.

• Your child avoids a task or challenge without even trying. This often signals a fear of failure or a sense of helplessness.
• He quits soon after beginning a game or a task, giving up at the first sign of frustration.
• He cheats or lies when he believes he's going to lose a game or do poorly.
• He shows signs of regression, acting babylike or very silly. These types of behavior invite teasing and name-calling from other youngsters, thus adding insult to injury.
• He becomes controlling, bossy, or inflexible as ways of hiding feelings of inadequacy, frustration or powerlessness.
• He makes excuses ("The teacher is dumb") or downplays the importance of events ("I don't really like that game anyway"), using this kind of rationalizing to place blame on others or external forces.
• His grades in school have declined, or he has lost interest in usual activities.
• He withdraws socially, losing or having less contact with friends.
• He experiences changing moods, exhibiting sadness, crying, angry outbursts, frustration or quietness.
• He makes self-critical comments, such as "I never do anything right," "Nobody likes me," "I'm ugly," "It's my fault" or "Everyone is smarter than I am."
• He has difficulty accepting either praise or criticism.
• He becomes overly concerned or sensitive about other people's opinions of him.
• He seems to be strongly affected by negative peer influence, adopting attitudes and behaviors like a disdain for school, cutting classes, acting disrespectfully, shoplifting, or experimenting with tobacco, alcohol or drugs.

He is either overly helpful or never helpful at home.

Boosting your Child's Self-Esteem

If you and/or your pediatrician or other professional have concluded that your child could use help with her self-esteem, start with some positive steps of your own. You can become the most influential person in getting your child's self-concept back on track.

Here are some suggestions:

• Spend time with your child. Find activities you can do together that will make her feel successful - and that are fun, too, without winners and losers. Attend her soccer games and music recitals. Show her that you are interested in her and what she accomplishes. By giving time and energy to your child, you will convey a powerful message of love and acceptance.
• Treat your child as an important person. Encourage her to express herself, listen without judging, accept her feelings and treat her with respect.
• Whenever possible, allow your child to make decisions and assume more responsibility in her life. Show your trust in her.
• Build close family relationships, and make your child feel that she is contributing to the family unit.
• Do not expose your youngster to, or confide in her about, adult topics or family/marital tensions that will cause her stress. Try to minimize her anxieties related to family crises and changes, providing her with as much continuity and stability as possible.
• Encourage your child to provide service to others - perhaps through Scouting or a similar type of program - in order to increase her sense of community, her feeling of belonging and being appreciated and her sense of importance and personal worth.
• Teach your child to praise herself. She should feel pride in her accomplishments.
• Tell your youngster how much you love her, and what a good and lovable child she is - without any conditions or strings attached. Although parents' actions and efforts convey love indirectly, children also need to hear the words "I love you."

Boosting your child's self-concept will not happen overnight. It may take months or years, and it is an ongoing process. If your child is not responding to your attempts at helping her, however, and worrisome or serious problems persist, talk to your pediatrician about the need for professional assistance.

Source: American Academy of Pediatrics

Strong emotions are hard for a young child to hold inside. When children feel frustrated, angry, or disappointed, they often express themselves by crying, screaming, or stomping up and down. As a parent, you may feel angry, helpless, or embarrassed. Temper tantrums are a normal part of your child's development as he learns self-control. In fact, almost all children have tantrums between the ages of 1 and 3. You've heard them called "the terrible twos." The good news is that by age 4, temper tantrums usually stop.

Your young child is busy learning many things about her world. She is eager to take control. She wants to be independent and may try to do more than her skills will allow. She wants to make her own choices and often may not cope well with not getting her way. She is even less able to cope when she is tired, hungry, frustrated, or frightened. Controlling her temper may be one of the most difficult lessons to learn.

Temper tantrums are a way for your child to let off steam when she is upset. Following are some of the reasons your child may have a temper tantrum:

• Your child may not fully understand what you are saying or asking, and may get confused.
• Your child may become upset when others cannot understand what she is saying.
• Your child may not have the words to describe her feelings and needs. After 3 years of age, most children can express their feelings, so temper tantrums taper off. Children who are not able to express their feelings very well with words are more likely to continue to have tantrums.
• Your child has not yet learned to solve problems on her own and gets discouraged easily.
• Your child may have an illness or other physical problem that keeps her from expressing how she feels.
• Your child may be hungry, but may not recognize it.
• Your child may be tired or not getting enough sleep.
• Your child may be anxious or uncomfortable.
• Your child may be reacting to stress or changes at home.
• Your child may be jealous of a friend or sibling. Children often want what other children have or the attention they receive.
• Your child may not yet be able to do the things she can imagine, such as walking or running, climbing down stairs or from furniture, drawing things, or making toys work.

Preventing temper tantrums

You should not be surprised if your child has tantrums only in front of you. This is one way of testing your rules and limits. Many children will not act out their feelings around others and are more cautious with strangers. Children feel safer showing their feelings to the people they trust.

Knowing this, you will still not be able to prevent all tantrums, but the following suggestions may help reduce the chances of a tantrum:

Encourage your child to use words to tell you how he is feeling, such as "I'm really mad." Try to understand how he is feeling and suggest words he can use to describe his feelings.

Set reasonable limits and don't expect your child to be perfect. Give simple reasons for the rules you set, and don't change the rules.

Keep a daily routine as much as possible, so your child knows what to expect.

Avoid situations that will frustrate your child, such as playing with children or toys that are too advanced for your child's abilities.

Avoid long outings or visits where your child has to sit still or cannot play for long periods of time. If you have to take a trip, bring along your child's favorite book or toy to entertain him.

Be prepared with healthy snacks when your child gets hungry.

Make sure your child is well rested, especially before a busy day or stressful activity.

Distract your child from activities likely to lead to a tantrum. Suggest different activities. If possible, being silly, playful, or making a joke can help ease a tense situation. Sometimes, something as simple as changing locations can prevent a tantrum. For example, if you are indoors, try taking your child outside to distract his attention.

Be choosy about saying "no." When you say no to every demand or request your child makes, it will frustrate him. Listen carefully to requests. When a request is not too unreasonable or inconvenient, consider saying yes. When your child's safety is involved, do not change your decision because of a tantrum.

Let your child choose whenever possible. For example, if your child resists a bath, make it clear that he will be taking a bath, but offer a simple decision he can make on his own. Instead of saying, "Do you want to take a bath?" Try saying, "It's time for your bath. Would you like to walk upstairs or have me carry you?"

Set a good example. Avoid arguing or yelling in front of your child.

Managing temper tantrums

As a parent, you can sometimes tell when tantrums are coming. Your child may seem moody, cranky, or difficult. He may start to whine and whimper. It may seem as if nothing will make him happy. Finally, he may start to cry, kick, scream, fall to the ground, or hold his breath. Other times, a tantrum may come on suddenly for no obvious reason. When your child has a temper tantrum, the suggestions below can help you both get through it successfully:

1.      Distract your child by calling his attention to something else, such as a new activity, book, or toy. Sometimes just touching or stroking a child will calm him. You may need to gently restrain or hold your child. Interrupt his behavior with a light comment like, "Did you see what the kitty is doing?" or "I think I heard the doorbell." Humor or something as simple as a funny face can also help.

2.      Try to remain calm. If you shout or become angry, it is likely to make things worse. Remember, the more attention you give this behavior, the more likely it is to happen again.

3.      Minor displays of anger such as crying, screaming, or kicking can usually be ignored. Stand nearby or hold your child without talking until he calms down. This shows your support. If you cannot stay calm, leave the room.

4.      Some temper tantrums cannot be ignored. The following behaviors should not be ignored and are not acceptable:

o                                Hitting or kicking parents or others

o                                Throwing things in a dangerous way

o                                Prolonged screaming or yelling

Use a cooling-off period or a "time-out" to remove your child from the source of his anger. Take your child away from the situation and hold him or give him some time alone to calm down and regain control. For children old enough to understand, a good rule of thumb for a time-out is 1 minute of time for every year of your child's age. (For example, a 4-year old would get a 4-minute time-out.) But even 15 seconds will work. If you cannot stay calm, leave the room. Wait a minute or two, or until his crying stops, before returning. Then help him get interested in something else. If your child is old enough, talk about what happened and discuss other ways to deal with it next time.

You should never punish your child for temper tantrums. He may start to keep his anger or frustration inside, which can be unhealthy. Your response to tantrums should be calm and understanding. As your child grows, he will learn to deal with his strong emotions. Remember, it is normal for children to test their parents' rules and limits.

As tempting as it can be, do not reward your child for stopping a tantrum. Rewards may teach your child that a temper tantrum will help her get her way. When tantrums do not accomplish anything for your child, they are less likely to continue.

You may also feel guilty about saying "no" to your child at times. But be consistent and avoid sending mixed signals. When parents don't clearly enforce certain rules, it is harder for children to understand which rules are firm and which ones are not. Be sure you are having some fun each day with your child. Think carefully about the rules you set and don't set too many. Discuss with those who care for your child which rules are really needed and be firm about them. Respond the same way every time your child breaks the rules.

Your child should have fewer temper tantrums by the middle of his fourth year. Between tantrums, his behavior should seem normal and healthy. Like every child, yours will grow and learn at his own pace. It may take time for him to learn how to control his temper. When the outbursts are severe or happen too often, they may be an early sign of emotional problems. Talk to your pediatrician if your child causes harm to himself or others during tantrums, holds his breath and faints, or if the tantrums get worse after age 4. Your pediatrician will make sure there are no serious physical or psychological problems causing the tantrums. He or she can also give you advice to help you deal with these outbursts.

It is important to realize that temper tantrums are a normal part of growing up. Tantrums are not easy to deal with, and they can be a little scary for you and your child. Using a loving, understanding and consistent approach will help your child through this part of his development.

Source: American Academy of Pediatrics

Understanding Disobedience

From time to time most children defy the wishes of their parents. This is a part of growing up and testing adult guidelines and expectations. It is one way for children to learn about and discover their own selves, express their individuality, and achieve a sense of autonomy. As they stretch their independent wings and engage in minor conflicts with their parents, they discover the boundaries of their parents' rules and of their own self-control.

Sometimes, however, these conflicts are more than occasional disturbances and become a pattern for how parents and children interact. Disobedience can have a variety of causes. At times, it is due to unreasonable parental expectations. Or it might be related to the child's temperament, or to school problems, family stress, or conflicts between his parents.

Youngsters who are generally cooperative and agreeable may suddenly become disrespectful and disobedient during middle childhood. This is usually a sign that they are experiencing a lot of inner turmoil or that a significant new stress is occurring around them, such as abuse or school failure. Their hostility is directed toward the nearest target, those closest to them, and is a way of coping with and expressing the stress they feel.

Some children may have a lengthy history of being out of control and noncooperative. This is a serious problem. When children have been disobedient for long periods--routinely talking back to and having outbursts aimed at their parents and others--there is often conflict and disorganization within the family as a whole. The children may reject their parents' authority, feeling that their mother and father disapprove not only of their behavior but of them as people. Thus, these youngsters learn to be unhappy with themselves, and their self-esteem can suffer greatly. Gradually, if the family relationships continue to deteriorate, the children become even more angry, sad, hostile, and aggressive.

When you have a chronically disobedient child, examine the possible sources of his inner turmoil and rebelliousness. If this has been a persistent pattern that has continued into middle childhood, closely evaluate your own family situation: How much respect do your family members show for one another? Do they respect one another's privacy, ideas, and personal values? How does the family work out its conflicts? Are disagreements resolved through rational discussion, or do people regularly argue or resort to violence? What is your usual style of relating to your child, and what forms does discipline usually take? How much spanking and yelling is there? Do you and your child have very different personalities and ways of getting along in the world that cause friction between you? Is your child having trouble succeeding at school or developing friendships? Is the family undergoing some especially stressful times?

If your child has only recently started to demonstrate disrespect and disobedience, tell him that you have noticed a difference in his behavior and that you sense he is unhappy or struggling. With his help, try to determine the specific cause of his frustration or upset. This is the first step toward helping him change his behavior.

If you react to your child's talking back by exploding or losing your temper, he will respond with disobedience and disrespect. By contrast, he will become more obedient when you remain calm, cooperative, and consistent. He will learn to be respectful if you are respectful toward him and others in the family. If he becomes disobedient and out of control, impose a timeout until he calms down and regains self-control.

When your child is obedient and respectful, compliment him for that behavior. Reward the behavior you are seeking, including cooperation and resolution of disagreements. These positive efforts will always be much more successful than punishment.

As a parent, you need to keep in mind that middle childhood is a vulnerable period of life. Young school-age children are quite egocentric, thinking that all events that happen around them have something to do with themselves. For example, in families where there is marital conflict, youngsters may misinterpret this problem, concluding that they themselves have been bad and have upset their parents. In the process their self-esteem may suffer, and they may be more prone to reacting inappropriately to the events around them.

Source: American Academy of Pediatrics

Understanding Disobedience

From time to time most children defy the wishes of their parents. This is a part of growing up and testing adult guidelines and expectations. It is one way for children to learn about and discover their own selves, express their individuality, and achieve a sense of autonomy. As they stretch their independent wings and engage in minor conflicts with their parents, they discover the boundaries of their parents' rules and of their own self-control.

Sometimes, however, these conflicts are more than occasional disturbances and become a pattern for how parents and children interact. Disobedience can have a variety of causes. At times, it is due to unreasonable parental expectations. Or it might be related to the child's temperament, or to school problems, family stress, or conflicts between his parents.

Youngsters who are generally cooperative and agreeable may suddenly become disrespectful and disobedient during middle childhood. This is usually a sign that they are experiencing a lot of inner turmoil or that a significant new stress is occurring around them, such as abuse or school failure. Their hostility is directed toward the nearest target, those closest to them, and is a way of coping with and expressing the stress they feel.

Some children may have a lengthy history of being out of control and noncooperative. This is a serious problem. When children have been disobedient for long periods--routinely talking back to and having outbursts aimed at their parents and others--there is often conflict and disorganization within the family as a whole. The children may reject their parents' authority, feeling that their mother and father disapprove not only of their behavior but of them as people. Thus, these youngsters learn to be unhappy with themselves, and their self-esteem can suffer greatly. Gradually, if the family relationships continue to deteriorate, the children become even more angry, sad, hostile, and aggressive.

When you have a chronically disobedient child, examine the possible sources of his inner turmoil and rebelliousness. If this has been a persistent pattern that has continued into middle childhood, closely evaluate your own family situation: How much respect do your family members show for one another? Do they respect one another's privacy, ideas, and personal values? How does the family work out its conflicts? Are disagreements resolved through rational discussion, or do people regularly argue or resort to violence? What is your usual style of relating to your child, and what forms does discipline usually take? How much spanking and yelling is there? Do you and your child have very different personalities and ways of getting along in the world that cause friction between you? Is your child having trouble succeeding at school or developing friendships? Is the family undergoing some especially stressful times?

If your child has only recently started to demonstrate disrespect and disobedience, tell him that you have noticed a difference in his behavior and that you sense he is unhappy or struggling. With his help, try to determine the specific cause of his frustration or upset. This is the first step toward helping him change his behavior.

If you react to your child's talking back by exploding or losing your temper, he will respond with disobedience and disrespect. By contrast, he will become more obedient when you remain calm, cooperative, and consistent. He will learn to be respectful if you are respectful toward him and others in the family. If he becomes disobedient and out of control, impose a timeout until he calms down and regains self-control.

When your child is obedient and respectful, compliment him for that behavior. Reward the behavior you are seeking, including cooperation and resolution of disagreements. These positive efforts will always be much more successful than punishment.

As a parent, you need to keep in mind that middle childhood is a vulnerable period of life. Young school-age children are quite egocentric, thinking that all events that happen around them have something to do with themselves. For example, in families where there is marital conflict, youngsters may misinterpret this problem, concluding that they themselves have been bad and have upset their parents. In the process their self-esteem may suffer, and they may be more prone to reacting inappropriately to the events around them.

Source: American Academy of Pediatrics

Around ten months of age, you may notice that you're child becomes much more "clutchy" about leaving you. When you're out of her sight, she'll know you're somewhere but not with her, and this will cause her great distress. She'll have so little sense of time that she won't know when, or even whether, you'll be coming back. Once she gets a little older, her memory of past experiences with you will comfort her when you're gone, and she'll be able to anticipate a reunion.

But for now she's only aware of the present, so every time you leave her sight, even to go to the next room, she'll fuss and cry. When you leave her with someone else she may scream as though her heart will break. At bedtime she'll refuse to leave you to go to sleep, and then she may wake up searching for you in the middle of the night. This developmental stage is known as separation anxiety. It can be a tough stage for both of you but it also marks the dawning realization for your child that each object is unique and permanent, and that there's only one of you.

Separation anxiety usually peaks between ten and eighteen months, and then fades during the last half of the second year. In some ways, this phase of your child's emotional development will be especially tender for both of you, while in others it will be painful. After all, her desire to be with you is a sign of her attachment to her first and greatest love, namely you. The intensity of her feeling as she hurtles into your arms is irresistible, especially when you realize that no one, including your child herself, will ever again think you are quite as perfect as she does at this age. On the other hand, you may feel suffocated by her constant clinging, while experiencing guilt whenever you leave her crying for you. Fortunately, this emotional roller coaster eventually will subside along with her separation anxiety.

If your child has a strong, healthy attachment to you, her separation anxiety probably will occur earlier than in other babies, and she'll pass through it more quickly. Instead of resenting her possessiveness during these months, maintain as much warmth and good humor as you can. Through your actions, you're showing her how to express and return love. This is the emotional base she'll rely on in years to come. The following suggestions may help ease separation anxiety.

• Your baby is more susceptible to separation anxiety when she's tired, hungry, or sick. If you know you're going out, schedule your departure so it occurs after she's napped and eaten. Try to stay with her as much as possible when she's sick.
• Don't make a fuss over your leaving. Instead, have the person staying with her create a distraction (a new toy, a visit to the mirror, a bath). Then say goodbye and slip away quickly.
• Remember that her tears will subside within minutes of your departure. Her outbursts are for your benefit to persuade you to stay. With you out of sight, she'll soon turn her attention to the person staying with her.
• Help her cope with separation through short practice sessions at home. Separation will be easier on her when she initiates it, so when she crawls to another room (one that's baby-proofed), don't follow her right away; wait for one or two minutes. When you go to another room for a few seconds, tell her where you're going and that you'll return. If she fusses, call to her instead of running back. Gradually, she'll learn that nothing terrible happens when you're gone and, just as important, you always come back when you say you will.
• If you take your child to a sitter's home or a child-care center, don't just drop her off and leave. Spend a few extra minutes playing with her in this new environment. When you do leave, reassure her that you'll be back later.

Source: American Academy of Pediatrics

This statement was approved as policy by the following organizations: the American Academy of Pediatrics; the American Academy of Family Physicians; the American College of Obstetricians and Gynecologists; NAACOG-The Organization for Obstetric, Gynecologic, and Neonatal Nurses; and the National Medical Associations.

Adolescents tend to underutilize existing health care resources. The issue of confidentiality has been identified, by both providers and young people themselves, as a significant access barrier to health care.

Adolescents in the United States, while generally considered healthy, have a range of problems, including some of such severity as to jeopardize their development and health, their future opportunities and even their lives. To illustrate, there is an urgent need to reduce the incidence of adolescent suicide, substance abuse, and sexually transmitted diseases and unintended pregnancy.

As the primary providers of health care to adolescents, we urge the following principles for the guidance of our professional members and for broad consideration in the development of public policy:

1.      Health professionals have an ethical obligation to provide the best possible care and counseling to respond to the needs of their adolescent patients.

2.      This obligation includes every reasonable effort to encourage the adolescent to involve parents, whose support can, in many circumstances, increase the potential for dealing with the adolescent's problems on a continuing basis.

3.      Parents are frequently in a patient relationship with the same providers as their children or have been exercising decision-making responsibility for their children with these providers. At the time providers establish an independent relationship with adolescents as patients, the providers should make this new relationship clear to parents and adolescents with regard to the following elements:

• The adolescent will have an opportunity for examination and counseling apart from parents, and the same confidentiality will be preserved between the adolescent patient and the provider as between the parent/adult and the provider.
• The adolescent must understand under what circumstances (eg, life-threatening emergency), the provider will abrogate this confidentiality.
• Parents should be encouraged to work out means to facilitate communication regarding appointments, payment, or other matters consistent with the understanding reached about confidentiality and parental support in this transitional period when the adolescent is moving toward self-responsibility for health care.

4.      Providers, parents, and adolescents need to be aware of the nature and effect of laws and regulations in their jurisdictions that introduce further constraints on these relationships. Some of these laws and regulations are unduly restrictive and in need of revision as a matter of public policy. Ultimately, the health risks to the adolescent are so impelling that legal barriers and deference to parental involvement should not stand in the way of needed health care.

Source: American Academy of Pediatrics

What should you do if your child wants to play with the neighborhood troublemaker? What if he starts hanging out with a youngster who lies, destroys property or bullies other children? What if he begins expressing values or attitudes you do not like? What if he adopts behaviors that are worrisome?

Dealing with negative peer influence is a challenge, but there are solutions. Some parents may demand that their own youngster stop spending time with this ¡°bad influence,¡± but this may not be the best strategy. Typically, children adamantly defend such a friend, and they may trivialize or rationalize his faults or shortcomings. They may ignore their parents, finding a way of seeing this playmate anyway. And if they do abide by their parents¡¯ wishes, other problems may ensue since the children's own judgment and ability to make wise decisions independently are affected.

In most cases a better strategy is to reinforce positive friendships with other children whose behavior and values meet with your approval. Encourage your youngster to invite these children over to your house to play. Arrange activities that are somewhat structured, mutually enjoyable and time-limited, such as bowling, bicycling or watching a sporting event. Also, arrange summer events (camp, special weekend trips) that bring the children together.

At the same time, do not hesitate to express your displeasure over the less desirable playmates. Speak calmly and rationally when you explain why you would prefer that your child not spend time with them, focusing on specific behavior rather than generalizing or criticizing their character. Let him know the consequences if he ends up adopting the unacceptable behavior that you have seen in these other children, while still not absolutely forbidding him to play with them. This approach will teach your youngster to think more logically and assume responsibility for his actions, and show that you trust his growing capacity to make the right decisions.

Late in the middle years, this type of approach becomes important as peer influences are very evident. Friendships often evolve into highly exclusive cliques in which children strongly influence one another. At most schools there are a variety of cliques, each with its own hierarchy of members. Youngsters attraction to particular friends may be based on anything from personality to extracurricular interests, from athletic ability to appearance. In these preadolescent years, youngsters in tightly knit inner circles may feel quite secure with one another, creating their own group identity by looking and talking alike, perhaps creating a secret handshake, and feeling much more "with it" than those on the outside looking in. These youngsters often feel a strong pressure to dress and talk in a particular way, listen to certain music and wear their hair in a specific style. This peer pressure begins to compete (and sometimes clash) with the influence of parents and their values.

Pre-adolescents also tend to be quite judgmental, labeling others and at the same time becoming increasingly concerned about what their friends think of them. If a peer is even just a little different, they may conclude, "He's terrible; I just hate him".

Source: American Academy of Pediatrics

People who are depressed and thinking about suicide often show changes in their behavior. These changes in behavior are usually an outgrowth of depression and are warning signs. If your teen shows these warning signs, please talk to her about her concerns and have her get help if the warning signs continue.

• Noticeable changes in eating or sleeping habits
• Unexplained, or unusually severe, violent or rebellious behavior
• Withdrawal from family or friends
• Running away
• Persistent boredom and/or difficulty concentrating
• Drug and/or alcohol abuse
• Unexplained drop in the quality of schoolwork
• Unusual neglect of appearance
• Drastic personality change
• Complaints of physical problems that are not real
• A focus on themes of death
• Giving away prized possessions
• Talking about suicide or making plans, even jokingly
• Threatening or attempting to kill oneself

Before committing suicide, people often threaten to kill themselves. These threats should always be taken seriously, as should previous suicide attempts. Most people who commit suicide have made at least one previous attempt.

Asking your teen whether he is depressed or is thinking about suicide lets him know that someone cares. You're not putting thoughts of suicide into his head. Instead you're giving your teen the chance to talk about his problems.

Remember that depression and suicidal feelings are treatable mental disorders. The first step is to listen to your adolescent. A professional must then diagnose your teen's illness and determine a proper treatment plan. Your teen needs to share her feelings, and many suicidal teens are pleading for help in their own way. Your teen needs to feel that there is hope–that people will listen, that things will get better, and that she can overcome her problems.

Parents and friends can help a depressed teen through the following strategies:

• Talk, ask questions, and be willing to really listen. Don't dismiss your teen's problems as unimportant. Parents and other influential adults should never make fun of or ignore an adolescent's concerns, especially if they matter a great deal to her and are making her unhappy.
• Be honest. It you're worried about your teen, say so. You will not spark thoughts of suicide just by asking about it.
• Share your feelings. Let your teen know he's not alone. Everyone feels sad or depressed at times.
• Get help for your teen and yourself. Talk to your pediatrician, teacher, counselor, clergy, or other trained professional. Don't wait for the problem to "go away." Although feelings of sadness and depression can disappear as quickly as they came, they can also build to the point that an adolescent thinks of suicide as the only way out. Be careful not to assume that your teen's problems have been so easily solved.

A teen attempting suicide should immediately be taken to a hospital emergency room for a psychiatric evaluation. If a depressed adolescent is assessed to be safe to go home, it's a good idea to remove from your home any lethal, accessible means to commit suicide, such as medications, firearms, razors, knives, etc.

Other sources of help

There are many sources of information to help troubled teens and their families. Often a pediatrician, who has charted the adolescent's physical and emotional progress since infancy, is in the best position to detect and help treat adolescent depression. Your teen may, however, need additional counseling. Check the Yellow Pages in your city for the phone numbers of local suicide hot lines, crisis centers, and mental health centers.

The following organizations can also supply information on suicide prevention:

American Academy of Child and Adolescent Psychiatry
3615 Wisconsin Ave, NW, Washington, DC 20016 202/966-7300

American Association of Suicidology
4201 Connecticut Ave, NW, Suite 310, Washington, DC 20008 202/237-2280

American Psychiatric Association
1400 K St, NW, Suite 501, Washington, DC 20005 202/682-6000

American Psychological Association
750 1st St, NE, Washington, DC 20002 202/336-5700

National Mental Health Association
1021 Prince St, Alexandria, VA 22314-2971 800/969-6642

With professional treatment and support from family and friends, teens who are suicidal can become healthy again.

Source: American Academy of Pediatrics

Traffic crashes are the leading cause of death for teens and young adults. More than 5,000 young people die every year in car crashes and thousands more are injured. Drivers who are 16 years old are more than 20 times as likely to have a crash as are other drivers. State and local laws, safe driving programs, and driver's education classes all help keep teens safe on the roads. Parents can also play an important role in keeping young drivers safe.

There are two main reasons why teens are at a higher risk for being in a car crash: lack of driving experience and their tendency to take risks while driving.

Lack of experience.

Teens drive faster and do not control the car as well as more experienced drivers. Their judgment in traffic is often insufficient to avoid a crash. In addition, teens do most of their driving at night, which can be even more difficult. Standard driver's education classes include 30 hours of class-room teaching and 6 hours of behind-the-wheel training. This is not enough time to fully train a new driver.

Risk taking.

Teen drivers are more likely to be influenced by peers and other stresses and distractions. This can lead to reckless driving behaviors such as speeding, driving while under the influence of drugs or alcohol, and not wearing safety belts.

There are several steps you an take to help make driving a safer experience for your teens. Check into graduate licensing programs that allow teens more responsibility in stages. As they move through each stage they gain confidence and experience that can help make them safer drivers.

It is also important to establish and discuss "house rules" about driving even before your teen gets a license. Remind your teen that these rules are in place because you care about his or her safety. If your teen complains about the rules, stand firm. You might say something like, "I don't care what other parents are doing — I care about you and don't want you to get in a crash." Remember, you control the car keys. Don't hesitate to take away driving privileges if your teen breaks any rules. Resist the urge to break the house rules yourself and let your teen drive because it is too much trouble for you to drive. Instead, try to arrange a car pool of parents and take turns driving.

