Lee Savio Beers, MD

Oral health has deservedly attracted increased attention over recent years. Cavities are the No. 1 chronic disease affecting young children, yet pediatric dentist availability is inadequate, and most pediatricians receive little education on oral health during their training. Additionally, recommendations for good oral health may be hard for parents to implement when their infant is crying for a bottle in the middle of the night or their toddler is fighting all efforts at good tooth brushing.

In my own practice, I feel very lucky to have a close partnership with an excellent pediatric dentistry department from whom I have learned a great deal. I have discovered a lot of facts, but also many practical tips that I have been able to use clinically and pass on to families. The first and most important thing I have learned from my dentistry colleagues is how important it is for pediatric primary care providers to ask about oral health at every visit. There are different ways to incorporate this into your history taking, but I typically ask when I am doing my ear, nose, and throat exam. I find this is most efficient, but also the best time to elicit parents’ questions and concerns about oral health (and also a time for me to provide positive feedback).

The second extremely helpful tip I have learned is how to get a good exam. Older patients are, of course, much more likely to be cooperative, and the very young infants also are fairly easy to examine. A mad 18-month-old, on the other hand, can be a real challenge! Again, as I was taught by my dental colleagues, I ask the parent to sit in a chair and put the child in their lap, facing them and with the child’s legs on either side of the parent’s hips. I also sit in a chair, facing the parent (at which point the child’s back is toward me). The parent then lays the child back along their legs, so that the child’s head is in front of me, and I am looking down their nose into their mouth. This is a perfect angle to be able to control the child’s mouth and get a direct look in – so I can be quick and thorough. For parents whose children really fight tooth brushing, I teach them this technique as well if there are two adults in the house available to help with the dental hygiene routine. In my experience, I find that in addition to providing control and a good angle for an exam, as long as you move them into the position slowly, young children find this a comforting position in which to have their mouth examined. They are somewhat cocooned by the parent’s legs and arms, which seems to help them feel protected and a little calmer.

Finally (and this is perhaps most based on my own experience as a parent), I talk with parents about how important it is to develop a regular routine of twice-daily brushing, even when your toddler fights it. Not every brushing will be perfect. Every parent has had those times where their child clamps down their lips, and you just don’t have the heart to really pry their mouths open to brush all corners of every last tooth. However, if a child learns that this is the routine, the fighting will become less and less with time. I tell parents it is better to get a mediocre tooth brushing in than no brushing at all. I also assure them that, particularly for younger children, they do not have to brush their teeth in the bathroom in front of the sink. As long as you are using an appropriately small amount of toothpaste, you can brush while sitting on the bed reading books or in the rocking chair. Some children do better with the routine of being in the bathroom, while others do better in a safer, feeling more comfortable environment.

Overall, as pediatric providers, we can be important partners with our dental colleagues in making sure that children – and their teeth – are healthy.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

Oral health has deservedly attracted increased attention over recent years. Cavities are the No. 1 chronic disease affecting young children, yet pediatric dentist availability is inadequate, and most pediatricians receive little education on oral health during their training. Additionally, recommendations for good oral health may be hard for parents to implement when their infant is crying for a bottle in the middle of the night or their toddler is fighting all efforts at good tooth brushing.

In my own practice, I feel very lucky to have a close partnership with an excellent pediatric dentistry department from whom I have learned a great deal. I have discovered a lot of facts, but also many practical tips that I have been able to use clinically and pass on to families. The first and most important thing I have learned from my dentistry colleagues is how important it is for pediatric primary care providers to ask about oral health at every visit. There are different ways to incorporate this into your history taking, but I typically ask when I am doing my ear, nose, and throat exam. I find this is most efficient, but also the best time to elicit parents’ questions and concerns about oral health (and also a time for me to provide positive feedback).

The second extremely helpful tip I have learned is how to get a good exam. Older patients are, of course, much more likely to be cooperative, and the very young infants also are fairly easy to examine. A mad 18-month-old, on the other hand, can be a real challenge! Again, as I was taught by my dental colleagues, I ask the parent to sit in a chair and put the child in their lap, facing them and with the child’s legs on either side of the parent’s hips. I also sit in a chair, facing the parent (at which point the child’s back is toward me). The parent then lays the child back along their legs, so that the child’s head is in front of me, and I am looking down their nose into their mouth. This is a perfect angle to be able to control the child’s mouth and get a direct look in – so I can be quick and thorough. For parents whose children really fight tooth brushing, I teach them this technique as well if there are two adults in the house available to help with the dental hygiene routine. In my experience, I find that in addition to providing control and a good angle for an exam, as long as you move them into the position slowly, young children find this a comforting position in which to have their mouth examined. They are somewhat cocooned by the parent’s legs and arms, which seems to help them feel protected and a little calmer.

Finally (and this is perhaps most based on my own experience as a parent), I talk with parents about how important it is to develop a regular routine of twice-daily brushing, even when your toddler fights it. Not every brushing will be perfect. Every parent has had those times where their child clamps down their lips, and you just don’t have the heart to really pry their mouths open to brush all corners of every last tooth. However, if a child learns that this is the routine, the fighting will become less and less with time. I tell parents it is better to get a mediocre tooth brushing in than no brushing at all. I also assure them that, particularly for younger children, they do not have to brush their teeth in the bathroom in front of the sink. As long as you are using an appropriately small amount of toothpaste, you can brush while sitting on the bed reading books or in the rocking chair. Some children do better with the routine of being in the bathroom, while others do better in a safer, feeling more comfortable environment.

Overall, as pediatric providers, we can be important partners with our dental colleagues in making sure that children – and their teeth – are healthy.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

Oral health has deservedly attracted increased attention over recent years. Cavities are the No. 1 chronic disease affecting young children, yet pediatric dentist availability is inadequate, and most pediatricians receive little education on oral health during their training. Additionally, recommendations for good oral health may be hard for parents to implement when their infant is crying for a bottle in the middle of the night or their toddler is fighting all efforts at good tooth brushing.

In my own practice, I feel very lucky to have a close partnership with an excellent pediatric dentistry department from whom I have learned a great deal. I have discovered a lot of facts, but also many practical tips that I have been able to use clinically and pass on to families. The first and most important thing I have learned from my dentistry colleagues is how important it is for pediatric primary care providers to ask about oral health at every visit. There are different ways to incorporate this into your history taking, but I typically ask when I am doing my ear, nose, and throat exam. I find this is most efficient, but also the best time to elicit parents’ questions and concerns about oral health (and also a time for me to provide positive feedback).

The second extremely helpful tip I have learned is how to get a good exam. Older patients are, of course, much more likely to be cooperative, and the very young infants also are fairly easy to examine. A mad 18-month-old, on the other hand, can be a real challenge! Again, as I was taught by my dental colleagues, I ask the parent to sit in a chair and put the child in their lap, facing them and with the child’s legs on either side of the parent’s hips. I also sit in a chair, facing the parent (at which point the child’s back is toward me). The parent then lays the child back along their legs, so that the child’s head is in front of me, and I am looking down their nose into their mouth. This is a perfect angle to be able to control the child’s mouth and get a direct look in – so I can be quick and thorough. For parents whose children really fight tooth brushing, I teach them this technique as well if there are two adults in the house available to help with the dental hygiene routine. In my experience, I find that in addition to providing control and a good angle for an exam, as long as you move them into the position slowly, young children find this a comforting position in which to have their mouth examined. They are somewhat cocooned by the parent’s legs and arms, which seems to help them feel protected and a little calmer.