You do not need to wait for graduated licensing laws to be passed in your state to adopt your own graduated driving rules. By slowly increasing driving privileges, you can help your teen get the experience needed to drive safely and responsibly. Here are some suggestions on how you can create a graduated licensing program for your teen driver. It may not be necessary to use all of the following restrictions; choose the ones that make the most sense for you and your teen.

Stage one

• teen must be at least 15-1/2 years old or have a legal learner's permit
• teen must drive with a licensed adult driver at all times, the parent if possible
• no driving between 10 pm and 5 am or no driving after sunset
• driver and all passengers must wear safety belts
• no use of tobacco, alcohol, or other drugs
• teen must remain ticket-free and crash-free for 6 months before moving up to the next stage

Stage two

• teen must be at least 16 years old or have driven with a learner's permit for at least 6 months
• teen must drive with a licensed adult driver during nighttime hours, the parent if possible
• teen allowed to drive unsupervised during daytime hours
• passengers restricted to one nonfamily member during daytime hours
• no use of tobacco, alcohol, or other drugs
• driver and all passengers must wear safety belts
• teen must remain ticket-free and crash-free for 12 months before moving up to the next stage

Stage three

• teen must be at least 18 years old or have driven at least 2 years at the previous stage
• no restrictions on driving as long as the teen driver remains ticket-free and crash-free for 6 months
• no use of tobacco, alcohol, or other drugs
• all passengers must wear safety belts

Other ways parents can help include:

• Require that your teen maintain good grades in school before he or she can drive. Check with your auto insurance company to see if any "good student" discounts are available.
• Set a good driving example (no use of alcohol or other drugs, no speeding, always wear your safety belt, and require that safety belts be worn by all passengers).
• Remind your teen how important it is to stay focused on driving, not getting distracted by excessively loud music or talking on a cellular phone.
• Let your teen know that driving after drinking or using other drugs will not be tolerated. Tell your teen to always call you or someone else for a ride any time he or she or any other driver has been drinking or using drugs. Let your teen know that you will pick him or her up. However, if you find he or she was drinking, it may be better to wait until the next day before you discuss the incident.
• Be alert to any signs that your teen has a drinking or other substance abuse problem. If you suspect a problem, urge your teen to talk with his or her pediatrician or school counselor. Such trusted adults can refer your teen for other help, if needed.
• Support efforts to protect teens. These might include "safe ride" programs or Mothers Against Drunk Driving (MADD). Encourage alcohol-free community events.
• Encourage schools to teach about the dangers of driving after drinking or using drugs.
• Support showing safety films in schools. Also support efforts to promote safety belt use in all vehicles that take children and teens to and from school.
• Driving is a privilege and a big responsibility. Teen drivers, because of their age and inexperience, are at a higher risk for car crashes. Licensing programs, rules of the road, and safe ride programs are designed to help teen drivers stay safe. Along with support and encouragement from parents, these programs are the best way to help teens learn to become responsible drivers.

Source: American Academy of Pediatrics

Part of being a parent is teaching your children about sex and sexuality. You can help your children feel good about themselves and teach them how to relate to others. Many parents feel uneasy talking about sexuality with their child. They wonder what information is right for the child's age. They may wonder how to bring up the subject or answer all the child's questions. Talking about sex for the first time is tough. You're likely to find the next time easier

How Children Learn

Learning about sex is a lifelong process that begins at birth. Family members, friends, the media, schools and church all play a role.

Early in life, children start forming their ideas about sex by watching their parents.

There are no strict rules for teaching your child about sexuality. Each family and each child are different. It's a good idea to give children information about 2 years before you think they will need it.

Your child also learns about sex from TV, music, books and magazines. Many teenagers watch about 24 hours of TV a week. On TV, a lot of the sex is casual. Parent should point out to their children that sex is not as simple as it is portrayed.

Many parents fear that talking about sex will increase sexual activity in their children. It doesn't. Not knowing about sex creates problems.

Talking About Sex

Talking about sex should start early in your child's life. Teach your preschool child the proper names for body parts and explain where babies come from in simple terms.

If you begin when your child is young, it will be easier to talk about sex when he or she is a teenager.

Teaching your child about sex should not be just an adult talking while the child listens. Key questions may not get asked or answered.

Always try to be honest.

Young Children

It's at the toddler stage that children first notice that the bodies of boys and girls and adults and children differ.

Your child may play with his or her own genitals and may express interest in the genitals of other children. This is normal. Do not respond with anger or scolding.

Primary School Years

During the primary school years, a child's interest in sex often is less obvious.

This is also the age when children tend to pick up sexual slang that offends the parents. Parents give mixed messages if they scold children for using such language, but then use it themselves.

Up to around age 9, children often want brief and direct answers to their questions.

By about age 10, children should know about sexually transmitted diseases (STDs), especially AIDS (acquired immunodeficiency syndrome).

Early Adolescence

Most children start puberty between ages 11 and 13. Their interest in their sexuality often increases a great deal. Their sexual organs mature, their sex glands start to produce hormones at an adult level, and they have spurts in height and weight.

Young people at this stage often compare themselves with their friends. Because bodies do not mature at the same rate, children often wonder if they are normal. Girls mature about two years ahead of boys — a fact that often disturbs both sexes.

Girls should be told of menstruation. Boys should be told about erections and "wet dreams." They should be explained to them before they occur.

Children also should be taught the benefits of not having sex. In surveys, many adolescents say they wish they'd waited until they were older to start having sex. Some children do start having sex in their early teens. You should make sure they have information about STDs, birth control and "safer" sex.

Teenage Years

Young people reach their full physical growth during their teenage years. They become sexually mature and may have strong sexual urges. Many teenagers have their first sexual experience at younger ages than their parents did.

Teenagers should be given a chance to talk openly about the risk of getting STDs, including HIV (human immunodeficiency virus).

If your child dates someone older than they are, it is likely they will face more pressure to have sex. Stress that sex should be a loving act and that it is wrong to force sex.

Teenagers also should know about other forms of sexual behavior. They should know the meaning of terms such as heterosexual, homosexual, gay, lesbian, bisexual and abstinence. Your children should be taught to respect a broad range of sexual expression.

Finally . . .
When teaching your children about sexuality, do the best you can. Try to help them become responsible, well-informed adults. Make an effort to listen, answer questions, and show love and respect for your child.

This excerpt from ACOG's Patient Education Pamphlet is provided for your information. It is not medical advice and should not be relied upon as a substitute for visiting your doctor. If you need medical care, have any questions, or wish to receive the full text of this Patient Education Pamphlet, please contact your obstetrician-gynecologist.

Source: American College of Obstetricians and Gynecologists

This is an exciting time for parents - in this stage, your baby seems to make real progress toward communicating. Your baby will recognize Mommy and Daddy, laugh, squeal and smile spontaneously. Her personality begins to become evident, and she becomes a more active and alert member of your family.

How does my baby communicate?

Crying will continue to be your baby's primary means of communication for many months. Aside from letting you know that she needs something (and perhaps even what she needs by the way she cries), your baby may cry when she is overwhelmed by all of the sights and sounds of the world. Sometimes she may cry for no apparent reason at all. Try not to get too upset when your baby cries and you aren't able to console her.

Your baby will respond to the sound of your voice by becoming quiet, smiling or getting excited and moving her arms and legs. She will begin smiling regularly at her mom and dad during this period. She probably won't smile and act friendly with strangers, but she may warm up to them with coos and body talk - or at least a curious stare.

Babies this age discover that they have the ability to vocalize: soon you'll have a cooing and gurgling machine! Some babies begin to repeat some vowel sounds, like "ah-ah" or "ooh-ooh," at about two months. Your baby will "talk" to you with a variety of sounds; she'll also smile at you and wait for your response, and respond to your smiles with her own. Her arms and legs will move, and her hands will open up. She may even mimic your facial expressions.

What should I do?

Your baby loves to hear your voice, so talk, babble, sing and coo away during these first few months. Respond enthusiastically to your baby's sounds and smiles. Tell her what she is looking at or doing and what you are doing. Name familiar objects as you touch them or bring them to your baby. Read to your baby; even at this tender age, it will help in the development of her growing brain. By listening to you, your baby will learn the importance of speech before she even understands or repeats any words herself.

Take special advantage of your baby's own "talking" to have a "conversation." If you hear her make a sound, repeat it and wait for her to make another. You are teaching your baby valuable lessons about tone, pacing, and taking turns when talking to someone else. You are also sending her the message that she's important enough to listen to. Don't interrupt or look away when she's talking - show her that you are interested and that she can trust you.

Babies this age seem to respond best to the female voice - the one historically associated with comfort and food. That's why most people will raise the pitch of their voices and exaggerate their speech when talking to a small baby. This is fine - studies have shown that talking "baby talk" doesn't delay the development of speech - but feel free to mix in some regular adult words and tone with the baby talk. It may seem early, but you are really setting the stage for your baby's first word.

Sometimes babies are not in the mood to talk or vocalize - and even babies need their space. If your baby turns away, closes her eyes, or becomes fussy or irritable, let her be. She may need a break from all the stimulation in the world.

There will probably be times when you have met all of your baby's needs, yet she continues to cry. Don't despair - your baby may be overly stimulated, have gastric distress, or may have too much energy and need a good cry. It is common for babies to have a fussy period at the same time every night, generally between early evening and midnight. This can be very upsetting, but the good news is that it's short-lived; most babies outgrow it around three months. There are some things you can try to soothe your baby. Some babies are comforted by motion, such as rocking or being walked back and forth across the room, while others respond to sounds, like soft music or the hum of a vacuum cleaner. It may take some time to find out what best comforts your baby during these stressful periods.

Should I be concerned?

You may want to talk to your doctor if your baby seems to cry for an unusual length of time or if the cries sound odd to you. Your doctor will be able to reassure you or look for a medical reason for your baby's distress. Chances are there is nothing wrong, and knowing this can help you relax and stay calm when your baby is upset.

There are some communication milestones that your baby will probably reach during this period. Babies this age usually:

• Pay attention to new faces and surroundings
• Respond to loud noises
• Smile at the sound of a parent's voice
• Smile at other people by 3 months
• Babble by 3 or 4 months

Keep in mind that babies communicate at different rates, just as they mature physically at different rates. There is usually no cause for concern, but talk to your doctor if your baby misses any of these milestones.

Source: American Medical Association

As a parent, don't ignore the prejudice to which your child may be exposed in the media or in his own experience. Keep in mind that you serve as the most powerful influence and role model for your youngster, and more than anyone else, you can mold his attitudes and his behavior toward others. Here are some guidelines to follow:

1.      Your actions toward the people in your life will lay the foundation for how your child relates to his peers and others. Examine your attitudes and the way you feel about people with traits and characteristics different from your own. Consider the different roles, relationships, and responsibilities within your own household, and what forms of age or gender discrimination may occur there. If you want your child to be free of prejudice, you need to demonstrate that attitude in your words and deeds.

2.      Nothing is more powerful in dispelling myths and stereotypes than person-to-person contact. Bring diversity into your own life. Make your friends and co-workers of different races and religions regular participants in your family's activities. Let your child experience that there are more similarities than differences among people. It is valuable to expose him to cultures and holidays different from his own: for example, with the cooperation of friends and neighbors, gentile children can attend a Bat Mitzvah or Passover seder, while Jewish youngsters can go to a church service or baptism. But your child should understand that these are only limited aspects of the differences and diversity that surround them.

3.      Children initially focus on differences in physical appearance. In language appropriate for your child's age, explain why people have different skin and eye color, hair type and other features. Discuss how differences in appearance are inherited from mothers and fathers. Talk about the diversity of your own child's ethnic heritage. At the same time, point out the similarities among all people, such as the need to be loved, the need for self-respect, and feelings of happiness and sadness, anger and pain, which everyone has at some time.

4.      Discuss your family's history of immigration to this country, or more recent moves to new neighborhoods and the adjustments that this required for the family. Talk to your children about their unique qualities, and the characteristics, feelings and dreams you and they share with people all over the world.

5.      Discuss the issue of prejudice with your youngster. Since many schools have curricula that promote discussions of diversity and prejudice, you may have the opportunity to reinforce this at home. Make it clear that diversity should be valued and that discrimination in any form is unacceptable. He should understand that teasing, insulting, rejecting, or diminishing another person based on race, religion, background, origin, economic status, gender or appearance will not be tolerated. Explain that there is no need for your child to build himself up by putting others down. (This may reflect a basic insecurity or unhappiness within himself.) Mistreating others can give your child a false sense of security that will produce anxiety when he is with others who are "different," particularly since they will invariably be able to do some things better than he can.

6.      If you sense that your youngster has negative attitudes toward others, or you witness or hear about any intolerant or discriminatory behavior on his part, do not ignore them. Address these prejudices by discussing why your child feels the way he does. Let rational thinking diffuse the emotional intensity of prejudice.

At the same time, encourage positive values toward diversity and harmonious and cooperative ways of living. Love and respect your child, so he can come to value and respect others.

7.      Help your youngster understand the erroneous basis of stereotypes and hatred. Call attention to negative stereotypes when they appear in the media, including television (programs and commercials), newspapers and magazines. Some common ways in which prejudice appears in the media and even in schools include:

·                                 Presenting other people in stereotypical roles: male doctors, black athletes overly emotional women.

·                                 Showing racial or ethnic minorities in only one role, such as Native Americans in traditional clothing, or people of color as poor.

·                                 Equating different cultures with single aspects of that culture, such as food, dress or special observances.

·                                 Always presenting minority individuals as the "different" person within a group, rather than as one of many within their own community.

8.      When choosing experiences for your child - including camps, schools, child care and extracurricular events - seek out diversity in racial and ethnic backgrounds among the other children participating.

9.      Use the library, bookshop and video-rental store to obtain material about other people and their cultures that depict them in a positive, sensitive humanistic light.

10. Actively work to reduce prejudice in your life and community. Establish a household in which all members are valued and respected. Participate in your child's school to assure that diversity is valued and reinforced. Join political and civic organizations and attend multicultural events, both to change the world in which your child lives and to demonstrate your commitment to addressing the prejudices that exist.

11. If your child personally experiences prejudice, he will probably feel hurt and angry. Yet because of social circumstances or his own stage of development, he may feel unable to express these emotions. You need to encourage him to vent his feelings, and you must acknowledge their validity, before trying to discuss them with reason. A child whose personhood has been attacked through prejudice needs to be supported and have his self-esteem bolstered by his family and friends. Then you can discuss the roots of prejudice with him, and how the two of you believe he should respond.

Source: American Academy of Pediatrics

Family problems come in all shapes and sizes; some are short-lived and easily managed, while others are more chronic and difficult to handle. Stress points include events such as illness and injury, changing jobs, changing schools, moving and financial difficulties.

Each family develops its own ways of coping with these stresses, some of which work better than others. Unsuccessful coping can be recognized by a number of characteristics, including the following:

Poor Communication

Family members either avoid talking with one another, or have not learned how to listen well to what others are trying to say through their words, expressions or actions.

Inability to Resolve Conflicts and Disagreements

This usually occurs because family members avoid discussing problems or even avoid admitting that problems exist. This allows the conflicts to continue - which, while causing some discomfort and unhappiness, allows the family to avoid what they see as the greater discomfort of facing the problem. Some families just have not learned the skills of negotiating or, for some other reason, cannot let go of bad or hurt feelings. Children are likely to pattern their behavior after their parents' behavior and may learn to refuse to talk about feelings and problems.

Poor Problem-Solving

Family members have trouble deciding what problems really exist, who is responsible, the options for solving them, and how the family can agree upon an option and act upon it. There may not be agreement on what the priorities are within the family.

Poor Division of Responsibilities

Families often have not decided how family responsibilities will be divided among family members. When that happens, family life can become chaotic, and many things do not get accomplished. At the other extreme, some families are not flexible at all, and family members do not help one another out or fairly reassign responsibilities as family circumstances change.

Insufficient Emotional Support

Families are, especially for children, the most important source of emotional support. During the middle years, children find it hard to obtain this emotional support outside the family. Children do not perform or develop well without this support.

Intolerance of Differences

Families function best when the individuality of each family member is acknowledged and appreciated. At the least, even if someone else's personal traits or characteristics are not highly valued, each family member needs to tolerate these traits and respect that individual. When family members withhold love from one another because of personal differences, children are likely to have a difficult time developing a healthy self-image, and they will have low self-esteem and poor social skills.

Overdependency on Others

Children need to succeed in order to feel capable of successfully managing life's stresses and challenges. If they are taught or encouraged to depend on others (within the family or outside it) to solve their problems, they will have low self-esteem and limited initiative and will have trouble succeeding in the world.

Chronic Crises

Families who have some of the above characteristics are likely to have trouble coping with life's inevitable crises. In these families even relatively simple problems are not resolved but take on the appearance and feel of major dilemmas. Thus, by their lack of successful coping skills, these families create additional problems for themselves and go from crisis to crisis, with little relief and little pleasure from life or from one another.

Although we all strive for perfection, there is no perfect family. Each family has its own strengths and weaknesses, assets and liabilities, challenges and problems. If your family seems overwhelmed with problems, or if there is a breakdown in relationships within your family, it is probably time for outside help.

As a parent, your task is to meet the multiple demands of family life with energy and creativity. By doing so, you will enable your children to grow and develop in positive, healthy ways and to experience satisfaction and success.

Source: American Academy of Pediatrics

Not too many years ago in the typical American family, only the father worked outside the home. Usually the mother was the homemaker and was there to greet the children when they returned home from school each day. But there have been dramatic changes in that picture. Today, the mothers of nearly 76 percent of children over the age of 5 are in the workforce, and during workdays no parent is at home or readily available. During school hours most children essentially are being looked after by a teacher, and after school, before their parents come home, they may be cared for by another adult - in many cases a relative, a neighbor or a commercial childcare facility. About 7 percent of middle-years children return from school to an empty house and care for themselves until their mother or father arrives. With most of their waking hours spent away from their parents, the quality of children's everyday experiences is difficult to predict and control.

Millions of families find that they need two wage-earners in order to buy a home, pay the rent, afford vacations or simply to maintain the family budget. In most communities, two-working-parent families are no longer exceptional.

The Impact of Working

When both parents are occupied with their jobs for eight or more hours per day, there are obvious effects on the family. On the positive side, the family has an increased income and thus fewer financial stresses. Also, when both parents work, there is a potential for greater equality in the roles of husband and wife. Depending on the nature of the parents' work, as well as the family's values, fathers may assume more responsibility for childcare and housework than has traditionally been the case. With their wives out in the workplace, men find it easier to define a greater role for themselves in child-raising. This is particularly evident when parents have staggered work schedules - for instance, if the father works daytime hours and is home after school and in the evening, while the mother works a shift such as 4:00 p.m. to midnight. Dad may then be in charge of preparing dinner, cleaning up the kitchen and helping the children with their homework.

The Risks of Shift Work

Many families are feeling the stress of overcommitted and overscheduled lives. But few families feel it more than those in which parents work at different times of the day. When parents work different shifts and are not home together very often, a strain is put on their relationship and the family. Even more difficult are jobs that have rotating shifts - firefighting and nursing, for instance - forcing parents to work different hours each week; those schedules can prevent families from establishing routines and rhythms and can seriously disrupt family stability.

In these families, husbands and wives often have little or no time together. If they are lucky they have a day or two during the week when they are both off, but their sleep schedules may be so different that they still spend very little time with each other. These people essentially pass messages to each other, and their parenting may be hampered by a minimum of teamwork.

When parents work different shifts, children often sense that a problem exists. They rarely see their parents together, and they sometimes yearn for a "normal" family life. Parents in these situations have to work especially hard at giving their children the feeling that their family really is a unit, despite the difficult schedules. They need to make the most of weekends and vacations and support each other in areas like household responsibilities and discipline.

For some families, shift work is a solution to providing good childcare and supervision for children who would otherwise be left in the care of another adult or on their own. Such arrangements may provide a financial benefit to the family and a sense of comfort to the child.

Parenting Alert

When both spouses work, there are two particular aspects of parenting that often suffer:

Some parents become less nurturing or less emotionally available. Caught up in the hectic pace of their lives, parents may give their children a little less attention and loving care than they need. Set aside time each evening to show your children some affection. Bedtime is often a good time for that.

Some parents are afraid to set limits. Setting limits is an important component of gaining the respect of your youngsters. For children to grow into happy and secure adults, they need to be sensitive to your feelings and values and listen to what you say. If you see that they follow the rules you set, they will adopt many of your values.

Source: American Academy of Pediatrics

By school age, children understand that death is an irreversible event. Yet even though youngsters recognize that death is something more than going to sleep for a long time, they still may have many unanswered questions that they may not verbalize: Where did grandmother go when she died? What is she feeling? Is she in pain? Why did she die? Can we ever see her again? Are you going to die too? Who will take care of me if you die?

Offer opportunities for your child to ask these questions. The more clearly and honestly you answer them, the better he will fare through the grieving process.

The reactions of children to death are highly personal. One child might quietly and sadly express his grief. Another might become rambunctious and oppositional. Still another might become extremely anxious. Youngsters often take their cues from watching the reactions of other family members, particularly their parents. In some families, death is a taboo subject, and children sense that they should not talk about it; in others, death is discussed openly and children feel comfortable expressing their sadness.

Should You Shield your Child?

Some adults believe that children should be shielded from death. They keep children away from funerals. They try not to cry in front of their youngsters. They may make up stories in an attempt to protect children from pain ("Grandma had to go away for a long time; we won't see her for a while"). They may avoid all discussions of the deceased.

Despite the good intentions of these actions, they don't work and are counterproductive. As with most topics, communicating with children about death should be honest and direct. Children need to grieve as much as adults do. They need to be able to share their feelings and talk about how they are going to miss the person who has died. By school age they have already been exposed to death, even if only indirectly, by watching television or hearing about it from friends. Death should not be covered up and hidden.

To help your child, you need to feel comfortable with your own grief reaction over the death of a loved one. It is appropriate for your child to see you cry when you feel sad; he will take comfort knowing that you are expressing your feelings so openly. This will make it easier for him to do the same.

Death of a Grandparent

When a grandparent dies, children may not find it as devastating as the loss of a parent or a sibling. To them, their grandparent is an older person, and when people get old, they often die. However, if the grandparent has provided day-to-day companionship for the child, perhaps even living with the family or residing nearby, the death will be much harder.

Also, with the passing away of a grandparent, children often think, "Now that my daddy's daddy is dead, does that mean that my daddy is going to die next?" If you sense this kind of reaction, reassure your child that you and your spouse are healthy and will probably live for a long time.

Death of a Parent

Whenever a child loses a parent, the event is traumatic and alters the course of her development. You cannot protect the child from what has happened, but you can help her face the reality of it.

If you are a surviving parent, in addition to dealing with your own feelings of loss, you need to help your child through this experience. Expect reactions ranging from regression and anxiety to anger and depression.

Be honest and open about what has taken place. Provide your child with a lot of comforting, both verbal and nonverbal. Reassure her that you are not going to leave her, too, and that life will get back into a routine as soon as possible.

If the primary caretaker (usually the mother) has died, and the father must return to work, he should find someone to assume a caretaking, nurturing role for a while - perhaps a relative or a nanny. Even so, while these substitutes can assist with day-to-day functions, the surviving parent will still need to spend more time with and give more attention to his child to help her adjust to their new life.

Death of a Sibling

When a brother or a sister dies, children can find it just as difficult as losing a parent, sometimes even more so. In some ways a sibling is the person to whom a child is closest. They have been constant companions, sharing many life experiences. Perhaps they even shared a bedroom.

When a sibling dies, children may feel guilty, particularly since at some point nearly every youngster wishes that her sibling were dead. Or they may have survival guilt ("Why did he die and I didn't?"). They may even feel guilty because of the jealousy they experienced if their sibling was ill and got extra parental attention.

If one of your children dies, do not ignore the others during the grieving process. Even though you may be overwhelmed with your own sadness, your other children need a lot of attention, comforting and understanding. Mobilize other extended-family members and friends to help give your children support. Try to avoid putting the deceased child on a pedestal, or your other children may feel they can never be as perfect or as good in your eyes.

Source: American Academy of Pediatrics

Every year, more than one million children in the United States experience the divorce of their parents. The average divorce takes place within the first seven years of marriage, so many of these children are under the age of 6. For many children, divorce can be as difficult as the death of a parent. The entire family is faced with the challenge of adjusting to a new way of life. When this happens, children need the guidance, patience, and love of both parents to help them through.

There are many things you can do to help your child adjust to the changes in your family, including the following:

Put Your Child First

The most important factor in how divorce affects a child's life is how parents treat each other and their children during and after the divorce. Keep in mind, divorce is a major event in your child's life, one that she has no control over. Parents must work together to make the changes as easy as possible for everyone. Even as the marriage ends, your role as a parent continues. In fact, it becomes more important than ever. Set aside your differences with your child's other parent and put your child first, by following these suggestions:

• Never force your child to take sides. Every child will have loyalties to both parents.
• Do not involve your child in arguments between the two of you.
• Do not criticize each other in front of your child or when your child might be listening to a conversation you are having with someone else. Even if you find out the other parent is saying bad things about you, explain to your child that when people get angry they sometimes say things that are hurtful.
• Discuss your concerns and feelings with your child's other parent when and where your child cannot hear.
• Avoid fighting in front of your child.

Allow Your Child To Be a Child

Resist using your child as a replacement for your ex-spouse. Avoid pressuring children with statements like, "You are the man in the family now" or "Now I have to depend on you." Children have a right to enjoy childhood and grow up at a normal pace. As they grow older, they will be able to take on more responsibility and help around the house. Don't expect too much too soon.

Respect the Relationship Between Your Child and the Other Parent

Allow your children to spend time with their other parent without making them feel guilty or disloyal to you. When a parent leaves, many children are afraid the other one may leave too. Reassure your children that you both still love them even though they may only be living with one parent at a time. It is important to let your children show their love to both parents. Unless your ex-spouse is unfit to parent, try not to let your differences keep your children away from him or her. Remember, one of the most important ways to help your children cope with a separation or divorce is to help them maintain a strong, loving relationship with both parents.

Keep Your Child's Daily Routine Simple and Predictable

Many divorced parents feel guilty that the divorce has upset their children. They find it hard to discipline the children when they need it. Making rules, setting a good example, and providing emotional support can be difficult. Giving in to your child's demands will not help. Anger or difficult behavior may be part of your child's attempts to cope with the divorce. Set sensible limits. Schedule meals, chores and bedtime at regular times so that your child knows what to expect each day. Parents living separately should agree on a set of consistent rules for both households. It is also very important to live up to your promises to visit or spend time with your child. A routine weekly or monthly schedule may be comforting to your child.

Adjusting to a New Life

Children have great strength and the ability to bounce back from rough times. After a divorce, children may even develop much closer relationships with each parent. In time, most children learn to accept the changes brought on by divorce. The challenge becomes much easier though, when both parents provide the understanding, support, and love that all children need from their mothers and fathers, even after they separate.

Use Help From the Outside

Children often turn to neighbors, grandparents and peers for comfort and attention. These relationships can offer support and stability to children as well as needed relief to a parent. Teachers or school social workers who are aware of the divorce and understand the child's problems also may be able to give a helping hand.

For many parents too, the changes are not easy. Many adults going through a divorce experience depression. If you are suffering from anxiety or depression as a result of a divorce or separation, don't be afraid to see a counselor. It is important for parents to be healthy so they can be available to their children during this difficult time. Social agencies, mental health centers, women's centers, and support groups for divorced or single parents are helpful. There are also many informative books and articles about divorce for both parents and children — check your local bookstore. Your pediatrician is very aware of the effects that separation and divorce may have on emotions and behavior. He or she can help you find ways to cope with the stress you and your children are feeling.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Source: American Academy of Pediatrics

One of the most challenging aspects of a blended family is for the children of each parent to become comfortable living together as brothers and sisters. Children who are brought into the same household with minimal preparation and are expected to function as a congenial, loving family are unlikely to succeed. Storybook relationships may appear to be developing in those first few weeks of getting to know one another, but this is generally only a honeymoon period until the children feel comfortable enough to express their disagreements and conflicts with one another.

In some cases, the remarried couple will have one or more babies of their own, who will become the existing children's half-siblings. While most school-age children generally like having a baby around, they may also complain about the drawbacks. A newborn is often the center of attention of family and friends, and that means a loss of focus on the older children. More important, the older children may feel jealous that their father or mother is starting a new family, and that the baby gets to live with both of her parents, while their own parents are divorced. Even so, most new additions to the family are treated with love by the other children.

With time, stepsiblings tend to become good friends and companions, and their relationships are enriching and rewarding.

Rivalry among Stepsiblings

As with any siblings, there will probably be some competition between the children in stepfamilies, much of it for their parents' attention. Stepsiblings should not be expected to spend all of their time together, and in fact, each child will need some time spent just with his or her own parent.

Stepfamilies may produce other situations that can create antagonism among children. The 12-year-old daughter of one spouse may feel real anger if she is frequently burdened with the responsibility of babysitting for the 3-year-old child of the other marriage partner. Also, when there are conflicts within the new family - for instance, disagreements over whom to visit during holidays - youngsters often band together with their own parent, forming camps and aggravating any rivalries that may already exist.

This is particularly important for the youngster who may live with her mother and whose father remarries. The child may recognize that her dad is now spending less time with her than with the stepchildren who live with him. She may think, "Why do they get to live with Dad and I don't? Does he like them better? I don't get to do as much with my dad anymore because of them."

Children in this situation should have some special time with their fathers on a regular basis. Parents must acknowledge and respect this need, finding afternoons or entire weekends that they can devote solely to their own children, who may live across town or in another part of the state.

Privacy and Personal Space

Sometimes a child is asked to share a room with a stepbrother or stepsister when, in the past, that same room was hers alone. Or when her stepfather's children come to visit him on the weekend, they may move into her room for a couple of days, sometimes creating anger and jealousy.

Privacy and personal space become important issues in blended families. Whenever possible, children should have their own rooms. Even if they share a room, however, each youngster should have her own toys and other possessions; she should not be forced to turn them all into community property.

Who Will Handle the Discipline?

All children need discipline. But in stepfamilies, parents often are unsure of who should administer it. Should a stepfather, for example, discipline his wife's children, or should she be the only one to handle it?

Too often, stepfathers attempt to assert authority and directly discipline their stepchildren, rather than letting their wives take the lead with their own youngsters. Particularly in the initial few months, stepparents should play a supportive role in discipline but allow their new spouse to continue being the primary disciplinarian. They should avoid sweeping statements like "From now on, we're going to do things this way!" The new couple should gradually make a transition to shared authority. This transition can be accomplished by a delegation of authority from the biological parent to the stepparent, saying something like "While you're with him, you need to mind what he says - or answer to me.''

After years of single parenting, many mothers may welcome having a male authority figure in the house. However, his presence does not relieve her from the responsibility of being the primary caretaker of her own youngsters. If her new husband becomes too assertive in parenting his wife's children, the children may resent him and complain to their mother about their mean stepfather. She may find herself caught in the middle between her husband and her children as conflicts escalate. And if she takes her spouse's side, her youngsters may feel betrayed. It is a position that can and should be avoided.

Also, if the new husband and wife disagree on disciplinary issues, the child may begin undermining and challenging the stepparent's authority, which is not good either for the child or for the marital relationship. When parents disagree this way, they need to negotiate their differences or problems will escalate.

Over time, stepfathers will develop a closer relationship with the children of their spouses, and they can eventually begin to assert more of their own influence. But at least initially, it is not appropriate for them to become the primary disciplinarian of someone else's children.

Source: American Academy of Pediatrics

If your child has decided that he wants to become involved in a sports activity, he will have to decide which one to select. Of course, he should choose one that he will enjoy; even though your first love may be baseball or softball, let him choose soccer if that is what appeals to him.

Some children prefer individual sports rather than team sports. These individual activities-such as swimming, running, tennis, and cycling-can become lifetime sports, offering enjoyment and health advantages throughout adulthood. Many of these same activities (running and swimming, for example) can provide an aerobic workout too.

If your child selects a team activity, investigate the programs available in your community. There are both contact and noncontact sports, and you and your child should evaluate which is more appropriate for his or her size, interests, and abilities. Many team sports (basketball, soccer) involve at least some contact, although others (T-ball, swimming, tennis) are purely noncontact activities. The nature of how some sports are played changes with a child's age. For example, soccer for younger children is played without much contact and rarely results in collisions. As a general rule, children up to the age of eight should participate only in noncontact sports; beginning at age eight, contact sports are acceptable alternatives. However, children should not participate in "collision" sports (football, hockey) earlier than age ten.

As you might expect, there is a greater chance of injury in contact and collision sports, but many children still enjoy these activities, particularly if the coach emphasizes participation, not winning. Also, take into account your youngster's physical maturity. His ability to compete with his peers-particularly in the collision sports-depends more on body size and weight than on age. A late-maturing junior high school youngster, for instance, may have fewer skills and be much more susceptible to injury in contact or collision sports than his more mature teammates and opponents. Do not pressure your child to participate in a sport for which he may lack the proper maturity level. You, your child, and your pediatrician should discuss the most appropriate activities or sports for your youngster, and whether the advantages of a contact or collision sport outweigh the potential risks.

No matter which program you choose, take time to find out about the program's philosophy before making a final decision. It's important to understand how the game will be played and what role each member will take on. Here are some questions you can ask to help you find out about those details:

• Do all team members get equal playing time? (Studies show that children would prefer to play regularly on a losing team rather than be relegated to the bench of a winning one.)
• Does the program emphasize mastery of the sport rather than winning? Is each child encouraged to reach his or her own potential in terms of skills development?
• Are youngsters given unconditional approval, with good efforts praised and mistakes met with gentle encouragement?
• Is the teaching of good sportsmanship emphasized?
• Are the needs of the children taken into consideration? For example, are practices at a convenient time and place, and are they limited to a reasonable length of time? Will the time demands prevent the children from participating in other activities and assuming other responsibilities?
• Are safety rules adhered to during practices and games? Is appropriate equipment available? Are children matched with others of the same size and strength? (This is particularly important in contact sports.)
• What expenses are involved, including the costs of equipment and travel?
• What are the expectations and demands on the parents' time?

Also, investigate the coach or coaches for whom your child will be playing. They can serve as important role models for your youngster. They should enjoy being with children and communicate well with them. They should respect each member of the team as an individual, not showing favoritism toward the best athletes on the team. They should be knowledgeable about the game they are coaching, not only in order to help children learn the sport properly but also to minimize the chance of injury. Their practices should be instructive, safe, and enjoyable, and games should emphasize participation, learning, and fun-not winning. Even when their players do not perform up to expectations, the coaches should provide support rather than react angrily.

Keep in mind that responsible parenting involves evaluating your children's athletic needs and expectations, investigating the sports that are available and which ones are most appropriate for them, estimating the quality of your youngsters' experience, and deciding whether a particular activity lends itself to a lifelong habit of exercise. Sports are one aspect of your child's life in which being an active advocate can have big payoffs.

Source: American Academy of Pediatrics

Make exercise a part of your lifestyle. Your goal should be some type of exercise every day, or at the very least, 3 to 4 times a week. Try to do some kind of aerobic activity that requires continuous physical activity without stopping for at least 20 to 30 minutes each time. Do the activity as often as possible, but do not exercise to the point of pain because this can lead to injury.

Like all things, exercise can be overdone. Signs you may be overdoing it include:

• Weight that falls below what is normal for your age, height, and build
• It starts to interfere with your normal activities
• Muscles that become so sore that you risk injuring yourself

If you notice any of these signs in yourself or your child, talk with your physician or you child's pediatrician before health problems occur.

Besides the physical and mental health benefits, regular physical activity can also help increase self-confidence, offer the opportunity to learn new skills and meet people with similar interests. To make more time for exercise, limit the amount of time you and your family watch television or play computer or video games. Whenever possible, eat 3 healthy meals a day, including at least 2 to 4 servings of fruit and 3 to 5 servings of vegetables each day. Limit your intake of fat, cholesterol, salt, and sugar. For even better health, don't smoke, drink alcohol, or do other drugs.

Exercise should also be a routine part of your family's day, just like eating, and sleeping. It may help to plan a physical activity as a family. Most people find that it is more fun to exercise with someone else. More importantly, though, is that everyone likes the exercise or activity. Everyone is more apt to stay in the habit of doing whatever activity they choose if it is one that they enjoy.

Try to pick a "life sport" that you or your family enjoy. Unlike a competitive team sport like football or baseball, a life sport is any kind of physical exercise or activity that you can do throughout your life. Examples of life sports are:

• Swimming
• Golf
• Bicycling
• Jogging
• Tennis
• Walking
• Skating

Regular exercise should include aerobic activity. Aerobic activity is continuous and it makes you breathe harder and increases your heart rate. This type of exercise increases your fitness level and makes your heart and lungs work more efficiently. It also helps to maintain a normal weight by burning off excess fat. Examples of aerobic activities are brisk walking, basketball, bicycling, swimming, in-line or ice skating, soccer, jogging, and taking an aerobics or step class. Baseball and football do not involve as much continuous exercise because you are not active the whole time. In general, the more aerobic an activity, the more calories – and eventually fat – will be burned.

Any type of regular, physical activity is good for your body. Household chores, such as mowing the lawn, vacuuming, or scrubbing, involve exercise and may have fitness benefits, depending on how vigorously you do the chores. Just about any physical activity will improve fitness. For example, walking is better than riding in a car, and using the stairs is better than taking an elevator. Making small changes like these in your everyday life can make you and your family more physically fit. The most important thing is to keep moving.

Be sure to include stretching exercises in your daily routine. Before doing any physical activity, stretch out your muscles. This warms them up and helps protect against injury. Stretching makes your muscles and joints more flexible, too. It is also important to stretch out after you exercise to cool down your muscles. Exercise videotapes, programs on television, and magazines can show you examples of how to stretch out different muscle groups, as well as different exercises everyone can do.

 Source: American Academy of Pediatrics

To be physically fit, you must work on all aspects of fitness, including the following:

• Cardiorespiratory endurance (aerobic fitness) – This is the ability of the heart, lungs, and circulatory system to deliver oxygen and nutrients to all areas of your body. When you are active, you breathe harder and your heart beats faster so that your body is able to get the oxygen it needs. If you are not fit, your heart and lungs have to work extra hard during physical activity.
• Body composition (body fat) – This is the percentage of body weight that is fat. Overweight people have more body fat in relation to the amount of bone and muscle in their bodies than do people who are physically fit. Overeating, not exercising enough, or both often lead to more body fat. Being overweight increases your risk of diabetes, high blood pressure, and heart attacks.
• Muscle strength and endurance – This is the amount of work and the amount of time that your muscles are able to do a certain activity before they get tired, such as lifting heavy objects or in-line skating.
• Flexibility – Flexibility is the ability to move joints and stretch muscles through a full range of motion. For example, people who are very flexible can bend over and touch the floor easily. A person with poor flexibility is more likely to get hurt during physical activity.

The chart below can help you gauge how exercise

Even in middle childhood some youngsters participating in competitive sports are looking for an edge that might make them run a little faster or throw a little harder. Often they will turn to nutrition for help.

However, there is no magical food or supplement that can transform an average athlete into a superstar. No matter what the age of your youngster, optimal performance depends more on a balanced diet, sufficient nutrients to meet the demands of physical activity, and adequate rest. To maintain that balance, some sports activities may require increases in:

Caloric (Energy) Intake.

Without adequate calories your child may feel weak and fatigued, and her athletic performance may suffer. To raise caloric consumption, your child should rely primarily upon carbohydrates (potatoes, rice, pasta, beans, bread), which are excellent sources of energy during exercise.

Protein Intake.

The protein needs of an athlete may be only a little higher than those of a more sedentary individual. Even so, some evidence suggests that a small increase in protein, in conjunction with exercise, may be important when trying to increase muscle mass and lean tissue. Often, simply by increasing caloric intake in a well-balanced diet, a child will obtain any additional protein she may require.

Fluid Intake.

Additional liquids are often overlooked, both by children engaged in sports and by their coaches. Yet during exercise, perspiring youngsters lose fluid that must be replaced to prevent dehydration and overheating. Children should drink plenty of water before exercising, and then drink again every ten to twenty minutes during exercise itself, even if they are not thirsty. This is particularly important when exercising in hot weather.

Fluid intake needs can vary widely from child to child, based on his or her body size, level of physical activity, and the weather. These requirements generally range from 1.5 to 3 quarts per day of fluid; your child should drink an extra 8 to 12 ounces of water for every half hour of strenuous physical activity.

Thanks to persuasive advertising, many children and their coaches believe that commercially prepared electrolyte or sports drinks have some advantages over water. These drinks do provide some replacement for the salts and sugars that are lost with vigorous exercise. However, they may be high in sugar, which can sometimes cause cramps, nausea, and diarrhea. Despite its simplicity, water is usually the best choice.

If your child is involved in a sport where his weight is important-perhaps wrestling or gymnastics-he might be drawn to unhealthy weight-management strategies, perhaps adopting a crash diet, taking laxatives, or consuming special supplements. Wrestlers, for example, in an attempt to "make weight," may be tempted to fast, which is potentially harmful. You might choose to consult your child's pediatrician or a registered dietitian to evaluate the adequacy of your child's diet. Your doctor will probably advise against rapid reduction in body weight.

Source: American Academy of Pediatrics

Does your child listen closely during story time? Does your child like to look through books and magazines? Does your child like learning the names of letters? If the answer is "yes" to any of these questions, your child may have already learned some important early reading skills and may be ready to learn some of the basics of reading. Learning to read happens gradually and it's important to support your child and foster interest along the way.

The following are a few tips to keep in mind as your child learns to read:

• Set aside time every day to read together. Many children like to have stories read to them at bedtime. This is a great way to wind down after a busy day and get ready for sleep.
• Leave books in your child's room for her to enjoy on her own. Make sure her room is reading-friendly with a comfortable bed or chair, bookshelf and reading lamp.
• Read books that your child enjoys. After a while, your child may learn the words to her favorite book. When this happens, let your child complete the sentences or take turns reciting the words.
• Do not drill your child on letters, numbers, colors, shapes or words. Instead, make a game out of it and find ways to encourage your child's curiosity and interests.

Reading books aloud is one of the best ways you can help your child learn to read. This can be fun for you, too. The more excitement you show when you read a book, the more your child will enjoy it. The most important thing to remember is to let your child set her own pace and have fun at whatever she is doing. Do the following when reading to your child:

• Run your finger under the words as you read to show your child that the print carries the story.
• Use funny voices and animal noises. Do not be afraid to ham it up! This will help your child get excited about the story.
• Stop to look at the pictures; ask your child to name things she sees in the pictures. Talk about how the pictures relate to the story.
• Invite your child to join in whenever there is a repeated phrase in the text.
• Show your child how events in the book are similar to events in your child's life.
• If your child asks a question, stop and answer it. The book may help your child express her thoughts and solve her own problems.
• Keep reading to your child even after she learns to read. A child can listen and understand more difficult stories than she can read on her own.

Once your child begins to read, have him read out loud. This can help build your child's confidence in his ability to read and help him enjoy learning new skills. Take turns reading with your child to model more advanced reading skills.

If your child asks for help with a word, give it right away so that he does not lose the meaning of the story. Do not force your child to sound out the word. On the other hand, if your child wants to sound out a word, do not stop him.

If your child substitutes one word for another while reading, see if it makes sense. If your child uses the word "dog" instead of "pup," for example, the meaning is the same. Do not stop the reading to correct him. If your child uses a word that makes no sense (such as "road" for "read"), ask him to read the sentence again because you are not sure you understand what has just been read. Recognize your child's energy limits. Stop each session at or before the earliest signs of fatigue or frustration.

Most of all, make sure you give your child lots of praise! You are your child's first and most important teacher. The praise and support you give your child as he learns to read will help him enjoy reading and learning even more.

The American Academy of Pediatrics gratefully acknowledges the assistance of the Reach Out and Read program in the development of this information. Reach Out and Read is a pediatric early literacy program that makes literacy promotion and giving out books part of pediatric primary care. This program is endorsed by the American Academy of Pediatrics. For more information about Reach Out and Read, please contact the program at:

Reach Out and Read
National Center
29 Mystic Ave
Somerville, MA 02145
617/629-8042
www.reachoutandread.org

Source: American Academy of Pediatrics

What a time of wonder these first few months are! From a sleeping and eating machine to a smiling, responsive infant, your baby will grow by leaps and bounds in many ways, including physically.

How much should my baby grow?
After losing some of her birth weight during the first few days of life, your baby will be starting to grow steadily. By the middle of her first month, she will probably be gaining about 0.5 to 1 ounce per day. After the first month, weight gain may average 1.5 to 2 pounds and length may increase 1 to 1.5 inches per month. These are just averages; as long as your baby is staying on her own growth curve, you should have no concerns about her progress. Your pediatrician will measure her weight, length, and head circumference and plot your baby's own growth path on a chart, so any growth problems can be spotted early.

Should I be concerned?
If your 1-3 month old is not growing at an average rate, or her own personal growth rate slows, your doctor will want to make sure she's eating enough and absorbing enough of what she's eating. Your doctor may want to know the following, among other things:

• How many feedings a day your baby gets
• How much your baby eats at each feeding
• How long a breast-feeding baby nurses at each feeding
• How many bowel movements your baby has each day, and their volume and consistency
• How often your baby urinates

Most of the time, baby's progress will simply be tracked over the next few months. But if your pediatrician detects a problem, he or she may recommend that you increase the number of feedings, or the amount fed at each feeding. In rare cases, there may be a physical reason for slow growth; these cases are investigated with special testing.

Another way to track your infant's growth is to watch her progress in other areas. For example, it's reassuring if your baby is reaching developmental milestones at about the average age. If at any time you have concerns about your baby's growth, or if she seems especially listless or unresponsive, call your doctor immediately.

Premature babies may be weighed weekly to make sure they are growing properly. Preemies should not be compared with full-term babies as they grow. They have some catching up to do!

What's next?
Some doctors recommend that hungry babies be started on solids at four months. After the first few months, your baby may need more energy, and therefore more calories, to keep growing.

Source: American Medical Association

Your newborn may seem to do little more during the first weeks of life than eat, sleep, cry, and, oh yes, provide dirty diapers for you to clean up. But in reality, all of his senses are functioning already, taking in the sights, sounds and smells of this new world he's entered. It's hard for us to know exactly what a newborn is feeling - but if you pay close attention to his responses to light, noise and touch, you can see his complex senses beginning to come alive.

Sight
A newborn's sight is perfectly set to see the most important things in the world to him - his parents' faces. New babies can see best at a distance of only 8 inches to 14 inches, bringing his eyes in focus when he's gazing up from the arms of Mom or Dad. Your newborn can see things further away, but it is harder for him to focus on distant objects. Still, the light shining in from a faraway window may catch his eye, and he may stare at another family member moving around the room.

After human faces, brightness and movement are the things he likes to look at best. Even a crude line drawing of two eyes, a nose and a mouth may keep his attention if held close enough. Although his sight is functioning, it still needs some fine tuning, especially when it comes to focusing far off. His eyes may even seem to cross or diverge (go "wall-eyed") briefly. This is usually just a sign that your newborn's eye muscles need to strengthen and mature a bit during the next few months.

Your newborn is better equipped to see contrasting colors than closely related hues. Black-and-white pictures or toys will keep his interest far longer than objects or pictures with lots of similar colors. Knowing that your newborn sees and enjoys seeing should prompt you to give him lots of interesting sights to look at, but don't overload him. One item at a time is plenty. And don't forget to move your baby around a bit during the day. You'll be providing a needed change of scenery to your little looker.

Hearing
Your newborn has been hearing sounds since way back in the womb! Mother's heartbeat, the gurgles of her digestive system, and even the external sounds of her voice and the voices of other family members have been part of his world for a while now. Once he's born, the sounds of the outside world come in loud and clear. Your baby may startle at the unexpected bark of a dog close by or a plate breaking on the floor. He may seem to be soothed by the gentle whirring of the clothes drier or the hum of the vacuum cleaner.

Try to pay attention to how he responds to your voice. Human voices, especially Mom's and Dad's, are his favorite "music." He already knows this is where care comes from: food, warmth, touch. If he's crying in his bassinet, see how quickly your approaching voice quiets him. See how closely he listens when you are talking to him in loving tones. He may not yet coordinate looking and listening, but even if he stares into the distance, he'll be paying close attention to your voice as you speak.

Taste and Smell
We assume newborns can smell because we know they can taste, and these are the two most closely related of the human senses. Research with new babies shows they prefer sweet tastes from birth and will choose to suck on bottles of heavily sweetened water but will turn away or cry if given something bitter or sour to taste.

Think of the world of smells an ordinary day affords your newborn: your clothes, dinner cooking on the stove, flowers in the yard. And at this point at least, you don't have to worry too much about your baby's taste buds. Breast milk (the best!) or formula will satisfy him completely!

Touch
As it is to most humans, touch is extremely important to your newborn. Through touch, he learns a lot about the world around him. At first, he is looking only for comfort. Having come from a warm and enveloping fluid before birth, he'll be faced with feeling cold for the first time, brushing up against the hardness of the crib, feeling the scratch of a rough seam inside his clothes. He'll be looking to his parents to provide the soft touch he needs: silky blankets, comforting hugs, and loving caresses upon his head. With almost every touch your newborn is learning about life, so provide him with lots of tender kisses and he'll find the world a soothing place to be.

Should I be concerned?
If you just want a little reassurance that your baby's senses are working well, you can do some unscientific testing for yourself. Hold a small light just out of his direct line of vision, about a foot away from his face. He should turn to look at the light. Don't be too worried if it doesn't hold his attention for too long - the fact that he responded by looking at the light indicates that he is seeing it. In just a few short weeks, your newborn baby will begin to follow a moving light with his eyes.

If your baby's eyes seem to cross or diverge (go "wall-eyed") more than just briefly, point this out to your doctor. Usually no intervention is necessary, but sometimes medical correction will be required. Also tell your doctor if your baby's eyes appear cloudy or filmy, or if they appear to wander in circles as they attempt to focus.

Most newborns will startle if surprised by a loud noise nearby. If you want to check that your baby is hearing, you can make a sharp noise while standing behind him. He should jump a little - but if he doesn't, don't worry. It may mean he was concentrating on something else and had "tuned out" the real world at that moment. Just try the noise test again later. There are other ways to rest assured your baby is hearing well. Does he stop crying once he hears your voice moving toward him? Does he respond to soft lullabies or other music? Do sounds made out of his line of vision capture his attention, even though he can't see where they are coming from?

If you have any further concerns about your newborn's ability to see or hear, you should bring them to your doctor's attention immediately. Even newborns can be tested using sophisticated equipment, if necessary. The sooner a potential problem is caught, the better it can be treated.

Source: American Medical Association

Even in these "gender-neutral" times, you've probably noticed significant differences between your sons and daughters (besides the obvious physical ones). Your own boys and girls may have varying interests. Their skills and aptitudes may differ. So might their styles of play, and the way they relate to friends.

In fact, boys and girls are different. Researchers, however, disagree on whether these differences are attributable to nature or nurture. Are they the result of genetics? Or is social conditioning primarily responsible? In this ongoing debate, there are no definitive answers. Some investigators believe differences between the sexes can be traced back to the womb, where the developing brains of boys and girls are exposed to varying hormones. But other investigators insist that these variations are primarily environmental in nature. After all, they say, boys and girls are often treated differently by the adults in their lives, including parents and teachers who often praise them for "gender appropriate" behavior and activities.

Certain gender differences, while present in the first years of life, become even more evident in school-age children. Although most boys and girls have these gender-specific characteristics and patterns of behavior, all boys are not alike, nor are all girls.

The gender-role behavior of children seems to be strongly influenced by their identification with the males and females in their lives. All children pick up characteristics from the men and women around them, incorporating these traits into their own personalities and value systems. They are also influenced by TV and sports heroes and adults in all other activities in their lives. Over time, the combined effect of these many influences may determine many of their masculine and feminine qualities. Perhaps more than any other factor, the subtleties of every child's relationship with his or her father and mother - and the attitudes of the parents toward each other and toward the child - will influence his or her gender-related behaviors.

Gender Identity in Early Childhood

A child's awareness of being a boy or a girl starts in the first year of life. It often begins by 8 to 10 months of age, when youngsters typically discover their genitals. Then, between 1 and 2 years old, children become conscious of physical differences between boys and girls; before their third birthday they are easily able to label themselves as either a boy or a girl as they acquire a strong concept of self. By age 4, children's gender identity is stable, and they know they will always be a boy or a girl.

During this same time of life, children learn gender role behavior - that is, doing things "that boys do" or "that girls do." So while playing house, boys will naturally adopt the father's role and girls the mother's, reflecting whatever differences they've noticed in their own families and in the world around them. Even if both parents work and share family responsibilities equally, your child will still find conventional male and female role models in television, magazines, books, billboards and the families of friends and neighbors. At this age, your son may also be fascinated by his father, older brothers, or other boys in the neighborhood, while your daughter will be drawn to her mother, older sisters and other girls.

Before the age of 3 children can differentiate sex-stereotyped toys that are identified with boys or girls. By 3 years of age they have also become more aware of boy and girl activities, interests and occupations; many begin to play with youngsters of their own sex in activities identified with that sex. For example, you probably saw your daughter gravitating toward dolls, playing house and baking. By contrast, your son may have played more aggressive and active games and might have been attracted to toy soldiers and toy trucks. By the time they enter kindergarten, children's gender identities are well established.

Children this age will often take this identification process to an extreme. Girls will insist on wearing dresses, nail polish, and makeup to school or to the playground. Boys will strut, be overly assertive and carry pretend guns wherever they go. This behavior reinforces their sense of being male or female.

Gender Identity in Middle Childhood

In middle childhood, gender identification continues to become more firmly established, not only in children's interest in playing more exclusively with youngsters of their own sex, but also in their interest in acting like, looking like, and having things like their same-sex peers. During this time of life you will see your child express his or her gender identity through gender-specific role behavior, some of which began during the preschool years.

All children engage in pretend play. However, the themes of this play tend to differ between the sexes. Boys may assume the role of a heroic character (perhaps one that they've seen on television), and engage in fantasy activities that involve righteous combat or danger. Boys in the middle years are also drawn to toys that move; that's why they like to play with trucks and balls. The play of girls often revolves around school or domestic themes (they may rock their "baby'' to sleep or apply a Band-Aid to their doll).

In nearly every culture that has been studied, boys are more aggressive than girls on the playground. One study found that boys spend much of their playtime participating in games, the majority of which are competitive; in fact, during play, fourth- and fifth-grade boys engage in competitive games about 50 percent of the time, compared to one percent for girls. Boys are also very focused on the rules of the games they're playing, and often argue with playmates over them ("You broke the rules!").

Girls tend to settle differences by talking them out. If there are disagreements about the rules, girls are more likely than boys to suggest a compromise, saying "Let's make the rules different, " or "Let's play a different game. " They are less likely to yell at one another, feeling it's more important to maintain the relationship than to prevail during a disagreement. Their games are more inclined to involve turn-taking than those of boys.

Boys are typically allowed and sometimes encouraged to be assertive, outspoken and loud, and their excesses are dismissed with the explanation, "Boys will be boys.'' However, you should guide your son toward channeling his aggressiveness in constructive ways, including burning off energy in physical play rather than confrontation. Roughhousing and fighting, although common among boys in this age group, tend to decline during the later years of middle childhood.

Keep in mind that children learn from their play, so guide your daughters (and your sons) into a broad array of experiences. They should be given toys and directed into activities that go beyond the stereotypes of their sex. Thus, while it's fine to give your daughter a doll, also present her with traditional boys' toys.

Source: American Academy of Pediatrics

Committee on Infectious Diseases and Committee on Pediatric AIDS

ABSTRACT

Children infected with human immunodeficiency virus (HIV) have had high rates of mortality attributable to measles, but until recently, measles vaccine was assumed to be safe for these children. A single fatal case of pneumonia attributable to vaccine type-measles virus has been documented in a young adult with acquired immunodeficiency syndrome. Because a protective immune response often does not develop in severely immunocompromised HIV-infected patients after immunization and some risk of severe complications exists, HIV-infected children, adolescents, and young adults who are severely immunocompromised (based on age-specific CD4 lymphocyte enumeration) attributable to HIV infection should not receive measles vaccine. All other HIV-infected children, adolescents, and young adults who are not severely immunocompromised should receive measles-mumps-rubella vaccine.