Finally (and this is perhaps most based on my own experience as a parent), I talk with parents about how important it is to develop a regular routine of twice-daily brushing, even when your toddler fights it. Not every brushing will be perfect. Every parent has had those times where their child clamps down their lips, and you just don’t have the heart to really pry their mouths open to brush all corners of every last tooth. However, if a child learns that this is the routine, the fighting will become less and less with time. I tell parents it is better to get a mediocre tooth brushing in than no brushing at all. I also assure them that, particularly for younger children, they do not have to brush their teeth in the bathroom in front of the sink. As long as you are using an appropriately small amount of toothpaste, you can brush while sitting on the bed reading books or in the rocking chair. Some children do better with the routine of being in the bathroom, while others do better in a safer, feeling more comfortable environment.

Overall, as pediatric providers, we can be important partners with our dental colleagues in making sure that children – and their teeth – are healthy.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

As a general pediatrician, I am fortunate that most of my patients are thriving and healthy. Even those with chronic disease have the access to lifesaving medicines and treatments that offer most of them the opportunity for a long, full life. Perhaps in part because so many of my patients are healthy, and death is not something I must face on a regular basis, each time it happens I feel a bit lost and unprepared.

Very sadly, over the past several months, four of my patients have died – each under very different circumstances. While the sadness and loss I, and others on their medical team, felt each time we learned of an untimely death in no way comes close to what our patient’s families are experiencing, we are still affected. As a medical team, we also share a responsibility to families to extend our support through their grief – which may extend for many, many years, and we often may continue to provide medical care for siblings or other family members, whose grief may go unrecognized or forgotten.

Over the years, I have realized how important it is to recognize and confront my own feelings about a patient’s death in order to be able to support their family. I also have realized that it is equally important to provide an opportunity for the rest of the patient’s care team to grieve and debrief. Often the care team may look to the physician to start or provide the opportunity for this conversation. Many emotions may unearth themselves – from fear to grief to overwhelming sadness. Addressing these emotions in a safe environment helps to ensure that, as providers, we then are able to provide helpful support to families in mourning.

The American Academy of Pediatrics has published a very thoughtful and helpful clinical report, "Supporting the Family After the Death of a Child," which walks the provider through important issues and concerns (Pediatrics 2012;130:1164-9). The most powerful step providers can take, which is identified in this report and I fully agree with, is to call or personally visit the family. Attending the patient’s funeral or memorial service also can be meaningful and important, but a private, personal contact is invaluable to allow the family the opportunity to ask questions or express concerns they may not want to express publicly. This is not a time for us as providers to offer advice or justification, but merely to listen and grieve together.

That said, there are times when it becomes clear – for whatever reason – that a family doesn’t want to or isn’t ready to talk with someone from the medical care team. In those circumstances, I still think the mere act of trying to reach out and express your sadness and condolences is important. There have been times when families reached back out to me weeks or months later with questions or thoughts – an initial attempt at contact helps a family to know that you are available and willing to talk. One mother called me months after her child’s death – she had begun the process of cleaning out her daughter’s room and wasn’t sure how to dispose of her medications. A simple piece of information I was able to give her made an impossibly hard task a little easier, and was another touch point for us to talk about her daughter’s many strengths and how much we all missed her.

The AAP report also highlights some family support resources that are useful to know about and share with families. The loss of a child is indescribable, and many find comfort in sharing their feelings with others who have gone through a similar experience. Some resources highlighted in the report are The Compassionate Friends, a national self-help support organization for parents who have lost a child (www.compassionatefriends.org); SHARE, an organization that serves parents who have lost a child through pregnancy loss, stillbirth, or in the first few months of life (www.nationalshare.org); Bereaved Parents of the USA, providing support to bereaved caregivers and siblings (www.bereavedparentsusa.org) and Survivors of Suicide, for those who have lost a family member or loved one to suicide (www.survivorsofsuicide.com).

Through their own actions and the utilization of community resources, pediatric providers can be an important support for grieving families.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at [email protected]. To read more commentaries, visit pediatricnews.com/views/practical-parenting.html.

As a general pediatrician, I am fortunate that most of my patients are thriving and healthy. Even those with chronic disease have the access to lifesaving medicines and treatments that offer most of them the opportunity for a long, full life. Perhaps in part because so many of my patients are healthy, and death is not something I must face on a regular basis, each time it happens I feel a bit lost and unprepared.

Very sadly, over the past several months, four of my patients have died – each under very different circumstances. While the sadness and loss I, and others on their medical team, felt each time we learned of an untimely death in no way comes close to what our patient’s families are experiencing, we are still affected. As a medical team, we also share a responsibility to families to extend our support through their grief – which may extend for many, many years, and we often may continue to provide medical care for siblings or other family members, whose grief may go unrecognized or forgotten.

Over the years, I have realized how important it is to recognize and confront my own feelings about a patient’s death in order to be able to support their family. I also have realized that it is equally important to provide an opportunity for the rest of the patient’s care team to grieve and debrief. Often the care team may look to the physician to start or provide the opportunity for this conversation. Many emotions may unearth themselves – from fear to grief to overwhelming sadness. Addressing these emotions in a safe environment helps to ensure that, as providers, we then are able to provide helpful support to families in mourning.

The American Academy of Pediatrics has published a very thoughtful and helpful clinical report, "Supporting the Family After the Death of a Child," which walks the provider through important issues and concerns (Pediatrics 2012;130:1164-9). The most powerful step providers can take, which is identified in this report and I fully agree with, is to call or personally visit the family. Attending the patient’s funeral or memorial service also can be meaningful and important, but a private, personal contact is invaluable to allow the family the opportunity to ask questions or express concerns they may not want to express publicly. This is not a time for us as providers to offer advice or justification, but merely to listen and grieve together.

That said, there are times when it becomes clear – for whatever reason – that a family doesn’t want to or isn’t ready to talk with someone from the medical care team. In those circumstances, I still think the mere act of trying to reach out and express your sadness and condolences is important. There have been times when families reached back out to me weeks or months later with questions or thoughts – an initial attempt at contact helps a family to know that you are available and willing to talk. One mother called me months after her child’s death – she had begun the process of cleaning out her daughter’s room and wasn’t sure how to dispose of her medications. A simple piece of information I was able to give her made an impossibly hard task a little easier, and was another touch point for us to talk about her daughter’s many strengths and how much we all missed her.

The AAP report also highlights some family support resources that are useful to know about and share with families. The loss of a child is indescribable, and many find comfort in sharing their feelings with others who have gone through a similar experience. Some resources highlighted in the report are The Compassionate Friends, a national self-help support organization for parents who have lost a child (www.compassionatefriends.org); SHARE, an organization that serves parents who have lost a child through pregnancy loss, stillbirth, or in the first few months of life (www.nationalshare.org); Bereaved Parents of the USA, providing support to bereaved caregivers and siblings (www.bereavedparentsusa.org) and Survivors of Suicide, for those who have lost a family member or loved one to suicide (www.survivorsofsuicide.com).

Through their own actions and the utilization of community resources, pediatric providers can be an important support for grieving families.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at [email protected]. To read more commentaries, visit pediatricnews.com/views/practical-parenting.html.

As a general pediatrician, I am fortunate that most of my patients are thriving and healthy. Even those with chronic disease have the access to lifesaving medicines and treatments that offer most of them the opportunity for a long, full life. Perhaps in part because so many of my patients are healthy, and death is not something I must face on a regular basis, each time it happens I feel a bit lost and unprepared.

Very sadly, over the past several months, four of my patients have died – each under very different circumstances. While the sadness and loss I, and others on their medical team, felt each time we learned of an untimely death in no way comes close to what our patient’s families are experiencing, we are still affected. As a medical team, we also share a responsibility to families to extend our support through their grief – which may extend for many, many years, and we often may continue to provide medical care for siblings or other family members, whose grief may go unrecognized or forgotten.

Over the years, I have realized how important it is to recognize and confront my own feelings about a patient’s death in order to be able to support their family. I also have realized that it is equally important to provide an opportunity for the rest of the patient’s care team to grieve and debrief. Often the care team may look to the physician to start or provide the opportunity for this conversation. Many emotions may unearth themselves – from fear to grief to overwhelming sadness. Addressing these emotions in a safe environment helps to ensure that, as providers, we then are able to provide helpful support to families in mourning.

The American Academy of Pediatrics has published a very thoughtful and helpful clinical report, "Supporting the Family After the Death of a Child," which walks the provider through important issues and concerns (Pediatrics 2012;130:1164-9). The most powerful step providers can take, which is identified in this report and I fully agree with, is to call or personally visit the family. Attending the patient’s funeral or memorial service also can be meaningful and important, but a private, personal contact is invaluable to allow the family the opportunity to ask questions or express concerns they may not want to express publicly. This is not a time for us as providers to offer advice or justification, but merely to listen and grieve together.

That said, there are times when it becomes clear – for whatever reason – that a family doesn’t want to or isn’t ready to talk with someone from the medical care team. In those circumstances, I still think the mere act of trying to reach out and express your sadness and condolences is important. There have been times when families reached back out to me weeks or months later with questions or thoughts – an initial attempt at contact helps a family to know that you are available and willing to talk. One mother called me months after her child’s death – she had begun the process of cleaning out her daughter’s room and wasn’t sure how to dispose of her medications. A simple piece of information I was able to give her made an impossibly hard task a little easier, and was another touch point for us to talk about her daughter’s many strengths and how much we all missed her.

The AAP report also highlights some family support resources that are useful to know about and share with families. The loss of a child is indescribable, and many find comfort in sharing their feelings with others who have gone through a similar experience. Some resources highlighted in the report are The Compassionate Friends, a national self-help support organization for parents who have lost a child (www.compassionatefriends.org); SHARE, an organization that serves parents who have lost a child through pregnancy loss, stillbirth, or in the first few months of life (www.nationalshare.org); Bereaved Parents of the USA, providing support to bereaved caregivers and siblings (www.bereavedparentsusa.org) and Survivors of Suicide, for those who have lost a family member or loved one to suicide (www.survivorsofsuicide.com).

Through their own actions and the utilization of community resources, pediatric providers can be an important support for grieving families.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. E-mail Dr. Beers at [email protected]. To read more commentaries, visit pediatricnews.com/views/practical-parenting.html.

In the December 2013 issue of Pediatrics, a clinical report on the use of antibiotics for upper respiratory tract infections caught my eye ("Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics," Pediatrics 2013;132:1146-54), both because of the clear applicability to my daily practice as a primary care provider and the considerable media attention surrounding it in the lay press.

While I (and the primary care providers I practice with) try to be very thoughtful and deliberate in our decision making about when and how we use antibiotics in the ambulatory setting, there is no question that parent education is an important and sometimes difficult part of implementing these treatment plans. I also was struck by the fact that in the same issue of the journal, there was an article describing a decline in emergency department visits for adverse events from the ingestion of cough and cold medications since the voluntary manufacturer withdrawal (of infant) and labeling revision (for all) of these over-the-counter pediatric medications ("Cough and Cold Medication Adverse Events After Market Withdrawal and Labeling Revision," Pediatrics 2013;132:1047-54).

While most of these events now are related to the unsupervised ingestion of medications, there still are many parents giving over-the-counter cough and cold medications to their young children, counter to recommendations. These two articles remind me that, while as medical providers we are understandably focused on recommending the safest and most effective treatment for children with viral upper respiratory tract (URI) infections, parents are understandably focused on how to make their miserable children feel better!

The principles for judicious antibiotic use laid out by Hersh et al. are clear and straightforward: Determine the likelihood of a bacterial infection, weigh the benefits versus the harms of antibiotic use, and then implement prescribing strategies, with consideration given to watchful waiting if appropriate. Putting these recommendations into practice, and importantly communicating them to families, is a trickier but worthy business. Numerous studies – and the clinical experience of myself and my colleagues – suggest that parents are generally less convinced that they need antibiotics or cough and cold medicines than that they need to do something to make their children feel better. These studies and experience also suggest that explaining why you are treating without antibiotics can happen within the same time that it takes to prescribe and give instructions on how to use an antibiotic, including administration, dosage, and side effects.

Everyone has their own personal style, but I find that framing my communications with families using the same principles I consider when deciding whether or not to prescribe an antibiotic is fast and effective.

As I am conducting my exam and determining the likelihood of a bacterial infection, I describe to the parents what I am doing. "Oh good," I may say, "even though I can hear a lot of congestion in the nose, I don’t hear anything in the lungs and little Johnny has a normal amount of oxygen in his blood ... These are both great signs that he does not have pneumonia or an infection deep in his lungs." I find that – no matter what the family member’s level of education or medical sophistication – hearing me talk through my thought process is infinitely more reassuring than watching me do an exam and then saying, "Well, looks like he has a cold."

Once I have diagnosed a viral infection, I take the family through my thought process of why antibiotics aren’t helpful. "It looks like he has a virus causing a really bad cold," I continue. "There is good and bad news about this – the good news is that these infections are usually not very serious and will go away on their own. The bad news is that they have to go away on their own, and this may take a little time. I know he feels pretty crummy now. While there aren’t any medicines to make this go away faster, there are things we can do to make little Johnny feel better and more comfortable while his body is doing its job." And then I tell them what those things are. As I was researching this article, I came across one medical group that had preprinted "prescriptions" for treating a viral URI that providers could fill out and give to families – a fun and fast way to share information.

Lastly, I look forward a little bit and communicate that part of the judicious use of antibiotics is knowing when you should use them. I explain that at any time things may change, and that if little Johnny seems to be getting worse or isn’t better within the expected time frame, the family should call the office or bring him in, and we may consider a different plan if indeed there have been changes. This simple act of explicitly letting families know that the evaluation of their child’s illness doesn’t end with the office visit goes a long way toward validating the family’s concerns, and making sure that as a provider I really am helping the child get better – even if I’m not giving antibiotics.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

In the December 2013 issue of Pediatrics, a clinical report on the use of antibiotics for upper respiratory tract infections caught my eye ("Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics," Pediatrics 2013;132:1146-54), both because of the clear applicability to my daily practice as a primary care provider and the considerable media attention surrounding it in the lay press.