ABBREVIATIONS: HIV, human immunodeficiency virus; MMR, measles-mumps-rubella (vaccine); IGIV, intravenous immune globulin.

BACKGROUND

Live attenuated measles virus vaccine has been recommended for children, adolescents, and young adults with known human immunodeficiency virus (HIV) infection to prevent morbidity and mortality attributable to measles.1,2 The immunosuppressive effect of HIV predisposes to high mortality rates in HIV-infected children who develop measles. In developing nations, the mortality rate attributable to measles has been 50% for HIV-infected children.1-3 From 1989 through 1991, 55,000 cases of measles occurred in the United States. New York City reported 19 deaths, 11 of which were known to be associated with HIV infection.2 Measles-mumps-rubella (MMR) vaccine had been recommended for all HIV-infected children because it appeared to be safe without serious or unusual reactions.4,5 MMR vaccine should be administered to children 12 to 15 months of age, and knowledge of HIV status is not a prerequisite for immunization.6

A single report of a 21-year-old college student who received a second dose of measles vaccine in September 1992 has provided the first indication of potential harmful consequences of measles vaccine in a severely immunocompromised HIV-infected person.5 This man had a CD4 cell count of 10/µL at the time of immunization, and Pneumocystis carinii pneumonia developed 1 to 2 months after he received the second dose of MMR vaccine. Approximately 1 year after vaccination, he was evaluated for progressive pulmonary disease. A transbronchial biopsy revealed multinucleated giant cells, and a measles virus was cultured that has been identified as vaccine-like by genomic sequencing. The patient died in December 1993, approximately 15 months after receipt of the vaccine. This patient had no identified measles rash, and progressive nodular disease was evident on the chest radiograph. Similar pulmonary disease associated with wild type and vaccine virus-induced disease has been reported in other immunocompromised patients.7,8 Progressive pulmonary disease attributable to wild type measles infection has developed in HIV-infected persons.9,10

Measles as the cause of the pneumonia in this HIV-infected patient was not appreciated until 11 to 12 months after administration of MMR vaccine. This long incubation period is unique; however, wild type measles virus may establish a persistent infection. This raises the possibility that other HIV-infected patients with pulmonary disease might not have been evaluated for the presence of measles virus, although no other cases of MMR-associated pulmonary complications have been reported after immunization in HIV-infected children.

MEASLES IMMUNITY IN HIV-EXPOSED OR HIV-INFECTED INFANTS

HIV-infected women have lower concentrations of measles-specific antibodies and they transmit less measles antibody to their infants, resulting in susceptibility at a younger age than usual.11

ADMINISTRATION OF MMR TO HIV-INFECTED CHILDREN, ADOLESCENTS, AND YOUNG ADULTS WITHOUT SEVERE IMMUNOSUPPRESSION

Several studies have substantiated a suboptimal and unpredictable response to MMR vaccine in HIV-infected children.12-14 Also, measles antibody titers decline more rapidly after immunization in HIV-infected children compared with uninfected children.15,16 However, the administration of MMR vaccine to HIV-infected children, adolescents, and young adults without severe immunosuppression continues to be important, and administration of vaccine before deterioration of the immunologic status provides the best opportunity to induce protection. Immunization of HIV-infected infants at 9 to 11 months was associated with somewhat better antibody responses17,18 than in children at 12 to 15 months in two small studies; this question of the optimal age of immunization is being addressed in a randomized study conducted by the AIDS Clinical Trial Group. Pending the results of this trial, HIV-infected children should be immunized as soon as they reach 12 months of age to induce an appropriate immune response. The second dose may be administered as soon as 30 days later in an attempt to induce early seroconversion. All persons in the household who are not HIV-infected and not otherwise immunocompromised should have immunity to measles. Immunity is defined as having been born before 1957, a history of physician-diagnosed measles, laboratory evidence of immunity, or age-appropriate immunization.

HIV-INFECTED CHILDREN, ADOLESCENTS, AND YOUNG ADULTS WITH SEVERE IMMUNOSUPPRESSION

Attenuated measles vaccine virus has caused fatal disease in one severely immunosuppressed HIV- infected patient. Because measles vaccine has been safely administered to >1000 HIV-infected children in the United States, we know that the risk of vaccine-induced virus disease is much less than that of wild type measles virus, but most of the children were not severely immunocompromised at the time of immunization. The antibody response to measles vaccine decreases as the level of immunosuppression increases.13,17,18 In one study, measles antibody developed after vaccination in 71% (12/17) of children without severe immunosuppression, but antibody developed in only 17% (3/18) of those with severe immunosuppression.15 In another study, 90% of HIV-infected children with CD4 lymphocyte counts <200/µL did not respond to measles vaccine, and severe disease after exposure to measles developed in some HIV-infected children who had been immunized.13 Thus, measles vaccine should not be administered to severely immunosuppressed HIV-infected children, adolescents, and young adults because they do not respond well to measles vaccine and there is some risk of serious complications. Whether a given CD4+ T-cell level achieved in response to antiretroviral therapy provides an equivalent assessment of the degree of immune system function or has the same predictive value for risk of opportunistic infections as do CD4+ T-cell levels obtained in the absence of therapy is unknown.

Mumps and rubella vaccine viruses have not been recognized to cause serious complications in HIV-infected persons, but these and other live vaccines should be withheld from severely immunocompromised persons as they are unlikely to benefit and complications could occur.

ASSESSMENT OF IMMUNOLOGIC STATUS OF HIV-INFECTED CHILDREN, ADOLESCENTS, AND YOUNG ADULTS

The HIV infection status of all infants born to HIV-infected women should be monitored.19 An HIV culture or a polymerase chain reaction are the preferred methods for diagnosing HIV infection among infants.19,20 The CD4 counts and percentages should be measured to assess the HIV-infected child's immune status, risk for disease progression, and need for antiretroviral therapy.20-22 Quality standards for the enumeration of CD4 lymphocytes in children, adolescents, and young adults infected with HIV have been established.20,23 All HIV-infected children, adolescents, and young adults should have an initial CD4 lymphocyte count determined and repeated at least every 3 to 4 months if the initial count is >500/µL. If the initial count is between 200 and 500/µL) and the patient is asymptomatic, the assay should be repeated at intervals determined by the physician but no less frequently than every 3 to 4 months.20,23

Severe Immunosuppression

The definition of severe immunosuppression is currently based on CD4+ T-lymphocyte enumeration stratified by age.24,25 Once a child has met the definition of severe immunosuppression, the child is always considered severely immunosuppressed.

Passive Immunization to Prevent Measles

Immunized HIV-infected children, adolescents, and young adults have contracted wild type measles and sustained severe disease. If exposed to measles, all HIV-infected infants, children, and adolescents, as well as children of unknown infectious status born to HIV-infected women, should receive 0.5 mL/kg (maximum dose, 15 mL) of immune globulin intramuscularly, regardless of their immunization status, because it is impossible to know in a timely fashion if the child has protective antibody. If the person exposed to measles is receiving intravenous immune globulin (IGIV) (400 mg/kg) and >3 weeks have elapsed since the last dose, the person should receive IG (0.5 mL/kg) or IGIV (400 mg/kg) as soon as possible. Because of the uncertainty regarding measles antibody concentrations in IGIV and the rapid metabolism of IGIV in HIV-infected children, some experts have chosen to administer an additional dose of IGIV if 2 or more weeks have elapsed since IGIV has been administered at the time of measles exposure.

RECOMMENDATIONS

1.      Severely immunosuppressed HIV-infected infants, children, adolescents, and young adults should not receive measles virus-containing vaccines.

2.      HIV-infected children, adolescents, and young adults without evidence of severe immunosuppression should receive MMR vaccine. The first dose should be administered at 12 months of age. The second dose may be given as soon as 28 days after the first dose. In the event of an outbreak in the community, vaccination with monovalent measles vaccine (or MMR) is recommended for infants as young as 6 months when exposure to natural measles is considered likely. Children vaccinated before the first birthday should be revaccinated with MMR at 12 months, and an additional dose may be given as soon as 28 days later.

3.      All members of the household of an HIV-infected person should receive measles vaccine unless they are HIV-infected and severely immunosuppressed, were born before 1957, have had physician-diagnosed measles, have laboratory evidence of measles immunity, have had age-appropriate immunizations, or have a contraindication to measles vaccine.

4.      If they are exposed to wild type measles, immune globulin prophylaxis should be administered to all HIV-infected children and adolescents and to children of unknown infection status born to HIV-infected women, regardless of the degree of immunosuppression or measles immunization status.  

REFERENCES

1.      Centers for Disease Control and Prevention. Measles in HIV-infected children, United States. MMWR Morb Mortal Wkly Rep. 1988;37:183-186

2.      Kaplan LJ, Daum RS, Smaron M, McCarthy CA. Severe measles in immunocompromised patients. JAMA. 1992;267:1237-1241

3.      Sension MG, Quinn T, Markowitz LE, et al. Measles in hospitalized children infected with human immunodeficiency virus. Am J Dis Child. 1988;142:1271-1272

4.      Friedman S. Measles in New York City. JAMA. 1991;266:1220

5.      Centers for Disease Control and Prevention. Measles pneumonitis following measles-mumps-rubella vaccination of a patient with HIV infection: 1993. MMWR Morb Mortal Wkly Rep. 1996;45:603-606

6.      American Academy of Pediatrics. Measles. In: Peter G, ed. 1997 Red Book. Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, IL: American Academy of Pediatrics; 1997:348-350

7.      Enders JF, McCarthy K, Mitus A, Cheatham WJ. Isolation of measles virus at autopsy in cases of giant-cell pneumonia without rash. N Engl J Med. 1959;261:875-881

8.      Mitus A, Holloway A, Evans AE, Enders JF. Attenuated measles vaccine in children with acute leukemia. Am J Dis Child. 1962;103:413-418

9.      Nadel S, McGann K, Hodinka RL, Rutstein R, Chatten J. Measles giant cell pneumonia in a child with human immunodeficiency virus Infection. Pediatr Infect Dis J. 1991;10:542-544

10. Markowitz LE, Chandler FW, Roldan EO, et al. Fatal measles pneumonia without rash in a child with AIDS. J Infect Dis. 1988;158:480-483

11. Embree JE, Datta P, Stackiw W, et al. Increased risk of early measles in infants with human immunodeficiency virus type 1-seropositive mothers. J Infect Dis. 1992;165:262-267

12. Krasinski K, Borkowsky W. Measles and measles immunity in children infected with human immunodeficiency virus. JAMA. 1989;261:2512-2516

13. Palumbo P, Hoyt L, Demasio K, Oleske J, Connor E. Population-based study of measles and measles immunization in human immunodeficiency virus-infected children. Pediatr Infect Dis J. 1992;11:1008-1014

14. Brena AE, Cooper ER, Cabral HJ, Pelton SI. Antibody response to measles and rubella vaccine by children with HIV infection. J Acquir Immune Defic Syndr. 1993;6:1125-1129

15. Walter EB, Katz SL, Bellini WJ. Measles immunity in HIV-infected children. Pediatr AIDS HIV Infect. 1994;5:300-304

16. Al-Attar I, Reisman J, Muehlmann M, McIntosh K. Decline of measles antibody titers after immunization in human immunodeficiency virus-infected children. Pediatr Infect Dis J. 1995;14:149-151

17. Arpadi SM, Markowitz LE, Baughman AL, et al. Measles antibody in vaccinated human immunodeficiency virus type 1-infected children. Pediatrics. 1996;97:653-657

18. Rudy BJ, Rutstein RM, Pinto-Martin J. Responses to measles immunization in children infected with human immunodeficiency virus. J Pediatr. 1994;125:72-74

19. El-Sadr W, Oleske JM, Agins BE, et al. Clinical Practice Guideline Number 7. Evaluation and Management of Early HIV Infection. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, January 1994; AHCPR publication 94-0572

20. American Academy of Pediatrics, Committee on Pediatric AIDS. Evaluation and medical treatment of the HIV-exposed infant. Pediatrics. 1997;99:909-917

21. National Pediatric and Family HIV Resource Center and National Center for Infectious Diseases, Centers for Disease Control and Prevention. 1995 revised guidelines for prophylaxis against Pneumocystis carinii pneumonia for children infected with or perinatally exposed to human immunodeficiency virus. MMWR Morb Mortal Wkly Rep. 1995;44(RR-4):1-11

22. Wilfert CM, Gross PA, Kaplan JE, et al. Quality standard for the enumeration of CD4+ lymphocytes in infants and children exposed to or infected with human immunodeficiency virus. Clin Infect Dis. 1995;21(suppl 1):S134-S135

23. Gross PA, Phair JP, Kaplan JE, Holmes KK, Masur H. Quality standard for the enumeration of CD4+ lymphocytes in adults and adolescents infected with human immunodeficiency virus. Clin Infect Dis. 1995;21(suppl 1):S126-S127

24. Centers for Disease Control and Prevention. 1994 revised classification system for human immunodeficiency virus infection in children less than 13 years of age. MMWR Morb Mortal Wkly Rep. 1994;43(RR-12):1-19

25. Centers for Disease Control and Prevention. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Morb Mortal Wkly Rep. 1992;41(RR-17):1-19

Source: American Academy of Pediatrics

AIDS, which stands for acquired immune deficiency syndrome, is a very serious disease that affects children, teens, and adults. It is caused by a virus called the human immunodeficiency virus (HIV). This virus is acquired and causes a deficiency in the body's immune system.

HIV is the virus that causes AIDS. When someone is infected with HIV, it means the virus is attacking the immune system. The immune system is the body's way of fighting infections and helping prevent some types of cancer. Damage to the immune system from HIV can occur over months, as sometimes happens in infants. Sometimes it occurs slowly over years, as more often happens in adults. AIDS is diagnosed in an HIV-infected person when the immune system is severely damaged or when certain other serious infections or cancer occurs.

Many people do not know they are infected with HIV because it can take many years for serious symptoms to develop. However, even if an infected person shows no symptoms, the infection can spread to others. Many people with HIV infection look and act healthy. You cannot tell just by looking at people whether they are infected with HIV. A blood test for HIV is the only way to be sure.

AIDS has rapidly become the leading cause of death in young adults and children in many areas in the United States. Although there is treatment available, there is no cure for AIDS. The disease can be prevented by educating yourself and your children about AIDS and HIV, including the behaviors that can increase the risk of getting AIDS.

HIV is spread from one person to another through certain body fluids. These fluids include blood and blood products, semen (sperm), fluid from the vagina, and breast milk. The following are ways HIV can be spread:

• By sexual intercourse (vaginal, anal, or oral) with a person who is infected with HIV. Both males and females can spread HIV. Latex condoms can help prevent the spread of HIV and other sexually transmitted diseases (STDs). The safest way to prevent these diseases is to abstain from all forms of sexual intercourse until married or in a long-term mature relationship with an uninfected partner.
• Through contact with an infected person's blood. Sharing syringes or needles for drug use or for other activities such as tattooing or ear piercing can spread HIV. Accidental injuries from contaminated needles can also cause HIV infection. This can happen if a person comes into contact with used needles that have been thrown away. Rarely, HIV has been spread by an infected person's blood directly contacting the mucous membranes, cuts, scrapes, or open sores of another person.
• To a baby by his or her HlV-infected mother during pregnancy, labor, delivery, or breastfeeding.
• Through blood or blood products from blood transfusions, organ transplants, or artificial insemination. This occurs very rarely because donors of blood, sperm, tissue, and organs in the United States are tested routinely for HIV.

It is very important to know how HIV is not spread. Fear and wrong information about HIV and AIDS cause suffering to those who have been infected with HIV. Make sure you and your children understand that HIV cannot be spread through casual contact with someone who has AIDS or is infected with HIV. You cannot get HIV in the following ways:

• Shaking hands
• Hugging
• Sitting next to someone
• Sharing bathrooms
• Eating food prepared by an HIV-infected person

Also, you cannot get HIV from the following:

• The air
• Insect bites
• Giving blood
• Swimming pools

Source: American Academy of Pediatrics

Anyone who is involved in risky behaviors should get an HIV test. Anyone who wants to know whether or not they have HIV can be tested. However, a negative test does not mean a person is uninfected if the risky behaviors took place only a few months before the test.

The following symptoms may suggest a need for HIV testing:

• Persistent fevers
• Loss of appetite
• Frequent diarrhea
• Poor weight gain or rapid weight loss
• Chronic lymph node swelling
• Persistent or recurring extreme tiredness or lethargy
• White spots in the mouth
• Recurring or unusual infections

While there is no cure for HIV or AIDS, there are medications that can help delay symptoms, help prevent the spread of HIV to an unborn baby, and help prevent additional infections in HIV-infected people.

HIV and AIDS are important issues to think about and discuss. Educating yourself and your family about HIV and AIDS is the best way to keep your family healthy. Make sure your child or teens knows the facts about this serious yet preventable disease.

It's important to introduce these discussions to your child at an early age. This will open the door to future communications and your child will be more willing to come to you with questions she may have. By the time your children are 3 or 4 years old, make sure you have clearly explained the following to them:

• They should never touch anyone else's blood or open sores.
• They should never touch needles or syringes. If they see someone who is bleeding or if they find a needle or syringe, they should tell an adult. Remind your children never to touch a needle or syringe if they find one in the garbage or on the ground.
• AIDS cannot be caught by playing with HIV-infected children.

By grade-school age, your child should begin to have a better understanding of illness and body parts. He or she should begin to learn more about how HIV can and cannot be spread.

For preteens and teenagers it is important to know that the best way to protect themselves against HIV and AIDS is to refrain from having any type of sexual intercourse. Urge your teenager to postpone sexual intercourse until married or in a long-term, mature relationship with an uninfected partner. Neither person should have any other sexual partners.

If teenagers do not postpone having sexual intercourse, then proper use of latex condoms and limiting the relationship to one partner will help them avoid HIV infection. This will also lower the risk of getting other sexually transmitted diseases (STDs) such as syphilis, gonorrhea, Chlamydia infection, and genital warts. Adolescents should also know about other types of birth control. However, it should be emphasized that other forms of birth control do not prevent HIV infection or other STDs.

Adolescents also need to know about the extremely high risk of being infected with HIV if they use drugs, especially intravenous (IV) drugs that are injected with needles. Sharing a needle or syringe spreads blood from one person to another. Also, people who do not use drugs themselves but are having sexual intercourse with an HIV-infected drug user can be infected with HIV. Sharing needles for non-drug use, such as for tattoos, ear piercing, intentional scarring or cutting with a razor or needle, or injecting drugs like steroids, can also spread HIV.

When talking to your adolescent about drugs, make sure your adolescent understands that using drugs is very dangerous. The risk of getting HIV increases even when non-IV drugs like alcohol or cocaine are used. This is because these drugs affect a person's judgment and may lead to risky behaviors such as having sex without a latex condom or having sex with multiple partners.

If your preteen or teenager is using drugs or alcohol or is involved in risky sexual behaviors, he is at higher risk of HIV infection. If you think that your adolescent or child is at risk of becoming infected with HIV, it is very important to discuss this with your pediatrician.

Source: American Academy of Pediatrics

What is jaundice?

Jaundice is a common condition in newborn infants that usually shows up shortly after birth. In most cases, it goes away on its own. If not, it can be treated easily.

A baby has jaundice when bilirubin, which is produced naturally by the body, builds up faster than a newborn's liver can break it down and get rid of it in the baby's stool. This happens because of one or more of the following reasons:

• The baby's developing liver is not yet able to remove the bilirubin from the blood
• More bilirubin is being made than the liver can handle
• Too much of the bilirubin is reabsorbed from the intestines before the baby gets rid of it in the stool

Too much bilirubin makes a jaundiced baby's skin look yellow. This yellow color will appear first on the face, then on the chest and stomach, and, finally, on the legs.

What is bilirubin?

Everyone's blood contains hemoglobin found in red blood cells. Red blood cells live only a short time and, as they die, the oxygen-carrying substance (hemoglobin) is changed to yellow bilirubin. Normal newborns have more bilirubin because their liver is not efficient at removing it. Older babies, children, and adults get rid of this yellow blood product quickly, usually through bowel movements.

Jaundice can be dangerous if the bilirubin reaches too high a level in the blood. The level at which it becomes dangerous will vary based on a child's age and if there are other medical conditions. A small sample of your baby's blood can be tested to measure the bilirubin level. Other tests may be needed to see if your baby has a special reason to make extra bilirubin that is causing the jaundice.

Parents should be aware of any changes in their newborn's skin color or the coloring in the whites of their child's eyes. Look at the baby under natural daylight or in a room that has fluorescent lights. A quick and easy way to test for jaundice is to press gently with your fingertip on the tip of your child's nose or forehead. If the skin looks white (this is true for babies of all races), there is no jaundice. If you see a yellowish color, contact your pediatrician to check your baby to see if significant jaundice is present.

Treating Jaundice in Healthy Newborns

Mild to moderate levels of jaundice do not require any treatment. If high levels of jaundice do not clear up on their own, your baby may be treated with special lights or other treatments. These special lights help get rid of the bilirubin by altering it to make it easier for your baby's liver to get rid of it. This treatment may require that your baby stay in the hospital for a few days. Some pediatricians treat babies with these lights at home. If your baby needs light therapy, talk to your pediatrician about how long the treatment lasts and where it will be done.

Another treatment is more frequent feedings of breastmilk or formula to help pass the bilirubin out in the stools. Increasing the amount of water given to a child is not sufficient to pass the bilirubin because it must be passed in the stools. Rarely, babies may require treatment of their blood to remove bilirubin. For example, in a few cases of very high bilirubin levels, a blood exchange is done to give a baby fresh blood and remove the bilirubin. Your pediatrician will give you more details if other treatments are necessary. Once your child's bilirubin level goes down, it is unlikely that it will increase again. However, if your child continues to look yellow after 3 weeks of life, talk to your pediatrician as other tests may need to be done.

Most breastfed babies do not have a problem with jaundice that requires interruption of breastfeeding. However, if your baby develops jaundice that lasts a week or more, your pediatrician may ask you to temporarily stop breastfeeding for a day or two. If you must temporarily stop breastfeeding, talk to your pediatrician about pumping your breasts so you can keep producing breast milk and can restart nursing easily.

If your baby has jaundice, do not be alarmed. Remember that jaundice in a healthy newborn is not serious and usually clears up easily. If your baby has a very serious case of jaundice and other medical problems, your pediatrician will talk to you about other treatments.

Source: American Academy of Pediatrics

Does your infant have a regular fussy period each day when it seems you can do nothing to comfort her? This is quite common, particularly between 6:00 p.m. and midnight, just when you, too, are feeling tired from the day's trials and tribulations. These periods of crankiness may feel like torture, especially if you have other demanding children or work to do, but fortunately they don't last long. The length of this fussing usually peaks at about three hours a day by 6 weeks, and then declines to one or two hours a day by 3 months. As long as the baby calms within a few hours and is relatively peaceful the rest of the day, there's no reason for alarm.

If the crying does not stop but intensifies and persists throughout the day or night, it may be caused by colic. About one-fifth of all babies develop colic, usually between the second and fourth weeks. They cry inconsolably, often screaming, extending or pulling up their legs and passing gas. Their stomachs may be enlarged or distended with gas. The crying spells can occur around the clock, although they often become worse in the early evening.

Unfortunately, there is no definite explanation for why this happens. Most often, colic means simply that the child is unusually sensitive to stimulation. As she matures, it will decrease, and generally it stops by 3 months. Sometimes, in breastfeeding babies, colic is a sign of sensitivity to a food in the mother's diet. The discomfort is only rarely caused by sensitivity to milk protein in formula. Colicky behavior may signal a medical problem, such as a hernia or some type of illness.

Coping with Colic

You may find it reassuring that there's a time limit to colic, but that doesn't stop the crying now. You may have to wait it out, but there are several things that might be worth trying. First, of course, consult your pediatrician to rule out any medical reason for the crying. Then ask him which of the following would be most helpful.

• If nursing, eliminate milk products, caffeine, onions, cabbage and any other potentially irritating foods from your diet. If bottle-feeding, try a formula that has no cow's milk. If food sensitivity is causing the discomfort, the colic should decrease within a day or two of these changes.
• Walk your baby in a body carrier to soothe her. The motion and body contact will reassure her, even if her discomfort persists.
• Rock her, run the vacuum in the next room, or place her where she can hear the clothes dryer. Steady rhythmic motion and sound may help her fall asleep.
• Introduce a pacifier. While some breastfed babies will actively refuse it, it will provide instant relief for others.
• Lay your baby tummy-down across your knees and gently rub her back. The pressure against her abdomen may help relieve her pain.
• Swaddle her in a blanket so that she feels secure and warm.
• When you're feeling tense and anxious, have someone else look after the baby and get out of the house. Even an hour or two away will help you maintain a positive attitude. No matter how impatient or angry you feel, do not shake the baby. Shaking an infant hard can cause blindness, brain damage or even death.

Source: American Academy of Pediatrics

This is an exciting time for parents - in this stage, your baby seems to make real progress toward communicating. Your baby will recognize Mommy and Daddy, laugh, squeal and smile spontaneously. Her personality begins to become evident, and she becomes a more active and alert member of your family.

How does my baby communicate?

Crying will continue to be your baby's primary means of communication for many months. Aside from letting you know that she needs something (and perhaps even what she needs by the way she cries), your baby may cry when she is overwhelmed by all of the sights and sounds of the world. Sometimes she may cry for no apparent reason at all. Try not to get too upset when your baby cries and you aren't able to console her.

Your baby will respond to the sound of your voice by becoming quiet, smiling or getting excited and moving her arms and legs. She will begin smiling regularly at her mom and dad during this period. She probably won't smile and act friendly with strangers, but she may warm up to them with coos and body talk - or at least a curious stare.

Babies this age discover that they have the ability to vocalize: soon you'll have a cooing and gurgling machine! Some babies begin to repeat some vowel sounds, like "ah-ah" or "ooh-ooh," at about two months. Your baby will "talk" to you with a variety of sounds; she'll also smile at you and wait for your response, and respond to your smiles with her own. Her arms and legs will move, and her hands will open up. She may even mimic your facial expressions.

What should I do?

Your baby loves to hear your voice, so talk, babble, sing and coo away during these first few months. Respond enthusiastically to your baby's sounds and smiles. Tell her what she is looking at or doing and what you are doing. Name familiar objects as you touch them or bring them to your baby. Read to your baby; even at this tender age, it will help in the development of her growing brain. By listening to you, your baby will learn the importance of speech before she even understands or repeats any words herself.

Take special advantage of your baby's own "talking" to have a "conversation." If you hear her make a sound, repeat it and wait for her to make another. You are teaching your baby valuable lessons about tone, pacing, and taking turns when talking to someone else. You are also sending her the message that she's important enough to listen to. Don't interrupt or look away when she's talking - show her that you are interested and that she can trust you.

Babies this age seem to respond best to the female voice - the one historically associated with comfort and food. That's why most people will raise the pitch of their voices and exaggerate their speech when talking to a small baby. This is fine - studies have shown that talking "baby talk" doesn't delay the development of speech - but feel free to mix in some regular adult words and tone with the baby talk. It may seem early, but you are really setting the stage for your baby's first word.

Sometimes babies are not in the mood to talk or vocalize - and even babies need their space. If your baby turns away, closes her eyes, or becomes fussy or irritable, let her be. She may need a break from all the stimulation in the world.

There will probably be times when you have met all of your baby's needs, yet she continues to cry. Don't despair - your baby may be overly stimulated, have gastric distress, or may have too much energy and need a good cry. It is common for babies to have a fussy period at the same time every night, generally between early evening and midnight. This can be very upsetting, but the good news is that it's short-lived; most babies outgrow it around three months. There are some things you can try to soothe your baby. Some babies are comforted by motion, such as rocking or being walked back and forth across the room, while others respond to sounds, like soft music or the hum of a vacuum cleaner. It may take some time to find out what best comforts your baby during these stressful periods.

Should I be concerned?

You may want to talk to your doctor if your baby seems to cry for an unusual length of time or if the cries sound odd to you. Your doctor will be able to reassure you or look for a medical reason for your baby's distress. Chances are there is nothing wrong, and knowing this can help you relax and stay calm when your baby is upset.