While I (and the primary care providers I practice with) try to be very thoughtful and deliberate in our decision making about when and how we use antibiotics in the ambulatory setting, there is no question that parent education is an important and sometimes difficult part of implementing these treatment plans. I also was struck by the fact that in the same issue of the journal, there was an article describing a decline in emergency department visits for adverse events from the ingestion of cough and cold medications since the voluntary manufacturer withdrawal (of infant) and labeling revision (for all) of these over-the-counter pediatric medications ("Cough and Cold Medication Adverse Events After Market Withdrawal and Labeling Revision," Pediatrics 2013;132:1047-54).

While most of these events now are related to the unsupervised ingestion of medications, there still are many parents giving over-the-counter cough and cold medications to their young children, counter to recommendations. These two articles remind me that, while as medical providers we are understandably focused on recommending the safest and most effective treatment for children with viral upper respiratory tract (URI) infections, parents are understandably focused on how to make their miserable children feel better!

The principles for judicious antibiotic use laid out by Hersh et al. are clear and straightforward: Determine the likelihood of a bacterial infection, weigh the benefits versus the harms of antibiotic use, and then implement prescribing strategies, with consideration given to watchful waiting if appropriate. Putting these recommendations into practice, and importantly communicating them to families, is a trickier but worthy business. Numerous studies – and the clinical experience of myself and my colleagues – suggest that parents are generally less convinced that they need antibiotics or cough and cold medicines than that they need to do something to make their children feel better. These studies and experience also suggest that explaining why you are treating without antibiotics can happen within the same time that it takes to prescribe and give instructions on how to use an antibiotic, including administration, dosage, and side effects.

Everyone has their own personal style, but I find that framing my communications with families using the same principles I consider when deciding whether or not to prescribe an antibiotic is fast and effective.

As I am conducting my exam and determining the likelihood of a bacterial infection, I describe to the parents what I am doing. "Oh good," I may say, "even though I can hear a lot of congestion in the nose, I don’t hear anything in the lungs and little Johnny has a normal amount of oxygen in his blood ... These are both great signs that he does not have pneumonia or an infection deep in his lungs." I find that – no matter what the family member’s level of education or medical sophistication – hearing me talk through my thought process is infinitely more reassuring than watching me do an exam and then saying, "Well, looks like he has a cold."

Once I have diagnosed a viral infection, I take the family through my thought process of why antibiotics aren’t helpful. "It looks like he has a virus causing a really bad cold," I continue. "There is good and bad news about this – the good news is that these infections are usually not very serious and will go away on their own. The bad news is that they have to go away on their own, and this may take a little time. I know he feels pretty crummy now. While there aren’t any medicines to make this go away faster, there are things we can do to make little Johnny feel better and more comfortable while his body is doing its job." And then I tell them what those things are. As I was researching this article, I came across one medical group that had preprinted "prescriptions" for treating a viral URI that providers could fill out and give to families – a fun and fast way to share information.

Lastly, I look forward a little bit and communicate that part of the judicious use of antibiotics is knowing when you should use them. I explain that at any time things may change, and that if little Johnny seems to be getting worse or isn’t better within the expected time frame, the family should call the office or bring him in, and we may consider a different plan if indeed there have been changes. This simple act of explicitly letting families know that the evaluation of their child’s illness doesn’t end with the office visit goes a long way toward validating the family’s concerns, and making sure that as a provider I really am helping the child get better – even if I’m not giving antibiotics.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

In the December 2013 issue of Pediatrics, a clinical report on the use of antibiotics for upper respiratory tract infections caught my eye ("Principles of Judicious Antibiotic Prescribing for Upper Respiratory Tract Infections in Pediatrics," Pediatrics 2013;132:1146-54), both because of the clear applicability to my daily practice as a primary care provider and the considerable media attention surrounding it in the lay press.

While I (and the primary care providers I practice with) try to be very thoughtful and deliberate in our decision making about when and how we use antibiotics in the ambulatory setting, there is no question that parent education is an important and sometimes difficult part of implementing these treatment plans. I also was struck by the fact that in the same issue of the journal, there was an article describing a decline in emergency department visits for adverse events from the ingestion of cough and cold medications since the voluntary manufacturer withdrawal (of infant) and labeling revision (for all) of these over-the-counter pediatric medications ("Cough and Cold Medication Adverse Events After Market Withdrawal and Labeling Revision," Pediatrics 2013;132:1047-54).

While most of these events now are related to the unsupervised ingestion of medications, there still are many parents giving over-the-counter cough and cold medications to their young children, counter to recommendations. These two articles remind me that, while as medical providers we are understandably focused on recommending the safest and most effective treatment for children with viral upper respiratory tract (URI) infections, parents are understandably focused on how to make their miserable children feel better!

The principles for judicious antibiotic use laid out by Hersh et al. are clear and straightforward: Determine the likelihood of a bacterial infection, weigh the benefits versus the harms of antibiotic use, and then implement prescribing strategies, with consideration given to watchful waiting if appropriate. Putting these recommendations into practice, and importantly communicating them to families, is a trickier but worthy business. Numerous studies – and the clinical experience of myself and my colleagues – suggest that parents are generally less convinced that they need antibiotics or cough and cold medicines than that they need to do something to make their children feel better. These studies and experience also suggest that explaining why you are treating without antibiotics can happen within the same time that it takes to prescribe and give instructions on how to use an antibiotic, including administration, dosage, and side effects.

Everyone has their own personal style, but I find that framing my communications with families using the same principles I consider when deciding whether or not to prescribe an antibiotic is fast and effective.

As I am conducting my exam and determining the likelihood of a bacterial infection, I describe to the parents what I am doing. "Oh good," I may say, "even though I can hear a lot of congestion in the nose, I don’t hear anything in the lungs and little Johnny has a normal amount of oxygen in his blood ... These are both great signs that he does not have pneumonia or an infection deep in his lungs." I find that – no matter what the family member’s level of education or medical sophistication – hearing me talk through my thought process is infinitely more reassuring than watching me do an exam and then saying, "Well, looks like he has a cold."

Once I have diagnosed a viral infection, I take the family through my thought process of why antibiotics aren’t helpful. "It looks like he has a virus causing a really bad cold," I continue. "There is good and bad news about this – the good news is that these infections are usually not very serious and will go away on their own. The bad news is that they have to go away on their own, and this may take a little time. I know he feels pretty crummy now. While there aren’t any medicines to make this go away faster, there are things we can do to make little Johnny feel better and more comfortable while his body is doing its job." And then I tell them what those things are. As I was researching this article, I came across one medical group that had preprinted "prescriptions" for treating a viral URI that providers could fill out and give to families – a fun and fast way to share information.

Lastly, I look forward a little bit and communicate that part of the judicious use of antibiotics is knowing when you should use them. I explain that at any time things may change, and that if little Johnny seems to be getting worse or isn’t better within the expected time frame, the family should call the office or bring him in, and we may consider a different plan if indeed there have been changes. This simple act of explicitly letting families know that the evaluation of their child’s illness doesn’t end with the office visit goes a long way toward validating the family’s concerns, and making sure that as a provider I really am helping the child get better – even if I’m not giving antibiotics.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at pdnews@ frontlinemedcom.com.

This month, I will be addressing a very common pediatric phenomenon – the formula shuffle. It is rare for me to go a week in clinic without addressing a parent’s concern about what type of formula they should use (or switch to) in some way, and I suspect many of you have the same experience.

An important disclaimer: Human breast milk is, as we all know, the best source of nutrition for infants in their first year of life. Before we think about educating families about formula, we should always be sure we are educating them as early and often as possible about the benefits of breast-feeding. If a family is struggling with formula choice in the hospital after delivery, or even in the first week of life (if the mother is still producing milk), it is very appropriate to readdress the issue of breast-feeding with a reminder that breast milk is better tolerated than formula! That said, many families still choose formula and/or may not be able to breast-feed for some reason; the remainder of this column will focus on formula-fed infants, but look for a future column focusing on supporting breast-feeding.

For families who choose to formula-feed their infant, the choice of what to use is understandably important to them. What they select will be their infant’s main source of nutrition for a good part of their first year of life. Infants feed often enough that much of a new parent’s day (and night) revolves around feeding – and preparing the formula, and washing bottles, and going to the store to buy formula – another argument for "ready-to-feed" breast milk! Likewise, if something is not going well – an infant is colicky or not sleeping well or spitting up a lot – you can understand why the choice of formula seems a likely culprit. Certainly, the formula manufacturers have figured this out. The number of different formulas for parents to choose from is overwhelming, even when you know and understand the nutritional science!

While a detailed review of indications for using different types and categories of formulas is well beyond the word limit of this column, there are a few basic principles I live by:

• When are specialized formulas indicated? There are sometimes clear medical indications for a specialized formula, such as prematurity, milk-protein allergy, and galactosemia. Be sure you know these, and are clear on what formulas are recommended for use in these situations. For example, soy-based formulas are not recommended for use with milk-protein allergy because a large number of these infants will have cross-reactivity to the soy.

• What about switching for fussiness, spitting up, or allergies? Outside of these clear medical indications, there is not very good evidence that switching formulas is generally very helpful for treating such conditions as fussiness, spitting up, or mild eczema/allergies. That is not to say there is no evidence, but it is generally not very strong or compelling. There is some evidence that extensively or partially hydrolyzed formulas may be helpful in preventing symptoms in infants at high risk for allergic disease (but breast milk is still better). This is not to say that you should never recommend switching formula for a child who does not have a clear medical indication, but you should be clear and thoughtful about why you are doing it. I am also very transparent with parents about what evidence does and doesn’t exist for my recommendation. All that said, I find that many parents have already made the switch on their own, which leads me to my next point.

• Stick with it. In general, almost all formulas provide adequate nutrition. If an infant is tolerating a formula and the parents are happy, I recommend sticking with it unless there is reason not to do so. I do, however, discourage rapid changing of formulas. I find this causes frustration (and wastes money) for the family with little benefit. Often many of the symptoms of concern settle out after a few weeks (often just because of developmental maturity!), so I encourage a 2- to 3-week trial before making another change.

Store-brand formulas are generally equivalent to brand-name formulas, as long as you are sure they aren’t counterfeit formulas or sold outside of the U.S. regulatory system. My general opinion is that there is also no significant benefit to organic formulas, but no real harm either. There has been some controversy that the carbohydrates used in some organic formulas have a sweeter taste, which may be unacceptable to some families, so parents should be made aware of this. In the end, the decision to use an organic formula or not is a personal one.

Most importantly, I try to respect the parents’ concern and desire to do what is best for their child. I reassure them that we will work together until things improve, and that they invariably almost always do.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. 

This month, I will be addressing a very common pediatric phenomenon – the formula shuffle. It is rare for me to go a week in clinic without addressing a parent’s concern about what type of formula they should use (or switch to) in some way, and I suspect many of you have the same experience.

An important disclaimer: Human breast milk is, as we all know, the best source of nutrition for infants in their first year of life. Before we think about educating families about formula, we should always be sure we are educating them as early and often as possible about the benefits of breast-feeding. If a family is struggling with formula choice in the hospital after delivery, or even in the first week of life (if the mother is still producing milk), it is very appropriate to readdress the issue of breast-feeding with a reminder that breast milk is better tolerated than formula! That said, many families still choose formula and/or may not be able to breast-feed for some reason; the remainder of this column will focus on formula-fed infants, but look for a future column focusing on supporting breast-feeding.

For families who choose to formula-feed their infant, the choice of what to use is understandably important to them. What they select will be their infant’s main source of nutrition for a good part of their first year of life. Infants feed often enough that much of a new parent’s day (and night) revolves around feeding – and preparing the formula, and washing bottles, and going to the store to buy formula – another argument for "ready-to-feed" breast milk! Likewise, if something is not going well – an infant is colicky or not sleeping well or spitting up a lot – you can understand why the choice of formula seems a likely culprit. Certainly, the formula manufacturers have figured this out. The number of different formulas for parents to choose from is overwhelming, even when you know and understand the nutritional science!

While a detailed review of indications for using different types and categories of formulas is well beyond the word limit of this column, there are a few basic principles I live by:

• When are specialized formulas indicated? There are sometimes clear medical indications for a specialized formula, such as prematurity, milk-protein allergy, and galactosemia. Be sure you know these, and are clear on what formulas are recommended for use in these situations. For example, soy-based formulas are not recommended for use with milk-protein allergy because a large number of these infants will have cross-reactivity to the soy.

• What about switching for fussiness, spitting up, or allergies? Outside of these clear medical indications, there is not very good evidence that switching formulas is generally very helpful for treating such conditions as fussiness, spitting up, or mild eczema/allergies. That is not to say there is no evidence, but it is generally not very strong or compelling. There is some evidence that extensively or partially hydrolyzed formulas may be helpful in preventing symptoms in infants at high risk for allergic disease (but breast milk is still better). This is not to say that you should never recommend switching formula for a child who does not have a clear medical indication, but you should be clear and thoughtful about why you are doing it. I am also very transparent with parents about what evidence does and doesn’t exist for my recommendation. All that said, I find that many parents have already made the switch on their own, which leads me to my next point.

• Stick with it. In general, almost all formulas provide adequate nutrition. If an infant is tolerating a formula and the parents are happy, I recommend sticking with it unless there is reason not to do so. I do, however, discourage rapid changing of formulas. I find this causes frustration (and wastes money) for the family with little benefit. Often many of the symptoms of concern settle out after a few weeks (often just because of developmental maturity!), so I encourage a 2- to 3-week trial before making another change.

Store-brand formulas are generally equivalent to brand-name formulas, as long as you are sure they aren’t counterfeit formulas or sold outside of the U.S. regulatory system. My general opinion is that there is also no significant benefit to organic formulas, but no real harm either. There has been some controversy that the carbohydrates used in some organic formulas have a sweeter taste, which may be unacceptable to some families, so parents should be made aware of this. In the end, the decision to use an organic formula or not is a personal one.

Most importantly, I try to respect the parents’ concern and desire to do what is best for their child. I reassure them that we will work together until things improve, and that they invariably almost always do.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. 

This month, I will be addressing a very common pediatric phenomenon – the formula shuffle. It is rare for me to go a week in clinic without addressing a parent’s concern about what type of formula they should use (or switch to) in some way, and I suspect many of you have the same experience.

An important disclaimer: Human breast milk is, as we all know, the best source of nutrition for infants in their first year of life. Before we think about educating families about formula, we should always be sure we are educating them as early and often as possible about the benefits of breast-feeding. If a family is struggling with formula choice in the hospital after delivery, or even in the first week of life (if the mother is still producing milk), it is very appropriate to readdress the issue of breast-feeding with a reminder that breast milk is better tolerated than formula! That said, many families still choose formula and/or may not be able to breast-feed for some reason; the remainder of this column will focus on formula-fed infants, but look for a future column focusing on supporting breast-feeding.