There are some communication milestones that your baby will probably reach during this period. Babies this age usually:

• Pay attention to new faces and surroundings
• Respond to loud noises
• Smile at the sound of a parent's voice
• Smile at other people by 3 months
• Babble by 3 or 4 months

Keep in mind that babies communicate at different rates, just as they mature physically at different rates. There is usually no cause for concern, but talk to your doctor if your baby misses any of these milestones.

Source: American Academy of Pediatrics

Parents and caregivers should now consider placing healthy infants on their backs when putting them down to sleep. This is because recent studies have shown an increased incidence of Sudden Infant Death Syndrome (SIDS) in infants who sleep on their stomachs. There is no evidence that sleeping on the back is harmful to healthy infants.

Keep the following points in mind:

1.      Infants should be placed for sleep in a nonprone position. Supine (wholly on the back) confers the lowest risk and is preferred.

2.      Do not place your infant to sleep on soft surfaces or with pillows

3.      This recommendation is for sleeping infants. A certain amount of "tummy time," while the baby is awake and observed, is recommended.

4.      Be certain that secondary caregivers such as grandparents and early education and child care centers know about this recommendation.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Source: American Academy of Pediatrics

Circumcision is a surgical procedure in which the skin covering the end of the penis is removed. Circumcision is usually performed by a doctor in the first few days of life. An infant must be stable and healthy to safely be circumcised.

Scientific studies show some medical benefits of circumcision. However, these benefits are not sufficient for the American Academy of Pediatrics (AAP) to recommend that all infant boys be circumcised. Parents may want their sons circumcised for religious, social and cultural reasons. Since circumcision is not essential to a child’s health, parents should choose what is best for their child by looking at the benefits and risks.

Many parents choose to have their sons circumcised because "all the other men in the family were circumcised" or because they do not want their sons to feel "different." Others feel that circumcision is unnecessary and choose not to have it done. Some groups, such as followers of the Jewish and Islamic faiths, practice circumcision for religious and cultural reasons. Since circumcision may be more risky if done later in life, parents may want to decide before or soon after their son is born if they want their son circumcised.

As noted above, research studies suggest that there may be some medical benefits to circumcision. These include the following:

• A lower risk of urinary tract infections (UTIs). A circumcised infant boy has about a 1 in 1,000 chance of developing a UTI in the first year of life; an uncircumcised infant boy has about a 1 in 100 chance of developing a UTI in the first year of life.
• A lower risk of getting cancer of the penis. However, this type of cancer is very rare in both circumcised and uncircumcised males.
• A slightly lower risk of getting sexually transmitted diseases (STDs), including HIV, the AIDS virus.
• Prevention of foreskin infections.
• Prevention of phimosis, a condition in uncircumcised males that makes foreskin retraction impossible.
• Easier genital hygiene.

Just as there are reasons parents may choose circumcision, they are reasons why parents may choose NOT to have their son circumcised:

• Possible risks. As with any surgery, circumcision has some risks. Complications from circumcision are rare and usually minor. They may include bleeding, infection, cutting the foreskin too short or too long, and improper healing.
• The belief that the foreskin is necessary to protect the tip of the penis. When removed, the tip of the penis may become irritated and cause the opening of the penis to become too small. Rarely, this can cause urination problems that may need to be surgically corrected.
• Some people believe that circumcision makes the tip of the penis less sensitive, causing a decrease in sexual pleasure later in life. This has not been proven by any medical or psychological study.

Almost all uncircumcised boys can be taught proper hygiene that can lower their chances of getting infections, cancer of the penis, and sexually transmitted diseases.

Source: American Academy of Pediatrics

Caring for a newborn is one of the greatest challenges a parent or caregiver faces. A new baby is completely dependent on loved ones to care for him or her.

A study in the September 22/29, 1999, issue of The Journal of the American Medical Association (Kotagal et al) reports that full-term babies born in Ohio covered by Medicaid who were discharged from the hospital following a short stay did not fare badly. Although the percentage of babies discharged just a day after a vaginal delivery and within two days of a cesarean birth have increased, this did not result in an increased rate of readmission to the hospital.

Feeding:

You should decide whether to breastfeed or bottle-feed before your baby is born. Breast milk provides the best nutrition for your baby and helps build stronger immunity to illnesses. However, if you decide or your doctor recommends that you do not breastfeed for any reason, bottle feeding your baby is a good alternative. You should feed your baby on demand. A newborn usually needs a feeding every two to three hours in the first month and less frequently as he or she grows older. Each feeding should last no more than 10 to 20 minutes.

Bathing:

A newborn only needs to be bathed two or three times a week during the first year. You should only give sponge baths during the first two weeks or until the umbilical cord falls off. You can then bathe the baby in a basin filled with two inches of warm water. Be sure to support the baby's head at all times during the bathing. Never leave your baby unattended in the bath.

Sleep:

Good sleep is essential for your baby's health. Always place your baby on his or her back to sleep to reduce the risk of sudden infant death syndrome (SIDS). Make sure the crib mattress is firm and covered by a sheet with no pillows or blankets that could block the baby's mouth or nose. Talk to the baby's doctor about what position is best if you have any concerns.

Immunizations:

Your baby needs to get a number of vaccinations within the first year that protect against 10 major childhood diseases. The baby should receive most of the immunizations before his or her second birthday. Be sure to work with the baby's doctor to stay current on the recommended immunization schedule.

When to See a Doctor:

• Excessive crying. It's normal for your baby to cry when he or she is hungry, needs to be burped, is cold, or needs a clean diaper; however, if the baby's cries sound peculiar or last for an unusual length of time, it could be a medical problem.
• Abnormal sleep. A newborn will spend most of the time sleeping. However, if the baby is rarely alert, does not wake up for feedings, or seems too tired or uninterested to eat, see your child's doctor right away.
• Infection of the umbilical cord. If you notice that the stump becomes infected (pus or red skin at the base of the cord, or crying when you touch the cord or skin next to it), alert the baby's doctor.

Things To Do:

• Give your baby lots of love and attention. You can't "spoil" a baby at this age.
• Whenever you travel in a car, place your baby in safety seat that is installed correctly in the back seat facing the back.
• Create a safe environment for your newborn by child-proofing your home.
• Take your baby for all the recommended checkups and vaccinations.
• Don't allow smoking or smoke around your baby.
• Keep your baby out of the sun (sunscreen shouldn't be applied to infants younger than 6 months).

Source: American Medical Association

here are many considerations when deciding whether to breastfeed or bottle-feed your baby. Breastfeeding has many advantages and is the best source of nutrition for your baby. However, in some situations, your doctor may recommend bottle-feeding with formula rather than breastfeeding. If you have some medical conditions, such as being infected with the human immunodeficiency virus (HIV) or hepatitis B, bottle-feeding with formula can protect your baby from exposure to the disease through your breast milk.

An article in the March 1, 2000, issue of The Journal of the American Medical Association (Nduati et al) reports on a study of women infected with HIV who fed their babies with either breast milk or formula. The researchers found that babies who were fed breast milk were more likely to become infected with HIV than babies who were fed formula.

Advantages of Breastfeeding for the Baby:

• Provides nutrients, hormones, and proteins that are essential for growth, brain development and digestion.
• Reduces the risk of infections of the middle ear, digestive system and respiratory tract by providing natural antibodies (proteins that fight infection).
• Reduces the risk of food allergies.
• Babies experience fewer digestive problems than with formula; breast milk includes enzymes to aid digestion and absorption of nutrients.
• Babies are less likely to experience anemia (lower than normal red blood cell levels).

Advantages of Breastfeeding for the Mother:

• Helps the uterus (the womb) return to its normal size more quickly after delivery.
• Helps the mother lose weight after delivery more quickly, because the body burns more calories when you are lactating (producing milk).
• May help reduce risk of breast cancer, if you nurse for at least three months.
• Can be more convenient; when you are with your baby, breast milk is always available.

When You Should Bottle-feed with Formula:

• If you are infected with HIV
• If you are infected with hepatitis B
• If you have tuberculosis and have not yet been treated for the disease
• If you are receiving certain cancer treatments
• If you smoke, drink heavily or use drugs (breast milk can pass nicotine, alcohol and other drugs to your baby)
• If you are taking medications, check with your physician about the best timing for breastfeeding. Since many medications are passed in breast milk, it might be better to take some medications after a breastfeeding session.
• You should tell your doctor about any of the above situations as soon as you know you are pregnant. If you think you are at risk of being infected with HIV, hepatitis B, or tuberculosis, your doctor can test for these diseases and let you know if it is safe to breastfeed.

Advantages of Bottle-feeding:

• You can use formula (or breast milk if you do not have a medical condition that would prohibit its use; obtained by using a breast pump) to bottle-feed your baby.
• Gives other parents and caregivers an extra opportunity to bond with the baby.
• Helps you know exact amount of food the baby is receiving.
• Can provide more flexibility to the mother's schedule.

Getting Started:

Even though breastfeeding is a natural process, it may take some time for you and your baby to become skilled at it. If you would like to breastfeed, you can speak with a health care provider who specializes in breastfeeding and be given instruction so that you know what to expect and you are more comfortable with the process.

Taking Care of Yourself:

You need to take care of yourself and ensure the quality of your breast milk by getting extra fluids (at least six to eight glasses of water per day) and extra calcium. You should avoid beverages that contain alcohol or caffeine before a breastfeeding session with your baby. You should also quit smoking for your health and the health of your baby.

Source: American Medical Association

General Information About Immunization

Q: Why are baby shots so important?

A: These shots protect your baby from nine diseases: measles, mumps, rubella (German measles), diphtheria, tetanus, pertussis (whooping cough), polio, Haemophilus influenzae type b (Hib) and hepatitis B.

Q: Are these diseases very serious?

A: Today, we might not think of these diseases as being very serious because, thanks to vaccines, we don't see them as often as we used to. But they can still be deadly. Measles used to kill hundreds - sometimes thousands - of people a year. In the 1920's, more than 10,000 people a year died from diphtheria. And in the 1940's and '50's, tens of thousands of children were crippled and killed by polio. Even today, these diseases can lead to pneumonia, choking, brain damage, heart problems and blindness in children who are not protected. And they still kill children every year.

Q: Are shots safe?

A: Yes, very safe. But like any medicine they can occasionally cause reactions. Usually these are mild, like a sore arm or a slight fever. Serious reactions are rare, but they can happen. Your doctor or nurse will discuss these issues with you before giving the shots. The important thing to remember is that children are in much more danger from the diseases than from the shots.

Q: How many shots does my child need, and when?

A: Your child should get his or her first shots at 2 months of age (or in some cases before he leaves the hospital after birth). You will have to go back for more shots four or five times before the child starts school. Your doctor or nurse will tell you when to come back. Remember, each of these visits is important! Your child needs several doses of each vaccine to be completely protected.

Q: Isn't getting all these shots expensive?

A: It doesn't have to be. If you take your child to a public health clinic, you might have to pay a small charge for the nurse to give the shots, but the shots themselves are free. Clinics that are supplied the vaccines from the government are forbidden by law from withholding the vaccinations because you can't pay.

Q: Why should I get my child immunized?

A: By getting your child immunized, you will be fighting disease in two ways. First, you will be protecting your own child. And second, since healthy children don't spread disease, you will be protecting others as well.

Q: How do vaccines work?

A: When you get an infection, your body reacts by producing substances called antibodies. These antibodies fight the disease and help you to get over the illness. They usually stay in your system, even after the disease has gone, and protect you from getting the same disease again. This is called immunity.

Newborn babies are immune to many diseases because they have antibodies they have gotten from their mothers. But this immunity doesn't last. It wears off during the first year of life.

Fortunately, we can keep children immune to many diseases, even after they lose their mothers' antibodies. We do this by vaccinating them against those diseases. The germs that cause disease are made into vaccines. These vaccines can be given to children as shots or as drops to be swallowed. Vaccines fool the body into thinking it is under attack by disease, and the body reacts by producing antibodies. These antibodies stay in the body. Then, if the child is exposed to the actual disease, he or she is protected.

Q: What will happen if my child doesn't get these shots?

A: Three things can happen.

1.      If your child is never exposed to any of these diseases, nothing will happen.

2.      If your child is exposed to any of these diseases, there is a good chance he or she will get the disease. What happens then depends on the child and the disease. At the least, the child could get a mild rash and have to stay inside for a few days. At the worst, the child could die.

3.      If your child gets one of these diseases, he or she could also spread it to other children who are not protected. If there are enough of these children in your community, it could lead to an epidemic, with many children getting sick.

Q: What are the chances of my child being exposed?

A: It's hard to say. Some of these diseases are very rare in the United States today, so the chances of exposure are small. Others are more common.

Q: What if my child didn't get her shots when she was supposed to, or has gotten behind schedule?

A: If you have children who did not begin their immunizations at 2 months of age, or who have had only some of their shots, they can still be fully immunized. It is never too late to start getting immunizations. If your children have had some of shots and then gotten behind schedule, they don't have to start over. The shots already given will count. Just continue the schedule where they left off. If you have children who were not immunized when they were infants, contact your doctor or the health department clinic. They will tell you when to bring the children in for their shots.

Source: Center for Disease Control

H influenzae type b is one of 10 childhood diseases your child needs to be vaccinated against. Your pediatrician can tell you more about other vaccines to protect against measles, mumps, rubella (German measles), diphtheria, tetanus, pertussis (whooping cough), polio, hepatitis B, and varicella (chickenpox).

Immunizations have provided protection for children for years–but the vaccines only work if you make sure your child gets immunized.

Immunization is just one important part of preventive health care for children. The American Academy of Pediatrics (AAP), representing the nation's pediatricians, is dedicated to working toward a better future for our children. Join us by making sure your children receive the best possible health care.

When Should My Child Get the Hib Conjugate Vaccines?

The immunization schedule will vary depending on which vaccine your child receives and at what age the series was started. The AAP recommends that your child receive 2 or 3 doses of the vaccine between 2 to 6 months of age and a booster dose at 12 to 15 months. Your child's pediatrician will tell you about the different Hib vaccines available and the recommended immunization schedule for each.

Are There Side Effects to Hib Conjugate Vaccines?

Most children have no side effects with the Hib conjugate vaccines. There have been no serious reactions linked to these vaccines. Those side effects that sometimes occur are mild and temporary. The possible side effects include:

• Soreness, swelling or redness where the shot was given
• A mild to moderate fever
• Fussiness

These symptoms may begin within 24 hours after the shot is given and usually go away within 48 to 72 hours.

Talk to your pediatrician about the possible reactions to these immunizations and when to call his or her office for more details. As with any medical problem, call your doctor promptly if you are concerned.

Source: American Academy of Pediatrics

The continued occurance of preventable childhood diseases emphasizes the necessity of vaccination for all children. Regular medical care includes vaccinations, which are an important part of your child's total health care.

Without protection provided by the Hib conjugate vaccines (Haemophilus influenzae type b conjugate vaccines), your child could suffer from serious illnesses that could have been prevented.

These vaccines provide protection during the first years of life, when it is easiest for your child to get H influenzae type b infection. When children are fully immunized with the H influenzae type b vaccine, they are protected against the illnesses caused by the H influenzae type b germ.

Haemophilus influenzae type b is a germ (or bacterium) that can cause several kinds of dangerous infections in children. It is very different from the "flu" (influenza virus).

Without timely immunizations, your child faces the risk of becoming very sick with serious diseases such as:

• Meningitis, a serious infection of the covering of the brain and spinal cord. Before the vaccine was used, H influenzae type b was the most common cause of bacterial meningitis in the United States. It caused about 12,000 cases of meningitis each year in children younger than 5 years of age–especially in babies 6 to 12 months old. Of those children infected, 1 in 20 died from this disease, and 1 in 4 developed permanent brain damage.
• Epiglottitis, a dangerous throat infection that can cause a child to choke to death if not treated immediately.
• Pneumonia and serious infections in the blood, bones, joints, skin, and the covering of the heart.

Source: American Academy of Pediatrics

"I've heard that vaccines are not needed because these diseases were disappearing even before the vaccines were developed."

This is not true. Many diseases do not occur or spread as much as they used to, thanks to better nutrition, less crowded living conditions, antibiotics, and, most importantly, vaccines. However, this does not mean that the bacteria and viruses that are responsible for these diseases have disappeared. Immunizations are still needed to protect children from these diseases.

For example, Haemophilus influenzae type b (Hib) diseases were a major problem a few years ago until the vaccine was developed for infants. Over several years, we went from 20,000 cases of Hib diseases to less than a few hundred. The vaccine is the only explanation for this decrease. Unvaccinated children are still at risk for Hib meningitis and other serious illnesses.

"Chickenpox is not a fatal disease, so that vaccine is not necessary."

This is not true. Each year, about 9,000 people are hospitalized for chickenpox. About 100 people die from the disease. The chickenpox vaccine will protect most children from getting chickenpox. Since the vaccine was licensed in 1995, millions of doses have been given to children in the United States. Many studies show the vaccine is safe and effective. Research is being done to see how long protection from the vaccine lasts and whether a person will need a booster shot in the future.

"I am breastfeeding so my child doesn't need immunizations."

Immunizations are still needed. While breastfeeding is the best nutrition for your baby, it does not prevent infections the way vaccines do. Your child may have fewer colds, but breastfeeding does not protect against many serious illnesses such as whooping cough, polio, and diphtheria like immunizations do.

"These diseases have been virtually eliminated from the United States, so my child doesn't need to be vaccinated."

Without immunizations at the right times, your child can still catch infectious diseases that may cause high fever, coughing, choking, breathing problems, and even brain injury. These illnesses may leave your child deaf or blind or cause paralysis.

Immunizations have reduced most of these diseases to very low levels in the United States. However, some of these diseases are still common in other parts of the world. Travelers can bring these diseases into this country. Without immunizations, these infections could quickly spread here.

Immunizations also help people who cannot be vaccinated or who do not respond to vaccines. They can only hope that people around them are immunized.

Source: American Academy of Pediatrics

"I read that the DTP vaccine can cause Sudden Infant Death Syndrome (SIDS)."

There is no scientific evidence that links the DTaP or DTP shot and SIDS. This myth continues because the first dose is given at 2 months of age, when the risk of SIDS is greatest. However, these events are not connected.

"I saw on the news that there are "hot lots" of vaccines that are more dangerous than other lots."

The federal government set up the national Vaccine Adverse Events Reporting System (VAERS) to receive reports of vaccine reactions. People may think that if a large number of VAERS reports result from a particular batch of vaccine (a "hot lot"), then it must be dangerous. To date, no vaccine lot has ever been found to be unsafe based on VAERS reports.

Keep in mind, all vaccines are licensed by the Food and Drug Administration (FDA). Vaccine manufacturing facilities are licensed and regularly inspected. In addition, every vaccine lot is safety-tested by the manufacturer. The fact that a vaccine is still being used means that the FDA considers it safe.

"I've heard that it is unsafe to immunize a child who has a cold and fever. Is this true?"

A child with a minor illness can safely be immunized. Minor illnesses include the following:

• low-grade fever
• ear infection
• cough
• runny nose
• mild diarrhea in an otherwise healthy child

"I've heard that some children have serious side effects from vaccines so they must not be very safe."

Reactions to vaccines may occur, but they are usually mild. Severe reactions to vaccines are very rare. Symptoms of a more serious reaction include the following:

• Very high fever
• Generalized rash
• Large amount of swelling at the point of injection

If any of these symptoms occur, call your pediatrician right away.

If your child experiences any side effects after a vaccination, talk to your pediatrician. Together you can decide whether your child should receive another dose of the same vaccine.

Children with other health problems may need to avoid certain vaccines or get them later than usual. For example, children with certain types of cancers or problems with their immune systems should not get live virus vaccines like the MMR, varicella, or oral polio vaccines. For children with seizures, the pertussis part of the DTaP vaccine may need to be delayed. Ask your pediatrician when the vaccine can be given.

"I've heard that giving a child more than one immunization at a time can be dangerous."

Studies and years of experience show that vaccines used for routine childhood immunizations can be safely given together. Side effects when multiple vaccines are given together are no greater than when each vaccine is given on separate occasions. Talk to your pediatrician if you are concerned about the number of vaccines your child is scheduled to receive.

"Immunizations hurt."

They may hurt a little, and your baby may cry for a few minutes. There may be some temporary swelling where your child was injected. However, protecting your child's long-term health is worth a few tears.

If your child is old enough to understand, explain that immunizations help prevent some very serious illnesses. Comfort and play with your child after the immunization. Acetaminophen can be used to help relieve some of the more common side effects, such as irritability and fever, but always check the dosage with your pediatrician.

Source: American Academy of Pediatrics

The success of modern vaccines is one of the truly extraordinary accomplishments of medical science. In earlier generations many children contracted communicable diseases like polio and whooping cough, frequently with devastating consequences. Some children died; others were left with permanent impairments, perhaps dependent on a wheelchair. But the development of vaccines has made many of these childhood illnesses relatively rare and has thus improved the lifetime health and well-being of millions of people.

Unfortunately, some parents have become complacent about their children's immunizations. They have erroneously presumed that these serious diseases have disappeared or have been eradicated. Some parents have been frightened away by reports of possible side effects associated with certain vaccines.

However, the risks of not receiving immunizations are immense. (In some states, parents are legally accountable to obtain appropriate care for their children.) As a responsible parent, you need to ensure that your child receives all of the currently recommended vaccines. Today's vaccines are safe and generally produce only mild side effects (such as fever or localized redness). Severe adverse reactions are extremely rare.

For maximum effectiveness and protection, immunizations should be administered at particular ages. Your child should receive most of his childhood immunizations before his second birthday. These will protect him against 10 major diseases: polio, measles, mumps, chickenpox, rubella (German measles), pertussis (whooping cough), diphtheria, tetanus, Haemophilus (Hib) infections and hepatitis B. Immunizations also are available against rotavirus, influenza, rabies, pneumococcus and hepatitis A for special circumstances.

When your child is given a vaccine, he actually receives that part of the "weakened" or killed infectious organism that is able to stimulate his body to produce antibodies against it. These antibodies then protect him against the disease, should he ever come in contact with it.

Recent epidemics of preventable diseases have prompted the American Academy of Pediatrics to change its immunization recommendations so that additional shots are now advised between ages 4 and 12. In most parts of the country, states and/or school districts require children to have completed these inoculations before they can enter kindergarten.

Children ages four through six should receive booster doses of diphtheria, tetanus and pertussis (DTaP), polio, and measles, mumps and rubella (MMR) vaccines prior to entering school. If your school-age child has not received these booster immunizations, they should be given promptly. Sometimes the booster MMR is given between ages 11-12 years. An additional Td (tetanus and diphtheria) booster is recommended at age 11-12, and then every 10 years.

Because research is ongoing into developing new and improved ways to protect children from serious diseases, immunization guidelines change frequently. Talk with your pediatrician about his or her recommendations for your child.

Treatment for Side Effects

Before immunizing your child, your pediatrician should review with you what reactions you can expect and how to treat them. Generally, fever is managed with acetaminophen. For local reactions your pediatrician may recommend that you apply cool compresses for symptomatic relief.

If your child has any reaction that makes him uncomfortable for more than four hours, notify your pediatrician, who will want to note it in your child's records and prescribe appropriate treatment.

Live Virus Vaccines (polio, measles, mumps, rubella and varicella)

No live virus vaccine should be given to an immunodeficient or immunosuppressed child. Because measles disease is more dangerous to an HIV-infected child than is measles vaccine, such children may receive MMR (but not oral polio or varicella vaccines). Children who cannot receive oral polio vaccine can be safely vaccinated with inactivated polio vaccine (IPV).

Source: American Academy of Pediatrics

At 12 months to 15 months, your child will receive a single shot immunizing her against mumps, measles and rubella. Though these diseases are best known for the rashes (measles and rubella) and glandular swelling (mumps) they produce, each may also cause serious medical complications. Immunizations against these diseases rarely cause any serious side effects, but your child may experience the following reactions, beginning seven to 10 days following the injection:

• A mild rash
• Slight swelling of the lymph nodes in the neck or diaper area
• Low-grade fever
• Sleepiness

Very rarely, children will have slight swelling over the jaw, as if they had mild mumps from the mumps vaccine. The rubella part of the vaccine sometimes causes joint pains and swelling or, very rarely, an inflammation of the nerves of the arms or legs.

Because not all children are immune to these diseases after one vaccination and in order to give additional protection, each child should receive a second MMR vaccine. This booster dose is recommended to be given at 4 to 6 years of age. If this dose was not given earlier, it should be given at 11 to 12 years of age. In recent years physicians have become particularly concerned about outbreaks of measles, with more than half of the affected children having received only one MMR inoculation.

Because this vaccine contains a small amount of egg protein, there are differing opinions about whether or not your healthy child should receive these vaccines, if she is highly allergic to eggs. However, your pediatrician may want to consult with an allergist or immunologist, who will advise you and your child's doctor before a decision is made concerning the use of the vaccine. Also, if your child is taking any medication that interferes with the immune system, or her immune system is weakened for any reason, she should not be given the MMR.

Source: American Academy of Pediatrics

Routine childhood immunizations should be up to date or accelerated prior to travel.

The following vaccines should be reviewed with a health care provider as far in advance of travel as possible to ensure the proper scheduling of recommended vaccines. The number of doses of routinely recommended vaccines a child needs depends on his or her age.

Infants and children up to 2 years of age should have received at least 3, and preferably 4 doses, of diphtheria, tetanus and acellular pertussis (DTaP) vaccine by 2 years of age. One dose of DTaP affords little protection, 2 doses provide some protection and 3 doses 70 percent to 80 percent protection. Parents must be aware that a child with less than the minimum of 3 recommended doses of DTaP may not be protected from pertussis. Travelers should consider receiving the remaining doses of the vaccine at the recommended intervals (at least one month between each of the first 3 doses; six months between the third and fourth dose) while abroad.

Measles, mumps and rubella (MMR) vaccine should be administered to all children 12 months of age or older. Measles vaccine or MMR may be given to infants 6 to 11 months of age who are going to areas of high risk for measles. Infants less than 6 months of age are protected by maternally derived antibodies.

Three doses of inactivated polio vaccine (IPV) are recommended for all infants and children by 2 years of age. If an unvaccinated child is traveling in less than four weeks to an area where polio is known to be present, a single dose of oral polio vaccine (OPV) is recommended. If four or more weeks is available before travel, IPV is recommended, with four weeks separating the 3 doses.

Three doses of hepatitis B vaccine are recommended for all children by 2 years of age. The vaccination series may be begun at birth. The first 2 doses should be separated by at least four weeks. The third dose should follow the second dose by at least two months, and be given at least four months after the first dose. The third dose should not be given before 6 months of age.

Three or 4 doses (depending on the brand of vaccine used) of Hib vaccine are recommended by age 2 years. The vaccine can be given as early as 6 weeks of age, and each of the first 2 or 3 doses should be separated by at least four weeks. The last (third or fourth) dose of the series should be given on or after 12 months of age.

The following immunizations may be recommended:

Immune globulin for protection against hepatitis A is recommended for infants and children under 2 years of age traveling to areas of the world with intermediate or high rates of hepatitis A. Hepatitis A vaccines are not currently licensed for use by children under 2 years old.

For typhoid fever, breast-feeding is likely to protect infants. Careful preparation of formula and food from boiled or chlorinated water can help protect non-breast-fed infants and children up to 2 years of age. The old, injectable killed typhoid fever vaccine is licensed for use in children as young as 6 months of age. The new injectable ViCPS typhoid vaccine is recommended for children between 2 and 6 years of age traveling to areas where there is questionable sanitation.

For meningococcal vaccine, effectiveness of the vaccine in children is dependent upon the child's age when the vaccine is administered. Protection may not be completely effective in children vaccinated between 3 months and 2 years, especially for vaccination before 3 months of age. The vaccine may be safely given to infants, but it may be less effective than in adults.

Yellow fever vaccine should not be administered to any infant under 4 months of age and children 4 to 6 months old should be considered only under very unusual circumstances. Infants 6 to 9 months old can receive the vaccine if they cannot avoid traveling to areas of risk and when a high level of protection against mosquito bites is not possible. Infants 9 months or older should be vaccinated as required or recommended for travel to South America or Africa.