For families who choose to formula-feed their infant, the choice of what to use is understandably important to them. What they select will be their infant’s main source of nutrition for a good part of their first year of life. Infants feed often enough that much of a new parent’s day (and night) revolves around feeding – and preparing the formula, and washing bottles, and going to the store to buy formula – another argument for "ready-to-feed" breast milk! Likewise, if something is not going well – an infant is colicky or not sleeping well or spitting up a lot – you can understand why the choice of formula seems a likely culprit. Certainly, the formula manufacturers have figured this out. The number of different formulas for parents to choose from is overwhelming, even when you know and understand the nutritional science!

While a detailed review of indications for using different types and categories of formulas is well beyond the word limit of this column, there are a few basic principles I live by:

• When are specialized formulas indicated? There are sometimes clear medical indications for a specialized formula, such as prematurity, milk-protein allergy, and galactosemia. Be sure you know these, and are clear on what formulas are recommended for use in these situations. For example, soy-based formulas are not recommended for use with milk-protein allergy because a large number of these infants will have cross-reactivity to the soy.

• What about switching for fussiness, spitting up, or allergies? Outside of these clear medical indications, there is not very good evidence that switching formulas is generally very helpful for treating such conditions as fussiness, spitting up, or mild eczema/allergies. That is not to say there is no evidence, but it is generally not very strong or compelling. There is some evidence that extensively or partially hydrolyzed formulas may be helpful in preventing symptoms in infants at high risk for allergic disease (but breast milk is still better). This is not to say that you should never recommend switching formula for a child who does not have a clear medical indication, but you should be clear and thoughtful about why you are doing it. I am also very transparent with parents about what evidence does and doesn’t exist for my recommendation. All that said, I find that many parents have already made the switch on their own, which leads me to my next point.

• Stick with it. In general, almost all formulas provide adequate nutrition. If an infant is tolerating a formula and the parents are happy, I recommend sticking with it unless there is reason not to do so. I do, however, discourage rapid changing of formulas. I find this causes frustration (and wastes money) for the family with little benefit. Often many of the symptoms of concern settle out after a few weeks (often just because of developmental maturity!), so I encourage a 2- to 3-week trial before making another change.

Store-brand formulas are generally equivalent to brand-name formulas, as long as you are sure they aren’t counterfeit formulas or sold outside of the U.S. regulatory system. My general opinion is that there is also no significant benefit to organic formulas, but no real harm either. There has been some controversy that the carbohydrates used in some organic formulas have a sweeter taste, which may be unacceptable to some families, so parents should be made aware of this. In the end, the decision to use an organic formula or not is a personal one.

Most importantly, I try to respect the parents’ concern and desire to do what is best for their child. I reassure them that we will work together until things improve, and that they invariably almost always do.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. 

With the sticky, hot summers we experience here in Washington, I have been thinking about and seeing many heat-related illnesses. In my last column, I wrote about "heat rash"; this month, I will be writing about the more serious problems of heat exhaustion and heat stroke. As I experienced firsthand after helping to care for an overheated and dehydrated young girl when I quickly (well, I planned for it to be quick) stopped by my daughter’s soccer camp to drop something off, this can be a significant issue during the summer and early fall. Outdoor play in oppressive temperatures can lead to heat illness; as young athletes begin intense training for their fall sports teams, the risk grows even higher.

Staying properly hydrated and inside during the peak hours of noon to 6 p.m. on very hot days are key tips to avoid heat illness. If a child or teen is outside and active during these peak hours, frequent breaks in the shade and more aggressive hydration can help them manage the high temperatures. When hydrating, it is important to drink fluids (noncaffeinated) not just during the periods of outdoor activity, but also before and after. A good rule of thumb is to drink 24 ounces 2 hours before exercise and then another 8 ounces right before. It sometimes can be hard to drink that much, so you can encourage parents to give their children a full water bottle to carry around when getting ready in the morning. During my daughter’s week of soccer camp in 95  weather, we also filled an extra water bottle for her to sip on in the car on the way over and again on the way home. During exercise, an additional 8 ounces every 20 minutes is optimal. Recommend to children and teens that they drink at each break until they are no longer thirsty, and then a little bit more.

Generally, for hydration before and after, and for shorter periods of exercise, water is best. Electrolyte sports drinks can be a useful adjunct if the temperatures are very high or if the child or teen is strenuously exercising for an hour or more. Many of these drinks are filled with sugar, however, and so 8 ounces every 20 minutes would be way too much. I recommend alternating with water, or offering one of the low-sugar/low-calorie electrolyte drink options. In our own house, we have discovered a great sports drink that the kids and I like the taste of that comes in small tablets you can dissolve in water and has no calories.

Equally as important, if despite every precaution, a child or adolescent begins to show signs of heat exhaustion – dizziness, nausea, vomiting, muscle cramps, decreased sweating, or headache – it is important to immediately remove them from the heat and help them to get cooled off and hydrated.

Moving inside, removing any heavy sports equipment, and patting their skin with cold water on a towel can help alleviate the symptoms of heat illness. Very frequent small sips of fluid should be started for rehydration. If she doesn’t begin to feel better relatively quickly – or is showing even more serious signs such as rapid breathing, behavioral changes, seizures, or syncope – parents and coaches should be encouraged to immediately seek further medical care as overheating can progress to heat stroke and become quite serious.

As pediatric providers – and even in my case as the parent of a young soccer player – we can play an important role in helping families, schools, camps, and teams prevent serious heat-related illness. Equally importantly, we want to encourage healthy, active, outdoor activity, and our advice can help families plan for this safely.

A terrific time to provide this counseling in a proactive way is when filling out the voluminous numbers of school and sports forms we all get every summer and fall. As you sign off on your patient’s sports physical, it only takes another minute or 2 to discuss the importance of staying hydrated and taking frequent breaks in the shade while practicing. Summer days and fall athletic practices get busy, and it can be easy to not realize right away if a child is not drinking enough or pushing too hard. It can be helpful to remind parents how serious heat illness can be. Athletes will be much less productive, and the trip to the amusement park a lot less fun if a child or teen is sidelined with heat illness. Safe participation in outdoor activities is everyone’s goal, and pediatric providers can easily and quickly support that.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at [email protected].

With the sticky, hot summers we experience here in Washington, I have been thinking about and seeing many heat-related illnesses. In my last column, I wrote about "heat rash"; this month, I will be writing about the more serious problems of heat exhaustion and heat stroke. As I experienced firsthand after helping to care for an overheated and dehydrated young girl when I quickly (well, I planned for it to be quick) stopped by my daughter’s soccer camp to drop something off, this can be a significant issue during the summer and early fall. Outdoor play in oppressive temperatures can lead to heat illness; as young athletes begin intense training for their fall sports teams, the risk grows even higher.

Staying properly hydrated and inside during the peak hours of noon to 6 p.m. on very hot days are key tips to avoid heat illness. If a child or teen is outside and active during these peak hours, frequent breaks in the shade and more aggressive hydration can help them manage the high temperatures. When hydrating, it is important to drink fluids (noncaffeinated) not just during the periods of outdoor activity, but also before and after. A good rule of thumb is to drink 24 ounces 2 hours before exercise and then another 8 ounces right before. It sometimes can be hard to drink that much, so you can encourage parents to give their children a full water bottle to carry around when getting ready in the morning. During my daughter’s week of soccer camp in 95  weather, we also filled an extra water bottle for her to sip on in the car on the way over and again on the way home. During exercise, an additional 8 ounces every 20 minutes is optimal. Recommend to children and teens that they drink at each break until they are no longer thirsty, and then a little bit more.