One cholera vaccine, administered parenterally with a 2-dose primary series, is currently licensed in the United States. The risk of cholera to U.S. travelers of any age is so low that it is questionable whether vaccination is of benefit. No data are available concerning the efficacy or side effects of cholera vaccine in children less than 6 months of age. Cholera vaccine is not recommended for children less than 6 months of age. Breast-feeding is protective against cholera; careful preparation of formula and food from safe water and foodstuffs should protect non-breast-fed infants. If a child under 6 months old is traveling to areas requiring cholera immunization, a medical waiver should be obtained before travel. For older infants and children traveling to areas that require vaccination, a single dose of vaccine is sufficient to satisfy local requirements.

Source: American Academy of Pediatrics

Chickenpox is one of the most common childhood diseases. It is usually mild and not life-threatening to healthy children. Anyone can get chickenpox at any age, but it occurs most frequently in children from ages 6 to 10.
The most obvious sign of chickenpox is a skin rash that develops on your child's scalp and body, then spreads to his face, arms, and legs over a period of 3 to 4 days. The rash forms between 250 to 500 itchy blisters that dry up into scabs 2 to 4 days later. School-age children often get a mild fever for 1 or 2 days before the rash appears. Other symptoms of chickenpox are:

• coughing
• fussiness
• loss of appetite
• headaches

Chickenpox can easily be spread in any of the following ways:

• by direct contact with an infected person, usually through fluid from broken blisters
• through the air when an infected person coughs or sneezes
• through direct contact with lesions (sores) from a person with shingles

A person with chickenpox is contagious from 1 to 2 days before the rash starts and for up to 5 days after the rash appears. Your child will have to stay home from child care or school until she is no longer contagious. An adult or child who has never had chickenpox is at risk of getting it and may not show symptoms for 10 to 21 days after being exposed to the virus. Within households, 80% to 90% of at-risk persons will develop chickenpox if they are exposed to a family member who has it.
Once someone has had chickenpox, the virus stays in the body of the infected person permanently. Later in life, the virus can reappear and cause shingles. Shingles can occur at any age, but usually occur after a person is 50 years old. About 10% to 20% of all people who have had chickenpox develop shingles. People with shingles typically feel numbness and itching or severe pain in the skin areas where the affected nerve roots are. Within 3 to 4 days, clusters of blister-like sores develop and last for 2 to 3 weeks.
Chickenpox can occur at any time of the year, but the peak times are in the winter and early spring, especially in moderate climates. Before the vaccine became available, there were about 4 million cases of chickenpox in the United States each year.
Treating Chickenpox
You may remember how itchy chickenpox was when you were a child. If your child scratches the blisters before they are able to heal, they can become infected, turn into small sores, and possibly leave scars. Discourage your child from scratching and keep his fingernails trimmed short just in case.
Oatmeal baths can help relieve itching and acetaminophen may help reduce your child's fever. Acetaminophen is a substitute for aspirin. Do not give your child aspirin or salicylate (a compound found in aspirin). They have been associated with Reye's syndrome, a disease that affects the liver and brain. If your child's fever lasts longer than 4 days, rises above 102° F after the third day of having chickenpox, or your child becomes dehydrated, call your pediatrician. Also let your pediatrician know if the rash gets very red, warm, or tender. It may mean your child has an infection and needs other treatment.
The drug acyclovir can help make a case of chickenpox less severe. Acyclovir is most often used for patients who are at risk of developing severe chickenpox, such as adolescents; children with certain skin or lung diseases; and children taking other prescribed medications, such as steroids. To be effective, acyclovir must be given within the first 24 hours of the onset of the chickenpox rash. You may want to discuss the use of acyclovir with your pediatrician.
Most healthy children who get chickenpox won't have any complications from the disease. However, each year in the United States, about 9,000 people are hospitalized for chickenpox and about 90 people die from the disease.
The most common complication from chickenpox is a bacterial infection of the skin. The next most common problems are pneumonia and encephalitis, an infection of the brain. The following groups of people are at higher risk of developing these problems:

• people who have weak immune systems or low resistance to disease
• infants under 1 year of age
• adolescents and adults
• newborns whose mothers had chickenpox around the time of delivery
• premature infants whose mothers have not had chickenpox
• children with eczema and other skin conditions
• children receiving therapy with salicylate (a compound found in aspirin)

When an adult gets chickenpox, the disease is usually more severe, often developing into pneumonia. Adults are almost 10 times more likely to be hospitalized for chickenpox than children under 14 years of age, and adults are more than 20 times more likely to die from the disease. If a pregnant woman gets chickenpox, her unborn baby may have complications.

Source: American Academy of Pediatrics

The following vaccines should be reviewed with a health care provider as far in advance of travel as possible to ensure the proper scheduling of recommended vaccines.

Primary Vaccine Series

For travelers older than 2 years of age the following immunizations normally given during childhood should be up-to-date:

• Measles, Mumps and Rubella (MMR) vaccine - at least 1 dose given on or after 12 months of age.
• Diphtheria, Tetanus and Acellular Pertussis (DTaP) vaccine - 4 or 5 doses until age 7; after age 7, 1 dose of adult tetanus and diphtheria (Td) vaccine every 10 years.
• Polio vaccine-at least 3 doses; inactivated polio vaccine (IPV) is currently recommended for routine vaccination in the United States.
• Haemophilus influenzae type b (Hib) vaccine - 3 or 4 doses, depending on the brand; not routinely recommended after 5 years of age.
• Hepatitis B vaccine - 3 doses
• Varicella vaccine (for persons who have never had chickenpox) - 1 dose between the ages of 12 months and 13 years; 2 doses if 13 years or older.

Children older than 2 years should be "on schedule" with each vaccine's primary-series schedule, while adults should have completed the primary series. The number of doses needed depends on the child's age. If you are unsure about your vaccine history, consult with your physician.

In addition, adult travelers may want to consider

• Influenza (flu) vaccine - recommended for adults 65 years or older and for other high-risk individuals.
• Pneumococcal vaccine - recommended for adults 65 years or older and for other high-risk individuals.

Booster or additional doses

TETANUS AND DIPHTHERIA

A booster dose of adult tetanus-diphtheria (Td) is recommended every 10 years.

POLIO

For persons who have received a complete series of polio vaccine (either IPV or OPV), an additional single dose of vaccine should be received by persons 18 years of age and older traveling to the developing countries of Africa (Southern, Central, East, West, and North), Asia (East and Southeast), the Middle East and the Indian subcontinent, and the majority of the New Independent States of the former Soviet Union. This additional dose of polio vaccine is necessary for travelers to risk areas only once in adulthood. Inactivated polio vaccine (IPV) is recommended for this dose.

MEASLES

Persons born in or after 1957 should consider a second dose of measles vaccine before traveling abroad.

The following immunizations may be recommended:

• Yellow fever vaccine is recommended if traveling to certain parts of Africa and South America.
• Hepatitis B vaccine should be considered for those who will live six months or more in areas where there are high rates of hepatitis B (Southeast Asia, Africa [Southern, Central, East, West and North], the Middle East, the islands of the South and Western Pacific, and the Amazon region of South America), and who will have frequent close contact with the local population. Children who have not previously received hepatitis B vaccine should be vaccinated. In general, hepatitis A vaccine and/or immune globulin (IG) is recommended for travelers to all areas EXCEPT Japan, Australia, New Zealand, Northern and Western Europe and North America (excluding Mexico).
• Typhoid vaccine is recommended for travelers spending time in areas where food and water precautions are recommended (including many parts of the world, especially developing countries).
• Meningococcal vaccine is recommended for travelers to sub-Saharan Africa (see map) during the dry season, which is from December through June, and especially if close contact with locals is anticipated.
• Japanese encephalitis or tick-borne encephalitis vaccines should be considered for long-term travelers to areas of risk.
• The risk of cholera to U.S. travelers is so low that it is questionable whether cholera vaccine is of benefit.

All vaccines (except cholera and yellow fever vaccines) may be safely administered simultaneously without any decrease in effectiveness. Immune globulin (IG) may be simultaneously administered at different body locations with an inactivated vaccine such as DTaP, IPV, Hib, and hepatitis A and B vaccines. However, IG diminishes the effectiveness of live-virus MMR and varicella vaccines if IG is given simultaneously. IG does not interfere with either OPV or yellow fever vaccine when given simultaneously.

Pregnancy and immunizations

Women who are pregnant or who are likely to become pregnant within three months should not receive MMR or B vaccines. Yellow fever or polio (OPV) vaccines should be given to pregnant women only if there is a substantial risk of exposure. If given during pregnancy, waiting until the second or third trimester minimizes theoretical concerns over possible birth defects.

Women in the second and third trimesters of pregnancy have been found to be at increased risk of complications from influenza. Because currently available influenza vaccine is an inactivated vaccine, many experts consider influenza vaccination safe during any stage of pregnancy. A study of influenza vaccination of more than 2,000 pregnant women demonstrated no adverse fetal affects associated with influenza vaccine. However, more data are needed. Some experts prefer to administer influenza vaccine during the second trimester to avoid a coincidental association with spontaneous abortion (miscarriage), which is common in the first trimester, and because exposures to vaccines have traditionally been avoided during this time.

No convincing evidence for risk to the unborn baby from inactivated viral or bacterial vaccines or toxoids administered to pregnant women has been documented. These vaccines include: hepatitis A, hepatitis B, rabies, injectable typhoid, meningococcal, pneumococcal, tetanus-diphtheria toxoid (adult formulation) and IPV. Immune globulin can be given to pregnant women. Specific information is not available on the safety of cholera vaccine during pregnancy; therefore, it is prudent on theoretical grounds to avoid vaccinating pregnant women.

All vaccines may be administered safely to children of pregnant women and to breast-feeding mothers.

Source: Centers for Disease Control

Is your child eating a healthy diet?

Proper nutrition is one of the most important influences on your youngster's well-being. A varied, balanced diet-containing vitamins, minerals, protein, carbohydrates, and even some fat-promotes growth, energy and overall health.

Food preferences are developed early in life, mostly during early and middle childhood. Once they are established, they are hard to break. Thus, the earlier you encourage healthful food choices for your child, the better.

From early on, your child will watch you for clues to proper food choices. She will copy many of your habits, likes and dislikes. During the middle years, the model you provide at home will be extremely important in both guiding and reinforcing good eating habits. However, as children spend many hours a day away from home, in school and with friends, a variety of social and other factors influence what and when children eat. As they hurry to catch the school bus in the morning, they may speed through breakfast, leaving a half-full plate as they rush out the door. For lunch at school - despite the school's effort to offer healthy choices - youngsters might choose high-fat or sugar-laden foods that do not contribute to a balanced diet. They also might become much more susceptible to pressures from friends to choose soft drinks rather than milk, or a candy bar instead of fresh fruit.

Even at this young age, children in competitive sports may be misled by a Little League coach or other authority figure to adopt certain questionable eating habits, on the premise that these might improve performance. A major influence on children is television advertising, which often promotes unhealthy food selections.

Monitoring Food Needs

In general, it is the parents' job to monitor what their child eats, while the child is in the best position to decide how much to eat. Normally, healthy and active children's bodies do a good job of "asking" for just the right amount of food, although their minds may lead them astray when choosing which foods to eat.

You can easily overestimate the amount of food your child actually needs, especially during the younger years of middle childhood. Youngsters of this age do not need adult-sized servings of food. However, if you are unaware of this, you might place almost as much food on your child's plate as on your own. As a result, your child must choose between being criticized for leaving food on his plate, or for overeating and running the risk of obesity.

Weighing your children occasionally is one way for you to monitor your youngsters' nutrition. There is rarely a reason for you to count calories for your children, since most youngsters control their intake quite well. As the middle years progress, children's total energy needs will increase and thus their food intake will rise, especially as they approach puberty. Between ages 7 and 10, both boys and girls consume about 1,600 to 2,400 calories per day, although caloric needs obviously vary considerably even under normal circumstances. Most girls experience a significant increase in their growth rate between ages 10 and 12 and will take in about 200 calories more each day, while boys go through their growth spurt about two years later and increase their food intake by nearly 500 calories a day. During this time of rapid growth, they will probably require more total calories and nutrients than at any other period in their lives - from calcium to encourage bone growth, to protein to build body tissue.

At most ages boys require more calories than girls, primarily because of their larger body size. But appetites can vary, even from day to day, depending on factors like activity levels. A child who spends the afternoon doing homework, for example, may have fewer caloric needs than one who plays outdoors after school. Every child's caloric needs are different.

Picky Eaters

Some parents worry that their child is not eating as much as she should. However, even with what seems to be relatively low food intake, children can grow at normal rates. Some children simply do not eat as much as their peers. Their appetite may not be as large, and/or they may be finicky eaters, unwilling even to taste certain types of foods.

At one time or another these characteristics seem to be a normal part of middle childhood. You do not usually have to worry that this frustrating behavior is impairing her growth. Appetites may fluctuate as youngsters grow. Even within the same family, brothers and sisters may vary considerably in the amounts and types of food they desire. Generally, children increase their food consumption considerably as they enter the growth spurts associated with puberty; until then, however, a child's appetite may be unpredictable.

Some children are less open to trying new foods than others. You might have more success introducing new foods as part of familiar foods that your child already enjoys. For instance, a child who dislikes hot cereal may be more receptive if you add bananas or raisins to it. While she may not enjoy cooked carrots, she still might eat them when they are part of a stew, meat loaf or soup. Do not fall into the trap of feeling she will starve and thus give in to her desire for junk food. Avoid special rewards or strong, coercive encouragement for trying something new ("You're going to bed early tonight unless you try the chicken!"). If you introduce foods in a confrontational way, you and your child may become caught up in a battle, and he may stubbornly resist these foods even more. Offering rewards for particular foods may give your youngster the impression that the food would otherwise be undesirable.

As frustrating as your child's picky eating habits may be, keep in mind that you, too, may have foods you like and dislike. In general, youngsters outgrow these food preferences without any harm to their physical well-being.

In most cases, go along with your child's wishes, as long as she likes enough foods to achieve a balanced diet. In our relatively affluent society severe malnutrition is uncommon. Nevertheless, when a child's caloric intake is severely restricted - as in an eating disorder, or during a chronic illness - then her development and her overall health can be seriously harmed. Certainly if your child is losing weight, discuss this situation with your doctor.

Source: American Academy of Pediatrics

For many children in this age group, food takes a backseat to the other wonders of a child's life - running, jumping, exploring. Just when it's time for children to begin eating adult foods in an adult manner, parents often have their hands full just trying to keep a toddler or preschooler sitting at the table!

What can you do to teach your child healthy eating habits and keep mealtimes pleasant and conflict-free? A good sense of humor can help, as can the suggestions below.

Healthy Mealtime Habits

At 2 years old, your child should be sharing conversation and good food with the rest of the family at mealtimes. Three well-balanced meals and two snacks a day should cover his nutritional requirements. The best news of all for Mom and Dad is that your toddler can feed himself. He's also quite adept at drinking from a cup, although you'll still want to opt for the type with a lid to cut back on spills. Your child's ability to feed himself will improve by age 3. By then, he'll be handling a fork well and might be trusted with a lidless cup. After age 3, you can direct your attention toward teaching table manners (don't talk with your mouth full, cut food into small bites, and so on), even though you've been showing your child by example all along.

Continue to be careful with foods your toddler can choke on, such as nuts, hot dogs, whole grapes, hard candies, large mouthfuls of peanut butter, and large pieces of raw vegetables. Chop or cut foods into small pieces, or wait until your child is better at chewing and swallowing. Since children this age are still prone to choke even on "safe" foods, don't leave your child alone while he is eating.

Family Meals

A child age 2 and older can join in the same healthy, well-balanced meals as the rest of the family, provided the child has not shown signs of any food allergies. Now might be a good time to recheck your own eating habits. Don't expect your child to want water with dinner if you're drinking soda. If you turn up your nose at fruits and vegetables, chances are your toddler will, too. For your child's sake, try expanding your food horizons at this time. You can help your toddler or preschooler develop his own good eating habits by:

• buying a variety of healthy foods, including fruits, vegetables, and whole-grain breads and cereals
• allowing your child to choose from the variety of foods you provide
• setting specific times for meals and snacks
• providing a healthy breakfast each morning
• limiting sugary, high-fat snacks and drinks (Not only do they contain little of nutritional value, they leave no room for healthy foods.)
• avoiding adding excessive salt to foods
• encouraging your child to drink water, not just high-calorie fruit juices and empty-calorie sodas
• avoiding caffeinated foods (such as chocolate) and drinks
• sitting down and sharing mealtimes with your child

Wanting the same favorite foods at every meal is common at this age. As your child asserts his growing independence, he may even refuse these favorite foods occasionally, just to show you he can! Don't worry if your toddler or preschooler doesn't seem to have a balanced diet on a daily basis. As long as you keep offering a variety of healthful foods over the course of the week, your child should get the nutrition he needs. You can head off struggles at the table by offering new foods along with a food or two that you know your child likes. That way, you'll know your child will eat something, and the new foods will seem less scary. Provide small, easy-to-handle portions so your child won't be overwhelmed.

As your child grows, you can further encourage good eating habits by involving him in the grocery shopping, allowing him to help prepare and serve food, and getting him to set the table before meals. Continue to encourage your child to try a wide variety of new foods one at a time, but don't get discouraged if he sticks to old favorites. He'll surprise you one day by taking a bite! When introducing new foods, look for signs of allergic reaction. If you notice that your child develops a rash or has trouble breathing after eating any food, call your doctor right away.

Healthy Food Away From Home

Somewhere between ages 2 and 5, your child may start preschool and may begin visiting his friends' homes without you. Play dates with friends can be exciting and fun, especially if the friend's parents aren't as vigilant about sticking with healthy foods as Mom and Dad! Don't fret about the occasional soda or candy bar. Just make sure your child views them as "once-in-a-while" foods. Explain that some foods are better for him than others, and choosing nutritious foods is healthier.

If your child regularly eats snacks or meals at day care or preschool, find out what kinds of foods are served. Make sure the food is nutritious and the meals balanced. If you're not happy with the menus, contact the school or center director and express your concerns. Connect with other like-minded parents if you have trouble getting results yourself. Most parents want healthy foods for their kids and will press for a change if they become aware of problems.

Source: American Academy of Pediatrics

Vegetarians

A vegetarian diet can be very healthy. After all, the typical American diet does contain too much saturated fat (usually animal fat). Vegetarians can get the nutrients they need by making wise food selections.

Some teens have been vegetarians since childhood, while some teens become vegetarians during adolescence. As teens develop social awareness and independence, their growing freedom may be reflected in their diet. It is important that teens who practice vegetarianism get the essential vitamins and nutrients they need to support the rapid growth that occurs during puberty. Remind your teen that just cutting meat out of a diet will not guarantee better nutrition - it has to be planned.

There are several kinds of vegetarianism. Some vegetarians eliminate all foods from animal sources - they are called vegans. Others kinds of vegetarianism might allow eggs and/or dairy products. Vegan vegetarians must take care to avoid caloric deficiencies, especially from protein, since highly nutritious, calorie-rich foods may be eliminated by the vegan diet. Vitamin and mineral deficiencies such as B12, calcium, and iron deficiencies are also important to avoid. Talk to your teen's doctor about proper nutrition; he or she may recommend a registered dietitian who can design an eating plan that optimizes food intake based on your child's preferences.

Young Athletes

Some teenage athletes expend a great deal of time and energy practicing and competing in their chosen sports. Everything possible should be done to ensure optimal nutrition to support your teen's efforts. This includes the avoidance of risky dietary behaviors associated with his search for the competitive edge. Your teen's physical performance depends on the same balanced diet that will keep his nonathletic classmates healthy. Make sure your budding basketball star, tennis ace, or football pro is getting enough calories to support his level of exertion. You can do this by adding carbohydrates, such as potatoes, rice, pasta, and beans, to your teen's diet. These are excellent sources of energy.

Teaching your teen, especially your athlete, to enjoy water is one of the healthiest gifts you can give him. Teens should be urged to drink plenty of water before exercise and every 10 minutes or so during their activity. For every half hour of strenuous activity, your child should drink an extra 8 to 12 ounces of water - the drink of choice. When drinking sports drinks, avoid those that are high in sugar, which can cause cramping, nausea, and diarrhea. Also, make sure your child balances practice and performance with adequate rest and relaxation. These are as necessary to his well-being as proper nutrition.

Special Concerns

Ad-proofing Your Teen

To a shy teenage boy nervous about dating, or a teenage girl worried about her body, advertising can be especially persuasive. Teach your teen that the ads showing a group of smiling teens sharing a sugary, caffeinated soft drink are only aimed at selling that soda, not maintaining good nutrition. Share with your teenager medical information that shows the lack of long-term results for people who purchase diet aids or who spend fortunes on diet "plans" that don't emphasize proper nutrition for a lifetime. These ad-savvy lessons can serve your teenager well in many areas and can encourage him to be an educated consumer.

Overweight and Underweight Teens

While rapid growth and weight gain are part of puberty and adolescence, many children and teens become overweight because of too many calories and too little exercise. Encourage your child to be physically active, whether it be in an organized sport or individual pursuit. Whatever your child likes, if it gets him moving for about 30 minutes a day, encourage it. If your teen tends to sit around and watch television or play video games, try gently introducing more physical activities into your family life. Take a walk together, go for a bike ride, or offer to take your teen and some friends to the pool. Although many teens are anxious to spend time away from their parents, maybe you can take advantage of the small time you have together to get some exercise.

Be aware of the teen who gains too little weight, especially the teenage girl who begins to lose weight rapidly yet still complains she is fat. Young girls may worry about the body changes that puberty brings, partly in response to the societal emphasis on thinness. Full hips and breasts may make them feel "fat," and they can get caught up in behavior patterns known as eating disorders. Some girls become obsessed with body weight and image. They will eat very small amounts of food - inadequate amounts to support normal growth and health. Some refuse to eat at all. This condition is known as anorexia nervosa. Other teens, again mostly girls, practice binge-and-purge behavior, known as bulimia. Both conditions are potentially life-threatening. If you suspect either condition, consult your child's physician.

Teenage boys are prone to nutritional problems as well. Many adolescent boys yearn to "pump up" to be bigger or heavier. Beware of nutritional supplements that promise more muscles. If a teenage boy is eating properly and consuming the right amount of a variety of foods, nutritional supplements are just a waste of money. If you are concerned about your teenager's eating habits, talk with your child's doctor. Counseling is often an effective way to get these kids back on track.

Congratulations! The years of close supervision of your child's diet and your teachings about good nutrition are paying off. You find your baby has grown into a vital and healthy teenager. In the future, your teen will be teaching the next generation about eating right, thanks to you!

Source: American Academy of Pediatrics

Understanding your toddler's diet

You'll probably notice a sharp drop in your toddler's appetite after his first birthday. Suddenly he's picky about what he eats, turns his head away after just a few bites, or resists coming to the table at mealtimes. It may seem as if he should be eating more now that he's so active, but there's a good reason for the change. His growth rate has slowed, and he really doesn't require as much food now.

Your toddler needs about 1,000 calories a day to meet his needs for growth, energy, and good nutrition. If you've ever been on a 1,000-calorie diet, you know it's not a lot of food. But your child will do just fine with it, divided among three small meals and two snacks a day. Don't count on his always eating it that way; however, because the eating habits of toddlers are erratic and unpredictable from one day to the next. He may eat everything in sight at breakfast but almost nothing else for the rest of the day. Or he may eat only his favorite food for three days in a row, then reject it entirely.

Your toddler needs foods from the same four basic nutrition groups that you do:

1.      Meat, fish, poultry, eggs

2.      Dairy products

3.      Fruits and vegetables

4.      Cereal grains, potatoes, rice, breads, pasta

When planning your child's menu, remember that cholesterol and other fats are very important for his normal growth and development, so they should not be restricted during this period.

By his first birthday, your child should be able to handle most of the foods you serve the rest of the family but with a few precautions. Be sure the food is cool enough so that it won't burn his mouth. Test the temperature yourself, because he'll dig in without considering the heat. Try to avoid foods that are heavily spiced, salted, buttered, or sweetened. These additions prevent your child from experiencing the natural taste of foods, and they may be harmful to his long-term good health. Young children seem to be more sensitive than adults to these flavorings, and may reject heavily spiced foods.

Your little one can still choke on chunks of food that are hard and large enough to plug his airway, so make sure anything you given him is mashed or cut into small, easily chewable pieces. Never offer him peanuts, grapes, carrots, whole or large sections of hot dogs, meat sticks, or hard candies. Hot dogs and carrots in particular should be quartered lengthwise and then sliced into small pieces. Also, make sure your toddler eats only while seated and supervised by an adult. "Eating on the run" increases his risk of choking. By his first birthday or soon thereafter, your toddler should drink his liquids from a cup. He'll need less milk now, because he'll get most of his calories from solid foods.

To get a better understanding of what an average day's meals should look like, take a look at the sample menu below:

Sample One Day Menu

This menu is planned for a one-year-old child who weighs approximately 21 pounds.

1 tablespoon = 1/2 ounce (15 cc)
1 teaspoon = 1/3 tablespoon (5 cc)
1 cup = 8 ounces (240 cc)

BREAKFAST
1/2 cup iron-fortified breakfast cereal or 1 cooked egg (not more than 3 eggs per week)
1/4 cup whole milk (with cereal)
1/2 cup juice
Add to cereal one of the following:
1/2 banana, sliced
2-3 large sliced strawberries

SNACK
1 slice toast or whole wheat muffin
1-2 tablespoons cream cheese or peanut butter (spread)
1 cup whole milk

LUNCH
1/2 sandwich-tuna, egg salad, peanut butter, or cold cuts
1/2 cup cooked green vegetables
1/2 cup juice

SNACK
1-2 ounces cubed cheese, or 2-3 tablespoons pitted and diced dates
1 cup whole milk

DINNER
2-3 ounces cooked meat, ground or diced
1/2 cup cooked yellow or orange vegetables
1/2 cup pasta, rice, or potato
1/2 cup whole milk

Source: American Academy of Pediatrics

One of the best ways to familiarize your child with good food choices is to encourage her to cook with you. Let her get involved in the entire process, from planning the menus to shopping for ingredients to the actual food preparation and its serving.

When you are planning meals with her, refer to the Food Pyramid, and try to include items from the important food groups. Explain the importance of making low-fat choices whenever possible, choosing chicken and fish rather than red meat in most cases, or choosing low-fat cheeses over higher-fat varieties. Particularly in her first few efforts at helping in the kitchen, let her select recipes that she and other family members have enjoyed in the past, so she can see what's involved in preparing them.

In assigning tasks to your child, keep in mind that they need to be age-appropriate. For instance, you wouldn't give a 6-year-old a sharp knife to chop vegetables, although she can certainly wash the lettuce. Nor would you let her remove a hot, heavy casserole pot from the oven, although she can carefully open the oven door for you.

Here are some other guidelines to keep in mind:

• Make certain that you or another adult is in the kitchen at all times when your child is helping out.
• When your child pares vegetables, show her how to point sharp edges away from her to avoid accidents.
• Explain how she should weigh and measure ingredients.
• Use the rear burners when cooking on the stove. Make sure that pot handles are turned inward so children can't accidentally knock them off the stove.
• Teach your child the importance of using potholders when touching hot saucepans and other items.
• Shut off the oven and burners when you're finished cooking.

Source: American Academy of Pediatrics

Introducing Solid Foods

At four months, your baby's diet should consist of breastmilk and/or formula (with added vitamins or iron if your pediatrician recommends it), but by four to six months you can begin adding solid foods. Some babies are ready for solids as early as three months, but most have not lost their tongue-thrust reflex at that age. Because of this reflex, a young infant will push his tongue against a spoon or anything else inserted into his mouth, including food. Most babies lose this reflex at about four months. Coincidentally, your baby's energy needs increase around this age, making it an ideal time to start adding different calories through solids.

You may start solid food at whichever feedings during the day are the best for you and your baby. To minimize the chances of choking, make sure your baby is sitting up, either in your lap or in an infant seat, when you introduce solids.

Your baby's first solid food should be rice cereal, followed by oatmeal and barley. Generally, it's a good idea to introduce wheat and mixed cereals last, because they may cause allergic reactions in very young babies.

You can use premixed baby cereals in a jar or dry varieties to which you add formula, breastmilk, or water. The prepared products are convenient, but the dry ones are richer in iron and can be varied in consistency to suit your baby. Whichever you choose, make sure that it's made for babies. This assures you that it contains the extra nutrients your child needs at this age.