Generally, for hydration before and after, and for shorter periods of exercise, water is best. Electrolyte sports drinks can be a useful adjunct if the temperatures are very high or if the child or teen is strenuously exercising for an hour or more. Many of these drinks are filled with sugar, however, and so 8 ounces every 20 minutes would be way too much. I recommend alternating with water, or offering one of the low-sugar/low-calorie electrolyte drink options. In our own house, we have discovered a great sports drink that the kids and I like the taste of that comes in small tablets you can dissolve in water and has no calories.

Equally as important, if despite every precaution, a child or adolescent begins to show signs of heat exhaustion – dizziness, nausea, vomiting, muscle cramps, decreased sweating, or headache – it is important to immediately remove them from the heat and help them to get cooled off and hydrated.

Moving inside, removing any heavy sports equipment, and patting their skin with cold water on a towel can help alleviate the symptoms of heat illness. Very frequent small sips of fluid should be started for rehydration. If she doesn’t begin to feel better relatively quickly – or is showing even more serious signs such as rapid breathing, behavioral changes, seizures, or syncope – parents and coaches should be encouraged to immediately seek further medical care as overheating can progress to heat stroke and become quite serious.

As pediatric providers – and even in my case as the parent of a young soccer player – we can play an important role in helping families, schools, camps, and teams prevent serious heat-related illness. Equally importantly, we want to encourage healthy, active, outdoor activity, and our advice can help families plan for this safely.

A terrific time to provide this counseling in a proactive way is when filling out the voluminous numbers of school and sports forms we all get every summer and fall. As you sign off on your patient’s sports physical, it only takes another minute or 2 to discuss the importance of staying hydrated and taking frequent breaks in the shade while practicing. Summer days and fall athletic practices get busy, and it can be easy to not realize right away if a child is not drinking enough or pushing too hard. It can be helpful to remind parents how serious heat illness can be. Athletes will be much less productive, and the trip to the amusement park a lot less fun if a child or teen is sidelined with heat illness. Safe participation in outdoor activities is everyone’s goal, and pediatric providers can easily and quickly support that.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at [email protected].

With the sticky, hot summers we experience here in Washington, I have been thinking about and seeing many heat-related illnesses. In my last column, I wrote about "heat rash"; this month, I will be writing about the more serious problems of heat exhaustion and heat stroke. As I experienced firsthand after helping to care for an overheated and dehydrated young girl when I quickly (well, I planned for it to be quick) stopped by my daughter’s soccer camp to drop something off, this can be a significant issue during the summer and early fall. Outdoor play in oppressive temperatures can lead to heat illness; as young athletes begin intense training for their fall sports teams, the risk grows even higher.

Staying properly hydrated and inside during the peak hours of noon to 6 p.m. on very hot days are key tips to avoid heat illness. If a child or teen is outside and active during these peak hours, frequent breaks in the shade and more aggressive hydration can help them manage the high temperatures. When hydrating, it is important to drink fluids (noncaffeinated) not just during the periods of outdoor activity, but also before and after. A good rule of thumb is to drink 24 ounces 2 hours before exercise and then another 8 ounces right before. It sometimes can be hard to drink that much, so you can encourage parents to give their children a full water bottle to carry around when getting ready in the morning. During my daughter’s week of soccer camp in 95  weather, we also filled an extra water bottle for her to sip on in the car on the way over and again on the way home. During exercise, an additional 8 ounces every 20 minutes is optimal. Recommend to children and teens that they drink at each break until they are no longer thirsty, and then a little bit more.

Generally, for hydration before and after, and for shorter periods of exercise, water is best. Electrolyte sports drinks can be a useful adjunct if the temperatures are very high or if the child or teen is strenuously exercising for an hour or more. Many of these drinks are filled with sugar, however, and so 8 ounces every 20 minutes would be way too much. I recommend alternating with water, or offering one of the low-sugar/low-calorie electrolyte drink options. In our own house, we have discovered a great sports drink that the kids and I like the taste of that comes in small tablets you can dissolve in water and has no calories.

Equally as important, if despite every precaution, a child or adolescent begins to show signs of heat exhaustion – dizziness, nausea, vomiting, muscle cramps, decreased sweating, or headache – it is important to immediately remove them from the heat and help them to get cooled off and hydrated.

Moving inside, removing any heavy sports equipment, and patting their skin with cold water on a towel can help alleviate the symptoms of heat illness. Very frequent small sips of fluid should be started for rehydration. If she doesn’t begin to feel better relatively quickly – or is showing even more serious signs such as rapid breathing, behavioral changes, seizures, or syncope – parents and coaches should be encouraged to immediately seek further medical care as overheating can progress to heat stroke and become quite serious.

As pediatric providers – and even in my case as the parent of a young soccer player – we can play an important role in helping families, schools, camps, and teams prevent serious heat-related illness. Equally importantly, we want to encourage healthy, active, outdoor activity, and our advice can help families plan for this safely.

A terrific time to provide this counseling in a proactive way is when filling out the voluminous numbers of school and sports forms we all get every summer and fall. As you sign off on your patient’s sports physical, it only takes another minute or 2 to discuss the importance of staying hydrated and taking frequent breaks in the shade while practicing. Summer days and fall athletic practices get busy, and it can be easy to not realize right away if a child is not drinking enough or pushing too hard. It can be helpful to remind parents how serious heat illness can be. Athletes will be much less productive, and the trip to the amusement park a lot less fun if a child or teen is sidelined with heat illness. Safe participation in outdoor activities is everyone’s goal, and pediatric providers can easily and quickly support that.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at [email protected].

Summer is here! Recently, a friend e-mailed a picture of her infant son to me (and several other physician friends) asking "Is this sunburn or heat rash?" As it turns out, it was urticaria; however, it reminded me what a common question this is from families as the temperatures rise.

The first point is that much of what a parent may be worried is heat rash is not, so a good exam and accurate diagnosis is important. Just as my friend’s son had urticaria, there are other skin conditions that should be considered in the differential diagnosis including sunburn, eczema, erythema toxicum neonatorum, infantile acne, and many others. There are actually three different kinds of "heat rash," or miliaria, which is thought to be caused by an obstruction of the eccrine sweat ducts and brought on by warm temperatures. Miliaria crystallina is the most superficial type of heat rash, with small, thin, fragile vesicles occurring mostly on the head, neck, and trunk; no underlying inflammation is seen. This form is typically seen in young newborns and is not itchy. Miliaria rubra is the form most of us probably think of when we think of "heat rash," manifesting as a local inflammatory reaction with small groups of itchy, erythematous papules and sometimes pustules (which is then called miliaria pustulosa). This form is also more commonly seen in younger infants. Miliaria profunda is less common, most often occurs in individuals who have had repeated episodes of miliaria rubra, and presents as flesh colored papules or pustules. These individuals may show signs of, or be at greater risk for, heat exhaustion because their ability to sweat is impaired.

"The first and most important treatment in most cases is reassurance that this is not a serious condition and will generally resolve on its own once the child is moved to a cooler environment."