When you do begin feeding solids, always use a spoon to feed your baby unless, at your pediatrician's recommendation, you are thickening the formula for an infant with gastroesophageal reflux (spitting up stomach contents). Some parents try putting solid foods in a bottle or infant feeder with a nipple, but feeding a baby this way can drastically increase the amount of food he takes in at each feeding and lead to excessive weight gain. Besides, it's important for your baby to get used to the process of eating, including sitting up, taking bites from a spoon, resting between bites, and stopping when he's full. This early experience will help lay the foundation for good eating habits throughout his life.

Even standard baby spoons may be too wide for a child this young, but a small coffee spoon will work well. Start with half a spoonful or less (about a quarter of a teaspoonful) and talk your baby through the process ("Mmm, see how good this is"). He probably won't know what to do the first time or two. He may look confused or insulted, wrinkle his nose, and roll the food around his mouth or reject it entirely. This is an understandable reaction, considering how different his feedings have been up to this point.

One way to ease the transition to solids is to give your infant a little milk first, then switch to very small half-spoonfuls of food, and finally finish off with more milk. This will prevent him from being overly frustrated when he's very hungry, and it will link the satisfaction of nursing with this new experience of spoon-feeding.

No matter what you do, most of the first few solid-food feedings are sure to wind up outside his mouth on his face and bib, so increase the size of his feedings very gradually, starting with just a teaspoonful or two, until he gets the idea of swallowing solids. Lastly, if he cries or turns away when you try to feed him, don't force the issue. It's more important that you both enjoy his mealtimes than for him to start these foods by a specific date. Go back to nursing or bottle-feeding exclusively for a week or two, then try again.

Source: American Academy of Pediatrics

In recent years vegetarianism has grown in popularity. School-age children have become more conscious that animals must be killed in order to obtain meat, and that knowledge may prompt them to choose a vegetarian diet. The good news is that vegetarian diets tend to be high in fiber and polyunsaturated fat, and low in cholesterol and calories.

If your child is following a vegetarian diet, however, it's wise to guard against nutritional deficiencies. There are various degrees of vegetarianism, and the strictness of the diet will determine whether your youngster is vulnerable to nutritional shortcomings.

Following are the common types of vegetarianism. Each of these groups does not eat meat, poultry, or fish, but they differ in other areas:

• Lacto-ovo-vegetarians consume eggs, dairy products, and plant foods.
• Lacto-vegetarians eat dairy products and plant foods but not eggs.
• Vegans eat only plant foods, no eggs or dairy products.

Children can be well nourished on all three types of vegetarian diet, but nutritional balance is very difficult to achieve if dairy products and eggs are completely eliminated. It is possible that insufficient amounts of calcium and vitamin D can be consumed if milk products are removed from the diet.

Also, because of the lack of meat products, vegetarians sometimes have an inadequate iron intake. They may also consume insufficient amounts of vitamin B-12, zinc, and other minerals. If caloric intake is also extremely low, this could cause a delay in normal growth and weight gain.

It's important to ensure an adequate intake of protein and essential amino acids. This can be done easily by ensuring your child eats a variety of non-meat protein sources such as beans and soy. As a general guideline, try to provide protein from more than one source, combining cereal products (wheat, rice) with legumes (dry beans, soybeans, peas), for example; when eaten together, they provide a higher quality mixture of amino acids than if either is consumed alone.

To be sure your child gets adequate levels of vitamin B-12, you might serve commercially prepared foods fortified with this vitamin. And certain vegetables, like broccoli and spinach, offer a dairy-free option for calcium. However, your child may still need a calcium and/or vitamin D supplement if he does not consume milk and other dairy products. Your pediatrician can help you determine what, if any, vitamin or mineral supplements may be necessary.

A Zen macrobiotic diet usually presents many more problems than a vegetarian diet. With a macrobiotic program, important foods (animal products, vegetables, fruit) are severely restricted in stages. This diet is generally not recommended for children. Youngsters who adhere to it may experience serious nutritional deficiencies that can impair growth and lead to anemia and other severe complications.

Source: American Academy of Pediatrics

Many children arrive home from school and head straight to the refrigerator for a snack. There is nothing wrong with moderate snacking, since youngsters have high levels of activity and may need more calories than three meals a day provide to meet their energy needs. For many children - particularly those who are quite physically active - snacks can help round out their nutritional requirements and provide as much as one fourth of their calories. In general, occasional snacks will not ruin their appetites for regular meals, as long as the snack is not eaten shortly before they sit down to lunch or dinner. Snacks are another opportunity for parents to provide healthy food choices to their children while reinforcing good eating habits - learning to get hungry, rather than eating to feel full all the time.

When snacking, children often reach for the closest food at hand. If your cupboard has cookies in it, that is probably what your child will eat. However, if there are healthier items in the refrigerator or on the kitchen table, your youngster will become accustomed to snacking on these foods. The healthiest and simplest choices are fruits and raw vegetables, which require little if any preparation. Encourage your child to make healthy snacks a habit by keeping fruit and cut vegetables (carrots, cucumbers, celery, peppers, broccoli) handy.

Children in the older range of the middle years also can learn some simple cooking techniques. As they prepare snacks for themselves, you can teach them to differentiate between healthy and less healthy choices. However, be sure they learn appropriate safety precautions for the use of a stove, oven, microwave or other cooking appliance.

Healthy Snacks for Any Mood

Your child's snacking moods may vary, but he can still consistently maintain healthy snacking habits. For instance, if his snacking mood is:

Thirsty! Cold skim or low-fat milk, mineral water with lime, chilled vegetable juice, fruit juice (apple, grape, grapefruit, orange, pineapple, raspberry).

Smooth! Yogurt, banana, papaya, mango, custard, cottage cheese, "fruit smoothie." ("Fruit smoothie" recipe: Blend one cup of skim milk, three ice cubes, your favorite fresh fruit, and a dash of vanilla, cinnamon, and nutmeg in a blender.)

Crunchy! Raw vegetables (asparagus, bell pepper, broccoli, cabbage, carrots, cauliflower, celery, zucchini), apples, corn on the cob, unbuttered popcorn, puffed-rice cakes, wheat crackers.

Juicy! Fresh fruit (berries, cantaloupe, grapes, grapefruit, kiwi, nectarine, orange, peach, plum, watermelon, frozen juice pops, tomato, pear).

Fun! Fruit, frozen grapes, frozen bananas.

Really hungry! Hard-boiled eggs, granola, sandwich, cereal with milk, bran muffin, peanut butter (on crackers or bread), nuts, cheese.

How to Reduce Dietary Fat and Cholesterol

Family eating habits determine what your child will learn to eat and enjoy. Here are some ways you and your family can limit fat and cholesterol in your diets:

• Keep fresh fruits and vegetables available.
• Serve whole-grain bread and cereals.
• Rely on low-fat milk and low-fat yogurt. Select cheeses that are lower in fat, for example.
• Include starchy foods (potatoes, pasta, rice) in your meals.
• Avoid high-fat and high-calorie toppings, including butter, margarine, sour cream, and gravy. Instead, use herbed cottage cheese, grated parmesan cheese, or low-fat yogurt as toppings.
• Serve lean meats, such as chicken, turkey, fish, lean beef cuts (lean hamburger, top loin, top round, eye of round) and lean pork cuts (tenderloin, loin, chops, ham). Cut away visible fat and remove the skin from poultry.
• Select margarine and vegetable oils (canola, corn, olive, sunflower and soybean oils).
• Choose frozen fruit bars, angel food cake, or low-fat frozen yogurt instead of rich, creamy desserts.
• When cooking, use nonstick vegetable sprays to cut down on added fat.
• Choose fat-free cooking techniques, such as baking, broiling, poaching, grilling, or steaming when preparing meat, fish and poultry. Do not use butter or margarine when preparing or serving vegetables.
• Serve vegetable-based and broth-based soups. Choose low-fat milk when making cream soups.

Source: American Academy of Pediatrics

As any parent of a teenage child can tell you, the teen years are a time of tremendous change. Body size and shape are transformed, thought processes become more abstract: in short, your child is becoming an adult. In the midst of all this change, good nutrition should be a constant in your adolescent's life. Healthy food choices provide the fuel for this incredible growth and form the basis of good eating habits that will last well into adulthood.

Family Meals

By now your teen may be well versed in healthy meal preparation and even cooking. In fact, about 7 in 10 teens regularly fix their own dinners, as do 1 in 3 children ages 6 to 11 years. Fewer families sit down together every night to a hearty, healthy, home-cooked meal. Now more than ever, meals seem to be grabbed on the go with less opportunity to consider nutritional balance.

To illustrate the important lesson of nutrition to your child, give him increasing responsibility for family meal preparation. Even before he's old enough to drive, he can take his turn as the supermarket shopper. Let your teen take your grocery list to the store and learn how to make the selections based on nutritional value.

Since teens highly value their independence, they tend to want to spend a lot of time away from home. One way to encourage a few family meals each week is to put your teenager in charge of dinner on certain evenings. Teach your teen to prepare favorite meals (even simple dinners can be nutritious). That way you can encourage healthy eating habits while spending quality time together. Since your teen consumes most of his daily calories away from your watchful eyes, the family meal is also a good way to pack in the most nutritious foods you can. Think of meals you share with your teen as an insurance policy for his well-being. The entire family will benefit nutritionally from your efforts.

Meals Away From Home

Time away from parents helps teens develop the social skills necessary to make it as adults. Will your child carry the good eating habits you've instilled out into the world? There are still a few things you can do to help:

• Make sure your child eats a nutritious breakfast.
• If your teen takes lunch to school, he should be encouraged to make his own - this allows more opportunities for teens to learn about nutrition through meal preparation. If your child eats the school lunch, keep an eye on snack and lunch menus to make sure they meet your standards for nutrition. If they don't, make your concerns known to your teen and to the appropriate staff at the school.
• Offer your teen advice on how to choose healthy foods in a restaurant. For example, encourage him to include a salad or vegetables in his meals when eating out.
• Continue to offer your teen new and interesting foods at home, so that he has a wide variety of healthy choices when he is eating out.

Many teens are fast-food fans, so remember to teach your adolescent the benefits of choosing low-fat selections. The typical cheeseburger, fries, and soda may be enticing, but encourage him to look for salads, grilled chicken sandwiches, and baked potatoes (without all the butter and sour cream). If your teenager simply must have that burger, suggest the simplest one on the menu rather than the double-decker, cheese-and-heavy-sauce-smothered advertised special. Remind your teen that fast-food restaurants offer milk and juices, too, encouraging him to limit the sodas and milk shakes. And remember to set a good example yourself. You'll be helping yourself as well as your teenager.

Breakfast

Whether your child chows down on a full breakfast at home, eats a brown-bag breakfast on the ride to school, or buys a cafeteria breakfast once he gets there, there is no meal that is more important than the first one of the day. Studies show that kids who skip breakfast or who eat unhealthy breakfast foods, like doughnuts or pastries, can have a hard time concentrating just a few hours later. To head off this problem, find foods your teen likes to eat and serve them in the morning, even if they're not "traditional" breakfast fare. Let your teen heat up some spaghetti or leftover pizza at 7 AM. These options sure beat sugary cereals and pastries nutritionally, and they will help your teen do his best all morning long.

If your child does not have time to eat at home, have your child pack a healthy breakfast to take along to school, such as low-fat yogurt, fruit, and whole-grain toast. Even if your teen claims that he is not hungry or has no time, encourage him to take something that can be eaten on the way. Also, remember to set a good example yourself by eating breakfast regularly.

Snacks

Teens are often "super-snackers" or "grazers." After-school activities, outings with friends, and late arrivals at home make snacking impossible to avoid. If this is the case with your teenager, you'll want to emphasize healthy food choices at snack time, since a lot of unwanted fat and calories can creep into a teen's diet through these extra little meals. The best idea, especially for today's hectic households, is to keep good-tasting, good-for-you foods accessible. Ask your teen what he'd like to have on hand and make the snacks easy to prepare and grab on the go. This lessens the temptation to eat high-fat fare. Maximize the nutritional value of snacks by combining a few of the ideas below:

• microwave popcorn (low-salt, low-fat variety)
• fresh fruit
• celery and carrot sticks with low-fat dip or dressing
• raisins and other dried fruits
• low-fat milk and yogurt
• low-sugar cereals
• unsweetened applesauce
• frozen bananas
• graham crackers
• fresh fruit juice or frozen fruit juice on a stick
• pretzels
• "trail mix" - dried fruits, nuts, low-sugar cereal, mini-pretzels

Source: American Academy of Pediatrics

ABSTRACT. This statement is intended to provide pediatric caregivers with advice about the nutritional needs of calcium of infants, children, and adolescents. It will review the physiology of calcium metabolism and provide a review of the data about the relationship between calcium intake and bone growth and metabolism. In particular, it will focus on the large number of recent studies that have identified a relationship between childhood calcium intake and bone mineralization and the potential relationship of these data to fractures in adolescents and the development of osteoporosis in adulthood. The specific needs of children and adolescents with eating disorders are not considered.

Approximately 99% of total body calcium is found in the skeleton, with only small amounts found in the plasma and extravascular fluid. Serum calcium exists in 3 fractions: ionized calcium (approximately 50%), protein-bound calcium (approximately 40%), and a small amount of calcium that is complexed, primarily to citrate and phosphate ions. Serum calcium is maintained at a constant level by the actions of several hormones, most notably parathyroid hormone and calcitonin. Calcium absorption is by the passive vitamin D-independent route or by the active vitamin D-dependent route.1

Understanding calcium needs for different age groups requires a consideration of the variable physiologic requirements for calcium during development. For example, during the first month of life, the regulatory mechanisms that maintain serum calcium levels may not be entirely adequate in some otherwise healthy infants, and symptomatic hypocalcemia can occur. However, in general, hypocalcemia is uncommon in healthy children and adolescents, and the primary need for dietary calcium is to enhance bone mineral deposition.

Calcium requirements also are affected substantially by genetic variability and other dietary constituents. The interactions of these factors make identification of a single unique number for the calcium "requirement" for all children impossible.2-4 However, several recent dietary guidelines have considered the data about calcium requirements and recommended calcium intake levels that are calculated to benefit most children (Table 1).2,3

In addition to calcium intake, exercise is an important aspect of achieving maximal peak bone mass. There is evidence that childhood and adolescence may represent an important period for achieving long-lasting skeletal benefits from regular exercise.5 For example, Welten et al6 showed in a large Dutch cohort of children that regular weight-bearing activity had a greater influence on peak bone mass than dietary calcium.

IDENTIFICATION OF MINERAL REQUIREMENTS DURING CHILDHOOD

Overview
It is recognized that a very low calcium intake can contribute to the development of rickets in infants and children, especially those consuming very restrictive diets (eg, a macrobiotic diet).7 There are no reliable data on the lowest calcium intake needed to prevent rickets or on the relationship among ethnicity, vitamin D status, physical activity, and diet in the causation of rickets in children fed low-calcium diets.8,9

Recent data support the possibility that a low bone mass may be a contributing factor to some fractures in children. A relationship between the adolescent growth spurt and the risk of fractures has been shown.10,11 Goulding et al12 reported lower bone mass at multiple sites in a group of 100 girls aged 3 to 15 years with distal forearm fractures compared with age-matched girls. For girls aged 11 to 15 years in the study by Goulding et al12 a lower calcium intake was reported for those with fractures compared with the control subjects. Wyshak and Frisch13 similarly reported that high calcium intakes seem to exert a protective effect against fractures in adolescent boys and girls. They also reported a positive relationship between cola beverage intake and bone fracture. Whether this is attributable to a potential effect of excessive phosphorus in the colas impairing bone mineral status or to the lack of calcium intake related to the substitution of colas for dairy products is uncertain. However, a direct harmful effect of a high phosphorus intake affecting the bone mineral status is unlikely in older children and adults.2 Further data on the relationship between calcium intake and fractures are needed before the magnitude of increased fracture risk at different calcium intake levels can be assessed. However, it is reasonable to conclude that low calcium intakes may be an important risk factor for fractures in adolescents. This risk may be an issue that adolescents can more readily relate to than a long-term risk of osteoporosis.

Maintaining adequate calcium intake during childhood is necessary for the development of a maximal peak bone mass. Increasing peak bone mass may be an important way to reduce the risk of osteoporosis in later adulthood.2,14 This is a more difficult end point to identify than the development of rickets or fractures. Therefore, surrogate markers of mineral status are used to assess the consequences of differing levels of calcium intake. The primary surrogates used are optimization of calcium balance or achievement of greater bone mass in children with increased calcium intake.3,14,15

In children with chronic illnesses, fractures may occur during childhood secondary to mineral deficiency associated with the disease process or the effects of therapeutic interventions (ie, corticosteroids) on calcium metabolism.16 However, minimal data generally are not available on the risks and benefits of increasing calcium intake in children with chronic illnesses above current dietary recommendations. Supplementation of vitamin D along with calcium may be necessary for a maximal response.17

Methods
Multiple approaches are used to assess mineral requirements in children. They include the following: 1) measurement of calcium balance in persons with various levels of calcium intake; 2) measurement of bone mineral content, by dual-energy radiograph absorptiometry or other techniques, in groups of children before and after calcium supplementation; and 3) epidemiologic studies relating bone mass or fracture risk in adults with childhood calcium intake.

The calcium balance technique consists of measuring the effects of any given calcium intake on the net retention of calcium by the body. This approach has been the most commonly used to estimate requirement for minerals. Its usefulness is based on the rationale that virtually all retained calcium must be used, especially by children, to enhance bone mineralization. It therefore is reasonable to expect that the dietary intake that leads to the greatest level of calcium retention is the intake that will lead to the greatest benefit for promoting skeletal mineralization and decreasing the ultimate risk of osteoporosis.18,19

The substantial limitations involved in obtaining and interpreting data about calcium balance are well known. These include substantial technical problems with measuring calcium excretion and the difficulty obtaining dietary intake control in children. Both of these are necessary for adequate balance studies. These problems have been partly overcome by the development of stable isotopic methods to assess calcium absorption and excretion.20 Nevertheless, more data are needed to establish the "optimal" level of calcium retention at different ages and the effects of development on calcium balance.6

A major advance in the field during the last 25 years has been the development and improvement of methods to measure total body and regional bone mineral content by using various bone density techniques. Currently, the technique used in many studies is dual-energy radiograph absorptiometry. This technique can rapidly measure the bone mineral content and bone mineral density of the entire skeleton or of regional sites with a virtually negligible level of radiation exposure. Furthermore, recent enhancements in the precision of the technique have made it particularly suitable for assessing the effects of calcium supplementation on bone mass in children of all ages.21

Several groups have directly assessed the effects of calcium supplementation on bone mass by using dual-energy radiograph absorptiometry or similar techniques.22-25 These studies, however, also have limitations. First, most supplementation studies done in children involved relatively short-term supplementation of 1 to 2 years. This period may be inadequate to fully assess the long-term benefits of calcium supplements on bone mineral density. The second is that these studies generally have been done using only 1 level of supplementation, which frequently has been given in pill form. This limited dosing approach makes it difficult to identify an optimal intake level or determine the relative benefits of dietary calcium versus supplements as a method of increasing calcium intake in children.

Several investigators have performed population-based epidemiologic studies relating childhood or adult bone mass or fracture risk to calcium intake in childhood. Although many of these studies are limited by their retrospective design, they have generally shown a positive association between calcium intake in childhood and childhood and adult bone mass. Not all studies have shown a benefit, however, and further data about this relationship are needed.3,26-28

RECOMMENDATIONS BY AGE GROUP

Overview
The specific requirements for calcium intake by infants, children, and adolescents have been extensively reviewed by 2 panels in North America since 1994.2,3 A summary of their recommendations is shown in Table 1.

Infants
The optimal primary nutritional source during the first year of life is human milk. No available evidence shows that exceeding the amount of calcium retained by the exclusively breastfed term infant during the first 6 months of life or the amount retained by the human milk-fed infant supplemented with solid foods during the second 6 months of life is beneficial to achieving long-term increases in bone mineralization. Available data demonstrate that the bioavailability of calcium from human milk is greater than that from infant formulas or cow's milk, although this comparison has not generally been made at comparable intake concentrations, ie, such as found in human milk.29 Nevertheless, it has been deemed prudent to increase the concentration of calcium in all infant formulas relative to human milk to ensure at least comparable levels of calcium retention. Relatively greater calcium concentrations are found in specialized formulas, such as soy formulas and casein hydrolysates, to account for the potential lower bioavailability of the calcium from these formulas relative to cow's milk-based formula. Specific concentration requirements cannot be set readily, but all formulas marketed should have demonstrated a net calcium retention at least comparable to that of human milk. Research data are not available to justify the use of very high levels of calcium in infant formula for full-term infants.

Premature infants have higher calcium requirements than full-term infants while in the nursery. These may be met by using human milk fortified with additional minerals or with specially designed formulas for premature infants.30 After hospitalization, there may be benefits to providing formula-fed premature infants formulas with higher calcium concentrations than those of routine cow's milk-based formulas.31 The optimal concentrations and length of time needed for such formulas are unknown.

Children
Few data are available about the calcium requirements of children before puberty. Calcium retention is relatively low in toddlers and slowly increases as puberty approaches. Most available data indicate that calcium intake levels of about 800 mg/d are associated with adequate bone mineral accumulation in prepubertal children. The benefits of greater levels of intake in this age group have been studied inadequately.20,32 One study found a benefit of calcium supplements to children as young as 6 years of age.16 However, further supporting data are needed for this finding. Perhaps of most importance in this age group is the development of eating patterns that will be associated with adequate calcium intake later in life.

Preadolescents and Adolescents
The majority of research in children about calcium requirements has been directed toward 9- to 18-year-olds. The efficiency of calcium absorption is increased during puberty, and the majority of bone formation occurs during this period.15,20,21,32,33 Data from balance studies suggest that for most healthy children in this age range, the maximal net calcium balance (plateau) is achieved with intakes between 1200 and 1500 mg/d. That is, at intake levels above this, almost all of the additional calcium is excreted and not used. At intakes below that level, the skeleton may not receive as much calcium as it can use, and peak bone mass may not be achieved.2,3,9,15,18-20 Virtually all the data used to establish this intake level are from white children; minimal data are available for other ethnic groups. The exact level that is best for a given person depends on other nutrients in the diet, genetics, exercise, and other factors.

Several controlled trials have found an increase in the bone mineral content in children in this age group who have received calcium supplementation.22-25 However, the available data suggest that if calcium is supplemented only for relatively short periods (ie, 1 to 2 years), there may not be long-term benefits to establishing and maintaining a maximum peak bone mass.34,35 This emphasizes the importance of diet in achieving adequate calcium intake and in establishing dietary patterns consistent with a calcium intake near recommended levels throughout childhood and adolescence. Unfortunately, long-term studies evaluating the consequences of maintaining currently recommended calcium intakes beginning in childhood or early adolescence are not available. Most available epidemiologic data, recently reviewed by the National Academy of Sciences and the National Institutes of Health, support the view that maintaining such a diet will increase peak bone mass and lower the incidence of fractures.2,3

Recent data obtained in African American adolescents suggest a link between lower diastolic blood pressure and increased calcium intake. Further studies are necessary to evaluate this relationship in children of multiple ethnicities and age groups.36

ACHIEVING RECOMMENDED INTAKES

The gap between the recommended calcium intakes and the typical intakes of children, especially those 9 to 18 years of age, is substantial (Table 1). Mean intakes in this age group are between approximately 700 and 1000 mg/d, with values at the higher side of this range occurring in males.3 Preoccupation with being thin is common in this age group, especially among females, as is the misconception that all dairy foods are fattening. Many children and adolescents are unaware that low-fat milk contains at least as much calcium as whole milk.

Knowledge of dietary calcium sources is a first step toward increasing the intake of calcium-rich foods. Table 2 gives typical amounts of calcium for some common food sources. The largest source of dietary calcium for most persons is milk and other dairy products.37 Other sources of calcium are, however, important, especially for achieving calcium intakes of 1200 to 1500 mg/d. Most vegetables contain calcium, although at low density. Therefore, relatively large servings are needed to equal the total intake achieved with typical servings of dairy products. The bioavailability of calcium from vegetables is generally high. An exception is spinach, which is high in oxalate, making the calcium virtually nonbioavailable. Some high-phytate foods, such as whole bran cereals, also may have poorly bioavailable calcium.38-40

Several products have been introduced that are fortified with calcium. These products, most notably orange juice, are fortified to achieve a calcium concentration similar to that of milk. Limited studies of the bioavailability of the calcium in these products suggest that it is at least comparable to that of milk.41 It is likely that more such products will soon become available. Breakfast foods also are frequently fortified with minerals, including calcium. Calcium intakes on food labels are indicated as a percentage of the "daily value" in each serving. This daily value is currently set as 1000 mg/d. Therefore, it is important to instruct families about reading and interpreting food labels.

Several alternatives exist for children with lactose intolerance. Lactose intolerance is more common in African Americans, Mexican Americans, and AsianPacific Islanders than in whites.42 Many children with lactose intolerance can drink small amounts of milk without discomfort. Other alternatives include the use of other dairy products, such as solid cheeses and yogurt, that may be better tolerated than milk. Lactose-free and low-lactose milks are available. Increasing the intake of nondairy products, such as vegetables, may be helpful, as may the use of calcium-supplemented foods.

For children and adolescents who cannot or will not consume adequate amounts of calcium from any dietary sources, the use of mineral supplements should be considered. Although supplements vary in their bioavailability, they may have bioavailability comparable to or greater than that of dairy products.43 Decisions about their use must be made on an individual basis, keeping in mind the usual dietary habits of the person, any individual risk factors for osteoporosis, and the likelihood that the use of the supplement will be maintained.

CONCLUSION

Recent studies and dietary recommendations have emphasized the importance of adequate calcium nutriture in children, especially those undergoing the rapid growth and bone mineralization associated with pubertal development. The current dietary intake of calcium by children and adolescents is well below the recommended optimal levels. The available data support recent recommendations for calcium intakes of 1200 to 1500 mg/d beginning during the preteen years and continuing throughout adolescence as recommended by the National Institutes of Health Consensus Conference2 and the National Academy of Sciences.3 Currently, evidence is inadequate to alter the dietary recommendations for children with chronic illnesses or those taking medications, such as corticosteroids, that alter bone metabolism. However, an effort should be made to achieve at least the recommended intake levels. The provision of adequate vitamin D also may be important for children with chronic illnesses.

RECOMMENDATIONS

1.      Pediatricians should actively support the goal of achieving calcium intakes in children and adolescents comparable to those in recently recommended guidelines.2,3 The prevention of future osteoporosis, as well as the possibility of a decreased risk of childhood and adolescent fractures, should be discussed as potential benefits to achieving these goals. Currently, relatively few children and adolescents achieve dietary calcium intake goals.

2.      To emphasize the importance of calcium nutriture, pediatricians should consider including the following questions about dietary calcium intake.

o                                What do you drink, either white or chocolate milk, with your meals?

o                                Do you drink milk with meals, snacks, or cereal or any other time during the day?

o                                Do you eat cheese, yogurt, or other dairy products such as cottage cheese?

o                                Do you drink calcium-fortified juices or eat any calcium-fortified foods?

o                                Do you eat any of the following: broccoli, tofu, oranges, or legumes (dried beans and peas)?

o                                Do you take any mineral or vitamin supplements?

3.      For children and adolescents whose calcium intake seems deficient, specific information about the sources of dietary calcium should be provided. Adolescents may need to be reminded that low-fat dairy products, including skim milk and low-fat yogurts, are good sources of calcium that are not high in fat.

TABLE 1
Dietary Calcium Intake (mg/d) Recommendations in the United States2,3*

* Recommended intakes were provided in different forms by each source cited. The Food and Nutrition Board of the National Academy of Sciences (NAS) released Recommended Dietary Allowances until 1997. In 1997, it chose to use the term adequate intake for the recommendations for calcium intake but indicated that these values were to be used as Recommended Dietary Allowances. The NIH Consensus Conference did not specify a specific term but indicated that these values were the "optimal" intake levels. Dietary recommendations by the NAS are set to meet the needs of 95% of the identified population of healthy subjects. The NAS guideline should be the primary guideline utilized. † For infant values, the 1994 NIH Consensus Conference indicated values for formula-fed infants, whereas the 1997 NAS report used the infant fed human milk as the standard.

TABLE 2
Approximate Calcium Contents of 1 Serving of Some Common Foods*

* Adapted from Raper et al,37 Weaver,38,39 and Weaver and Plawecki.40
† Low-fat milk has comparable or greater calcium levels than whole milk.
‡ The calcium from spinach is essentially nonbioavailable.

Source: American Academy of Pediatrics

Vitamins and minerals are important elements of the total nutritional requirements of your child. Because the human body itself is unable to produce adequate amounts of many vitamins, they must be obtained from the diet. The body needs these vitamins in only tiny amounts, and in a balanced diet they are usually present in sufficient quantities in the foods your youngster eats. Thus, in middle childhood, supplements are rarely needed.

For some youngsters, however, pediatricians may recommend a daily supplement. If your child has a poor appetite or erratic eating habits, or if she consumes a highly selective diet (such as a vegetarian diet containing no dairy products), a vitamin supplement should be considered. Chewable tablets are available for children who have difficulty swallowing pills.

These over-the-counter supplements are generally safe; nonetheless, they are drugs. If taken in excessive amounts (in tablets, capsules or combined with other supplements), some supplements - particularly the fat-soluble vitamins (A, D, E and K) - can be toxic. Scientists are finding that in some special situations and diseases, vitamin supplementation can be an important contributor to health. However, so-called megavitamin therapy or orthomolecular medicine - in which vitamins are given in extremely large doses for conditions ranging from mental retardation to hyperactivity to dyslexia - has no proven scientific validity and may pose some risks. Vitamin C, for example, when consumed in megadoses in hopes of undermining a cold, can sometimes cause headaches, diarrhea, nausea and cramps. Always consult your pediatrician before giving your child supplements. And don't leave a bottle of vitamins on the table as though they were a condiment like salt or pepper; taking vitamins should be done with careful consideration.

Sources for Various Vitamins and Minerals

As much as possible, try to maximize the vitamins your child receives in her regular meals. Following are some of the vitamins and minerals necessary for normally growing children, and some of the foods that contain them.

Vitamin A promotes normal growth, healthy skin, and tissue repair, and aids in night and color vision. Rich sources include yellow vegetables, dairy products and liver.

The B vitamins promote red blood cell formation and assist in a variety of metabolic activities. They are found in meat (including liver), poultry, fish, soybeans, milk, eggs, whole grains and enriched breads and cereals.

Vitamin C strengthens connective tissue, muscles, and skin, hastens the healing of wounds and bones and increases resistance to infection. Vitamin C is found in citrus fruits, strawberries, tomatoes, potatoes, Brussels sprouts, spinach and broccoli.

Vitamin D promotes tooth and bone formation and regulates the absorption of minerals like calcium. Sources include fortified dairy products, fish oils, fortified margarine and egg yolks. Although vitamin proponents insist that large doses of vitamin D - far greater than the U.S. Recommended Daily Allowances - can build even stronger bones, there is no evidence to support this claim, and excessive quantities of vitamin D are potentially toxic. Sunlight also contributes to dietary sources of vitamin D, stimulating the conversion of a naturally occurring compound in the skin to an active form of the vitamin.

Especially during periods of rapid growth, iron is essential for the production of blood and the building of muscles. When iron levels are low, your child may demonstrate symptoms such as irritability, listlessness, depression and an increased susceptibility to infection. However, a deficiency of iron is much more common in adolescence than in middle childhood. Once girls begin menstruation, they need much more iron than boys do. The best sources of iron include beef, turkey, pork and liver. Spinach, beans and prunes also contain modest amounts of iron. Some cereals and flour are enriched with iron.

As your child matures, calcium is necessary for healthy bone development. An inadequate calcium intake during childhood can not only affect present growth but might also help contribute to the development of weakened and porous bones (osteoporosis) later in life. Low-fat milk, cheese, yogurt and sardines are excellent sources of calcium. Some vegetables, such as broccoli and spinach, also contain modest amounts of calcium. Some fruit juices are now fortified and provide a good source of calcium.

Source: American Academy of Pediatrics

The American Academy of Pediatrics is committed to breastfeeding as the ideal source of nutrition for infants. For those infants who are formula-fed, either as a supplement to breastfeeding or exclusively during their infancy, it is common practice for pediatricians to change the formula when symptoms of intolerance occur. Decisions about when the formula should be changed and which formula should be used vary significantly, however, among pediatric practitioners. This statement clarifies some of these issues as they relate to protein hypersensitivity (protein allergy), one of the causes of adverse reactions to feeding during infancy.

Abbreviation

IgE, immunoglobulin E.

Symptoms of food protein allergy include those commonly associated with immunoglobulin E (IgE)-associated reactions, such as angioedema, urticaria, wheezing, rhinitis, vomiting, eczema, and anaphylaxis.1 Non-IgE-associated, immunologically mediated conditions have also been associated with the ingestion of cow's milk, soy, and other dietary proteins in infant feedings. These disorders include pulmonary hemosiderosis,2 malabsorption with villous atrophy,3 eosinophilic proctocolitis,4 enterocolitis,5 and esophagitis.6 Finally, some infants may experience extreme irritability or colic as the only symptom of food protein allergy.7 The prevalence in infancy of milk protein allergy is low — 2 percent to 3 percent.8-10 Thus, the use of hypoallergenic-labeled infant formulas, which cost as much as three times more than standard formulas, should be limited to infants with well-defined clinical indications. Adverse reactions to cow's milk associated with other conditions such as phenylketonuria and lactose intolerance may also be alleviated by the use of alternative formulas, although not necessarily those intended to treat infants with protein allergy.

Formula Development and Labeling

Before new potential hypoallergenic formulas are tested in trials using human infants, comprehensive preclinical testing must be conducted to examine for toxicity and suitability to maintain a positive nitrogen balance and to attempt to predict whether infants allergic to cow's milk will react adversely to them. This testing should include efforts to determine the molecular weight profile of residual peptides, the amount of immunologically recognizable material present, and the ability of the product to sensitize or provoke reactions in animal models of allergenicity.11-14

To establish the risk of hypersensitivity in infants, carefully conducted preclinical studies must be performed that demonstrate a formula may be hypoallergenic. The formula needs to be tested in infants with hypersensitivity to cow's milk or cow's milk-based formula and the findings verified by properly conducted elimination-challenge tests.15 These tests should, at a minimum, ensure with 95 percent confidence that 90 percent of infants with documented cow's milk allergy will not react with defined symptoms to the formula under double-blind, placebo-controlled conditions.16 Such formulas can be labeled hypoallergenic. If the formula being tested is not derived from cow's milk proteins, the formula must also be evaluated in infants or children with documented allergy to the protein from which the formula was derived. It is also recommended that after a successful double-blind challenge, the clinical testing should include an open challenge using an objective scoring system to document allergic symptoms during a period of seven days.16 This is particularly important to detect late-onset reactions to the formula.17

Any formula with residual peptides may provoke reactions in infants allergic to cow's milk.17,18 Extensively hydrolyzed proteins derived from cow's milk, in which most of the nitrogen is in the form of free amino acids and peptides <1500 kDa, have been used in formulas for >50 years for infants with severe inflammatory bowel diseases or cow's milk allergy. These formulas, as well as the newer free amino acid-based formulas, have been subjected to extensive clinical testing and meet the standard for hypoallergenicity.19-21

Hypoallergenic formulas are intended for use by infants with existing allergic symptoms. Recently formulas have also been promoted to prevent the development of allergy in infants at high risk for developing allergic symptoms. The ability to determine which infants are at high risk is imperfect, although many markers, including elevated levels of cord blood IgE and serum IgE in infancy and an atopic family history, have been identified.22 Because a family history of allergy is at least as sensitive and specific as any other marker,23 infants from families with a history of allergy should serve as the study participants in clinical testing of formulas that claim the ability to prevent allergy from developing. These infants should be fed the formula exclusively from birth for at least six months under the conditions of a controlled, randomized study and observed for at least 12 additional months. Allergic symptoms during the period of observation should be documented with a validated clinical scoring system and allergic symptoms verified by double-blind, placebo-controlled testing. When compared with infants fed a standard cow's milk formula, infants fed formulas that claim to prevent or delay allergy should have a statistically significant lower prevalence of allergy at the end of the observation period.16

Clinical Practice Treatment

Breast milk is the optimal sole source of nutrition for healthy infants for the first six months of life. Breastfeeding should be continued for the first 12 months of life or longer. Although the incidence of food allergy is very low in breastfed infants compared with formula-fed infants, rare cases of anaphylaxis to cow's milk proteins have been reported in those breastfed as well as more frequent cases of cow's milk-induced proctocolitis.24-26 The pathophysiology of these reactions in the breastfed infant is not well-understood. However, immunologically recognizable proteins from the maternal diet can be found in breast milk.27,28

Elimination of cow's milk, eggs, fish, peanuts and tree nuts and other foods from the maternal diet may lead to resolution of allergic symptoms in the nursing infant. For those infants whose symptoms do not improve or whose mothers are unable to participate in a very restricted diet regimen and for formula-fed infants with cow's milk allergy, alternative formulas can be used to relieve the symptoms.

In infants allergic to cow's milk, milk from goats and other animals29 or formulas containing large amounts of intact animal protein are inappropriate substitutes for breast milk or cow's milk-based infant formulas. Soy formulas have a long history as alternative formulas in infants who are allergic. Eight to 14 percent of infants with symptoms of IgE-associated cow's milk allergy will also react adversely to soy,30 but reports of anaphylaxis to soy are extremely rare. Those infants allergic to cow's milk and who do not have an adverse reaction at the start of feeding on a soy formula tolerate it very well.31 Thus, although soy formulas are not hypoallergenic, they can be fed to infants with IgE-associated symptoms of milk allergy, particularly after the age of six months.29 There is a significantly higher prevalence of concomitant reactions between cow's milk and soy proteins (25 percent-60 percent) among those infants with proctocolitis and enterocolitis32 and therefore soy is not recommended for the treatment of infants with these non-IgE-associated syndromes.31

Formulas based on partially hydrolyzed cow's milk proteins (1000-100,000 times higher concentrations of intact cow's milk proteins compared with extensively hydrolyzed protein) have provoked significant reactions in a high percentage of infants allergic to cow's milk33,34 and are not intended to be used to treat cow's milk allergy. Extensively hydrolyzed formulas have also provoked allergic reactions in infants allergic to cow's milk,17,18 but at least 90 percent of these infants tolerate extensively hydrolyzed formulas as well as the more recently introduced free amino acid-based infant formulas. Although the majority of infants with colic will not respond to a hypoallergenic formula, those with severe colic may benefit from a one- to two-week trial of a hypoallergenic formula.7

Prophylaxis

Recent studies, one a randomized and prospectively controlled study of preterm infants followed up for 18 months35 and a second prospective nonrandomized and uncontrolled study of full-term infants followed up for 17 years,36 have demonstrated that breastfeeding exclusively for at least six months reduces the risk of later respiratory allergic symptoms and eczema. Although many of the studies that have examined the ability of breastfeeding to delay or prevent allergic disease have significant methodologic shortcomings,22,37 the total of these studies suggests that breastfeeding exclusively has a protective effect, at least in high-risk infants and particularly if it is combined with maternal avoidance of cow's milk, egg, fish, peanuts and tree nuts during lactation.

More definitive prospective studies of the use of alternative formulas for allergy prophylaxis in high-risk infants are needed. However, the prospective studies available that utilized blinded food challenges to confirm allergic symptoms suggest that asymptomatic formula-fed infants at high risk for allergy given alternatives to cow's milk formulas may have a lower future risk of allergic disease or delayed onset of allergic symptoms. In one recently reported study, infants at high risk for allergy fed an extensively hydrolyzed formula or breastfed infants whose mothers avoided cow's milk, egg, and peanuts and did not introduce these foods into their infants' diets had a reduced prevalence of all allergic disorders at one year compared with the control group fed a standard cow's milk formula.38 However, at seven years of age there were no differences in allergic respiratory symptoms between the two groups.

A recent meta-analysis of all prospective controlled trials of a partially hydrolyzed formula showed a significant prophylactic effect of the partially hydrolyzed formula on the development of atopic symptoms at 60 months of age.39 The studies analyzed did not all include confirmation of allergic symptoms by blinded challenge. In the only prospective study of allergy prophylaxis in high-risk infants that compared a partially and extensively hydrolyzed formula, only the extensively hydrolyzed formula prevented the development of allergy during the first 18 months of life in high-risk infants.40 The other comparison groups in this study were fed a cow's milk-based formula or were breastfed exclusively for more than nine months. Solid feedings were delayed until four months of age, and eggs, cow's milk and fish were eliminated from the mothers' diets and their introduction delayed in their infants' diets until after the first year of life. Randomized prospective studies of soy protein-based formulas have not shown a preventive effect of these formulas on the development of allergy in high-risk infants.41,42 No published studies have examined the effectiveness of free amino acid-based formulas on allergy prevention in high-risk infants.

Conclusion

Hypoallergenic formulas, like all formulas intended for infant feeding, must demonstrate nutritional suitability to support infant growth and development. To be labeled hypoallergenic, these formulas, after appropriate preclinical testing, must demonstrate in clinical studies that they do not provoke reactions in 90 percent of infants or children with confirmed cow's milk allergy with 95 percent confidence when given in prospective randomized, double-blind, placebo-controlled trials.

Extensively hydrolyzed and free amino acid-based formulas have been subjected to such studies and are hypoallergenic. Currently available, partially hydrolyzed formulas are not hypoallergenic. Carefully conducted randomized controlled studies in infants from families with a history of allergy must be performed to support a formula claim for allergy prevention. Allergic responses must be established prospectively, evaluated with validated scoring systems, and confirmed by double-blind, placebo-controlled challenge. These studies should continue for at least 18 months and preferably for 60 to 72 months or longer where possible.

Recommendations

1.      Breast milk is an optimal source of nutrition for infants through the first year of life or longer. Those breastfeeding infants who develop symptoms of food allergy may benefit from:

a.                              maternal restriction of cow's milk, egg, fish, peanuts and tree nuts and if this is unsuccessful,

b.                              use of a hypoallergenic (extensively hydrolyzed or if allergic symptoms persist, a free amino acid-based formula) as an alternative to breastfeeding. Those infants with IgE-associated symptoms of allergy may benefit from a soy formula, either as the initial treatment or instituted after six months of age after the use of a hypoallergenic formula. The prevalence of concomitant is not as great between soy and cow's milk in these infants compared with those with non-IgE-associated syndromes such as enterocolitis, proctocolitis, malabsorption syndrome, or esophagitis. Benefits should be seen within two to four weeks and the formula continued until the infant is one year of age or older.

2.      Formula-fed infants with confirmed cow's milk allergy may benefit from the use of a hypoallergenic or soy formula as described for the breastfed infant.

3.      Infants at high risk for developing allergy, identified by a strong (biparental; parent, and sibling) family history of allergy may benefit from exclusive breastfeeding or a hypoallergenic formula or possibly a partial hydrolysate formula. Conclusive studies are not yet available to permit definitive recommendations. However, the following recommendations seem reasonable at this time:

a.                              Breastfeeding mothers should continue breastfeeding for the first year of life or longer. During this time, for infants at risk, hypoallergenic formulas can be used to supplement breastfeeding. Mothers should eliminate peanuts and tree nuts (eg, almonds, walnuts, etc) and consider eliminating eggs, cow's milk, fish, and perhaps other foods from their diets while nursing. Solid foods should not be introduced into the diet of high-risk infants until six months of age, with dairy products delayed until one year, eggs until two years, and peanuts, nuts, and fish until three years of age.

b.                              No maternal dietary restrictions during pregnancy are necessary with the possible exception of excluding peanuts;

4.      Breastfeeding mothers on a restricted diet should consider the use of supplemental minerals (calcium) and vitamins.

Source: American Academy of Pediatrics

Understanding Eating Disorders

Eating is something that most people look forward to. It can mean experiencing good food, doing something healthy for your body, and spending time with family or friends. Many social events such as parties and holidays also involve food. But, for a person who has an eating disorder, eating brings about very different feelings. Constant thoughts about eating and an intense fear of gaining weight become an obsession for a person who has an eating disorder.

Living with an eating disorder is very hard. The road to recovery is not easy but, with treatment, a person can recover and go on to lead a healthy life. Without help, a person with an eating disorder can have a number of medical problems, become very sick, and even die.

The two most common eating disorders are anorexia nervosa and bulimia nervosa. Anorexia is self-starvation. Bulimia is a disorder in which a person eats large amounts of food ("bingeing") and then rids the body of that food before it can be absorbed ("purging"). A person who is bulimic purges either by vomiting or using laxatives or diuretics (water pills). Some people have symptoms of both anorexia and bulimia.

Anorexia and bulimia starve the body of food. This causes many physical changes to occur which can lead to kidney and liver damage, very low blood pressure, and heart failure. Other physical changes that can happen include:

• The constant feeling of being cold because the body has lost the fat and muscle it needs to keep warm. This may make the anorexic exercise even more in an attempt to get warm.
• Eyes become vacant and hollow.
• Bones stick out and the skin shrinks around the bones, often making the stomach seem like it is sticking out (leading the anorexic to still think that she is fat or overweight).
• Hair on the head falls out, while fine hair appears on other parts of the body for warmth.
• Hair and fingernails become brittle and skin becomes dry and rough due to a lack of protein and vitamins in the diet.
• Menstrual periods stop (or do not start at all if a girl developed anorexia before her first period). This puts the anorexic at higher risk of developing osteoporosis, a disease that causes bones to become brittle and break more easily.
• Pain in the abdomen, constipation, and bloating.
• Stunted growth, resulting in permanent short stature.
• Anemia.

Most anorexics and bulimics are girls; however, boys can suffer from these disorders as well. Adolescents experience many social pressures, especially from the media, to be thin. This pressure to be thin or to diet can be especially strong for teens if their friends are dieting or trying to lose weight. It is easy for teens to get over-the-counter diet pills to reduce their appetite so that they do not eat as much ( a practice that can become habit-forming. Diet pills can raise blood pressure, cause kidney damage, make a person dizzy or hallucinate, or even lead to fatal stroke.

There is no single cause of an eating disorder. Many factors may be involved and are different for each person. Some factors include:

• Feeling insecure
• An excessive desire to be in control
• A distorted body image (feeling fat) and striving for the perfect body
• A family history of depression or an eating disorder
• Severe family problems
• A history of sexual abuse
• Extreme social pressures
• Pressure from activities such as running, gymnastics, wrestling, or ballet

It is important, however, for both girls and boys to understand that not everyone has the type of body that is superthin. In fact, only a small number do. If a person is not meant to be naturally thin, that person needs to accept that fact and learn to like his or her body the way it is. It is important to have a healthy attitude toward weight and to feel good about oneself.

Understanding anorexia
Anorexia is self-starvation. This disorder mainly affects females between 14 and 18 years of age. A person with anorexia has such an intense fear of becoming fat that she hardly eats anything and becomes dangerously thin. Anorexics often weigh as little as 80 to 100 pounds. Many anorexics also over-exercise and may abuse diet pills to keep from gaining weight. If the condition gets worse, anorexics can die from suicide, heart attack, or starvation.

Some people who struggle with eating disorders alternate between anorexic and bulimic behaviors. About half of all people who have anorexia at one time or another develop some symptoms of bulimia (mainly the bingeing and purging).

When a person develops anorexia nervosa, her behavior changes, especially in regard to eating. A person with anorexia may:

• Eat only "safe" foods, usually those low in calories and fat.
• Cut up food into very small pieces.
• Spend more time playing with food than eating it, such as rearranging it on the plate throughout a meal.
• Buy, prepare, and cook food only for others.

As the anorexic becomes more obsessed with food, her personality changes as well. She may become more self-centered, as all her energy and focus is on herself and staying thin. In addition, a person with anorexia may:

• Exercise compulsively.
• Wear baggy clothing to hide extreme thinness, or complain that normal clothing is too tight.
• Spend less time with friends and family, becoming more isolated, withdrawn, and secretive.
• Develop rituals to keep her mind off her hunger, such as chewing each bite of food 30 times before swallowing.
• Get angry if she is not able to exercise or if her daily routine is disturbed.

Teens who develop anorexia are usually good students, even overachievers. They try to get along with others, tend to be perfectionists, and do not like to admit they need help with anything. To others they appear to be in control. However, they are actually unsure of themselves, are self-critical, and have low self-esteem. They are very concerned about whether other people like them and about pleasing others. Some of these negative feelings may come from having a poor body image (the way a person feels about how his or her body looks).

Many young people think that losing weight will make them feel better about how they look. This is why most people who develop anorexia start by dieting. The message they get from our culture, including the media, is that a slim body is attractive and desirable. They may also start dieting in response to some kind of major life change, like puberty or going away to college. Because anorexics have low self-esteem, they do not feel confident that they can handle these changes. They do not feel like they have control. Dieting makes them feel better about themselves and becomes something they are able to do well on their own. Over time, the dieting is really no longer about food, but becomes a way for the anorexic to feel like she has control over her life.

Understanding bulimia
Bulimia and anorexia share some of the same symptoms. As with anorexia, food and staying thin become an obsession, but the bulimic does not starve herself. Instead, the bulimic gets an uncontrollable urge to binge (eat a large amount of food in a short period of time) and then purge this food from her body.

Bulimia usually develops between the ages of 15 and 24 and affects mostly females. A bulimic's weight is usually within the range of what is normal for her size and height, but it tends to go up and down a lot because of all the bingeing and purging.

A bulimic no longer has full control over eating. She may be afraid to eat in restaurants or with other people because she cannot control the urges to binge or the urges to purge after eating normal amounts of food. This fear may cause her to avoid social situations and isolate herself from other people. Bulimics may also change in other ways by:

• Becoming very secretive about food, spending a lot of time thinking about and planning the next binge, and setting aside certain times to binge.
• Stealing food or hoarding it in strange places, such as under the bed or in closets.
• Bingeing on foods with distinct colors in order to know when they are later thrown up.
• Spending a lot of time, energy, and money, because bulimia is a time-consuming and expensive addiction.

People who develop bulimia often have a hard time dealing with and controlling impulses, stress, and anxieties. They are not happy with their body image and think they are overweight or fat. This leads them to start dieting, but then, in response to anxiety and other emotions, they give in to their impulses and cravings for food by bingeing.

During a binge, a person with bulimia may eat between 3,000 and 7,000 calories, often in less than a few hours. Depression, boredom, or anger often trigger a binge. Eating during a binge is almost robot-like. The bulimic chews and swallows without paying attention to what the food tastes like or whether she is hungry or full. Binges usually end when there is no more food to eat, when the stomach hurts so much from eating, or when something such as a phone call breaks the bulimic's concentration on bingeing.

After eating large amounts of food, the bulimic feels guilty and is afraid of gaining weight. To ease her guilt and fear, she purges the food from her body by vomiting or taking pills that cause diarrhea. After bingeing she may turn to extreme exercise or strict dieting. This period of "control" lasts until the next binge, and then the cycle starts all over again. Bulimia becomes an attempt to control two very strong impulses ( the desire to be thin and the desire to eat.

The following changes may be signs that a person has bulimia:

• Teeth start to decay from contact with stomach acids during vomiting.
• Weight goes up and down.
• Menstrual periods become irregular.
• The face and throat look puffy and swollen.
• Periods of dizziness and blackouts occur.
• Dehydration due to loss of body fluids occurs. The bulimic may need to be hospitalized if this happens.
• Constant upset stomach, constipation, and sore throat may be present.
• Damage to vital organs, such as the liver and kidneys, heart failure, and death can occur.

Treating Eating Disorders

Recognizing the early signs of an eating disorder is important for successful treatment. Otherwise, it may be too late. If someone answers "yes" to any of the following statements, that person should get help right away.

• I cannot stop dieting, even though my family and friends warn me that I have lost too much weight.
• Even though I have lost a lot of weight, when I look in the mirror I still think that certain parts of my body are fat.
• I cannot stop exercising.
• I do not get my menstrual period monthly.

The chance of successfully treating someone who has an eating disorder is much higher if the disorder is detected early and the person begins to get help. Treatment depends on many things, including the person's willingness to cooperate, family and support structure, and the stage of the disorder.

Successful treatment of eating disorders involves many health professionals who work together by treating a certain aspect of the disorder. Treatment begins with a visit to a pediatrician, who will examine the person's medical condition to see how the eating disorder has affected the body. If the effects are severe, the person may need to be hospitalized for treatment.

In treating anorexia, increasing the person's weight is crucial. If the anorexic needs to be hospitalized, her treatment will focus on getting her weight back up to a normal level. If she refuses to eat, she may need a feeding tube to get the proper nutrients into her body. Hospitalization often helps the anorexic slowly change her behavior so that when she returns home, she can gain weight slowly with outpatient pediatric and psychiatric treatment. A person with bulimia may need hospitalization to control the cycles of bingeing and purging and to replace needed nutrients in the body.

Counseling is necessary to help a person with an eating disorder understand how she uses food as a way of handling problems and feelings. It will help her improve her self-image (including body image) and develop independence so that she can take control of her life in positive ways. A mix of individual therapy and family therapy is usually most effective in treating eating disorders. Since an eating disorder usually affects a person's entire family, a therapist can try to help family members understand the disorder. The therapist can also help families create a supportive home environment for the person with an eating disorder. Occasionally, people who have eating disorders also have problems with alcohol abuse or other substance abuse, and may need to be treated for those as well.

Anorexia and bulimia are both very serious eating disorders that do not go away by themselves. However, eating disorders are treatable with help. A person with an eating disorder needs professional help to recover and become healthy again.

For other resources and help with eating disorders, contact the following organizations:

National Association of Anorexia Nervosa and Associated Disorders
Box 7
Highland Park, IL 60035
708/ 831-3438

American Anorexia/Bulimia Association
418 E 76th St
New York, NY 10021
212/ 734-1114

Anorexia Nervosa and Related Eating Disorders
Box 5102
Eugene, OR 97405
503/ 344-1144

Source: American Academy of Pediatrics

Your child should consume a variety of foods from the five major food groups that make up the "food pyramid". Each food group supplies important nutrients, including vitamins and minerals. These five groups and typical minimum servings are:

• Vegetables: Three servings to five servings per day. A serving may consist of one cup of raw leafy vegetables, 3/4 cup of vegetable juice, or 1/2 cup of other vegetables, chopped raw or cooked.
• Fruits: Two servings to four servings per day. A serving may consist of 1/2 cup of sliced fruit, 3/4 cup of fruit juice, or a medium-size whole fruit, like an apple, banana or pear.
• Bread, cereal, or pasta: Six servings to 11 servings per day. Each serving should equal one slice of bread, 1/2 cup of rice or pasta or 1 ounce of cereal.
• Protein foods: two servings to three servings of 2-3 ounces of cooked lean meat, poultry or fish per day. A serving in this group may also consist of 1/2 cup of cooked dry beans, one egg, or 2 tablespoons of peanut butter for each ounce of lean meat.
• Dairy products: two servings to three servings per day of 1 cup of low-fat milk or yogurt, or 11/2 ounces of natural cheese.

Fiber

Fiber is a carbohydrate component of plant foods that is usually undigestible. It is found in foods like fruits, vegetables, whole-grain breads, cereals, brown rice, beans, seeds and nuts. In adults, increased fiber has been linked with a reduction of chronic gastrointestinal problems, including colon cancer, irritable bowel syndrome and diverticulitis. In children, however, fiber's only proven benefit is its ability to ease constipation-providing bulk that can promote regular frequency of bowel movements, soften the stools, and decrease the time it takes food to travel through the intestines. However, since food preferences and eating habits may be established early in life, and since high-fiber foods contain other nutrients, parents should include these foods in children's daily diets.

Protein

Your child requires protein for the proper growth and functioning of his body, including building new tissues and producing antibodies that help battle infections. Without essential amino acids (the building blocks of protein), children would be much more susceptible to serious diseases.

Protein-rich plants - such as dried beans and peas (legumes), grains, seeds and nuts -can be used as valuable sources of protein. Other protein-rich foods include meat, fish, milk, yogurt, cheese and eggs. These animal products contain high-quality protein and a full array of amino acids.

Bear in mind