In general, treatment for miliaria is conservative and focused on helping to relieve any immediate symptoms. The exception to this is of course patients with miliaria profunda – who should be monitored for signs of heat exhaustion, and patients with signs or symptoms of superinfected skin lesions. That being said, the first and most important treatment in most cases is reassurance that this is not a serious condition and will generally resolve on its own once the child is moved to a cooler environment. Sometimes changing into lighter, looser clothing, using cool compresses, or giving a cool bath (but not ice cold) also can be helpful. If a patient has miliaria rubra and seems to be very itchy and uncomfortable, that can be managed topically with calamine lotion, lanolin, or topical corticosteroids if needed. Occasionally, an oral antihistamine may be needed for cases of more severe itching, although usually symptoms can be managed with topical treatments only. For patients with recurrent miliaria, applying anhydrous lanolin before exercising or going into the heat can help prevent further occurrences.

Anytime you see a patient with true heat rash, or anything the parent is worried may be heat rash, it is a great opportunity to discuss sun/heat safety. Reminders about staying out of the sun at peak hours, wearing sunscreen and hats, keeping hydrated, and knowing the signs and symptoms of heat illness are timely – although, of course, also be mindful and sensitive to the fact that a parent may be feeling worried that they did something "wrong" or irresponsible that brought on her child’s skin condition. On the flip side, I also sometimes have families tell me with the best intentions that "I’m just not ever going to take them outside now," so reassurance that it is good for kids to be outside experiencing the world around them (albeit safely!) is also a good reminder.

Overall, with reassurance and good advice, heat rash is a generally a benign and time-limited condition, and families should be able to quickly return to enjoying their fun summer activities.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at [email protected].

Summer is here! Recently, a friend e-mailed a picture of her infant son to me (and several other physician friends) asking "Is this sunburn or heat rash?" As it turns out, it was urticaria; however, it reminded me what a common question this is from families as the temperatures rise.

The first point is that much of what a parent may be worried is heat rash is not, so a good exam and accurate diagnosis is important. Just as my friend’s son had urticaria, there are other skin conditions that should be considered in the differential diagnosis including sunburn, eczema, erythema toxicum neonatorum, infantile acne, and many others. There are actually three different kinds of "heat rash," or miliaria, which is thought to be caused by an obstruction of the eccrine sweat ducts and brought on by warm temperatures. Miliaria crystallina is the most superficial type of heat rash, with small, thin, fragile vesicles occurring mostly on the head, neck, and trunk; no underlying inflammation is seen. This form is typically seen in young newborns and is not itchy. Miliaria rubra is the form most of us probably think of when we think of "heat rash," manifesting as a local inflammatory reaction with small groups of itchy, erythematous papules and sometimes pustules (which is then called miliaria pustulosa). This form is also more commonly seen in younger infants. Miliaria profunda is less common, most often occurs in individuals who have had repeated episodes of miliaria rubra, and presents as flesh colored papules or pustules. These individuals may show signs of, or be at greater risk for, heat exhaustion because their ability to sweat is impaired.

"The first and most important treatment in most cases is reassurance that this is not a serious condition and will generally resolve on its own once the child is moved to a cooler environment."

In general, treatment for miliaria is conservative and focused on helping to relieve any immediate symptoms. The exception to this is of course patients with miliaria profunda – who should be monitored for signs of heat exhaustion, and patients with signs or symptoms of superinfected skin lesions. That being said, the first and most important treatment in most cases is reassurance that this is not a serious condition and will generally resolve on its own once the child is moved to a cooler environment. Sometimes changing into lighter, looser clothing, using cool compresses, or giving a cool bath (but not ice cold) also can be helpful. If a patient has miliaria rubra and seems to be very itchy and uncomfortable, that can be managed topically with calamine lotion, lanolin, or topical corticosteroids if needed. Occasionally, an oral antihistamine may be needed for cases of more severe itching, although usually symptoms can be managed with topical treatments only. For patients with recurrent miliaria, applying anhydrous lanolin before exercising or going into the heat can help prevent further occurrences.

Anytime you see a patient with true heat rash, or anything the parent is worried may be heat rash, it is a great opportunity to discuss sun/heat safety. Reminders about staying out of the sun at peak hours, wearing sunscreen and hats, keeping hydrated, and knowing the signs and symptoms of heat illness are timely – although, of course, also be mindful and sensitive to the fact that a parent may be feeling worried that they did something "wrong" or irresponsible that brought on her child’s skin condition. On the flip side, I also sometimes have families tell me with the best intentions that "I’m just not ever going to take them outside now," so reassurance that it is good for kids to be outside experiencing the world around them (albeit safely!) is also a good reminder.

Overall, with reassurance and good advice, heat rash is a generally a benign and time-limited condition, and families should be able to quickly return to enjoying their fun summer activities.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at [email protected].

Summer is here! Recently, a friend e-mailed a picture of her infant son to me (and several other physician friends) asking "Is this sunburn or heat rash?" As it turns out, it was urticaria; however, it reminded me what a common question this is from families as the temperatures rise.

The first point is that much of what a parent may be worried is heat rash is not, so a good exam and accurate diagnosis is important. Just as my friend’s son had urticaria, there are other skin conditions that should be considered in the differential diagnosis including sunburn, eczema, erythema toxicum neonatorum, infantile acne, and many others. There are actually three different kinds of "heat rash," or miliaria, which is thought to be caused by an obstruction of the eccrine sweat ducts and brought on by warm temperatures. Miliaria crystallina is the most superficial type of heat rash, with small, thin, fragile vesicles occurring mostly on the head, neck, and trunk; no underlying inflammation is seen. This form is typically seen in young newborns and is not itchy. Miliaria rubra is the form most of us probably think of when we think of "heat rash," manifesting as a local inflammatory reaction with small groups of itchy, erythematous papules and sometimes pustules (which is then called miliaria pustulosa). This form is also more commonly seen in younger infants. Miliaria profunda is less common, most often occurs in individuals who have had repeated episodes of miliaria rubra, and presents as flesh colored papules or pustules. These individuals may show signs of, or be at greater risk for, heat exhaustion because their ability to sweat is impaired.

"The first and most important treatment in most cases is reassurance that this is not a serious condition and will generally resolve on its own once the child is moved to a cooler environment."

In general, treatment for miliaria is conservative and focused on helping to relieve any immediate symptoms. The exception to this is of course patients with miliaria profunda – who should be monitored for signs of heat exhaustion, and patients with signs or symptoms of superinfected skin lesions. That being said, the first and most important treatment in most cases is reassurance that this is not a serious condition and will generally resolve on its own once the child is moved to a cooler environment. Sometimes changing into lighter, looser clothing, using cool compresses, or giving a cool bath (but not ice cold) also can be helpful. If a patient has miliaria rubra and seems to be very itchy and uncomfortable, that can be managed topically with calamine lotion, lanolin, or topical corticosteroids if needed. Occasionally, an oral antihistamine may be needed for cases of more severe itching, although usually symptoms can be managed with topical treatments only. For patients with recurrent miliaria, applying anhydrous lanolin before exercising or going into the heat can help prevent further occurrences.

Anytime you see a patient with true heat rash, or anything the parent is worried may be heat rash, it is a great opportunity to discuss sun/heat safety. Reminders about staying out of the sun at peak hours, wearing sunscreen and hats, keeping hydrated, and knowing the signs and symptoms of heat illness are timely – although, of course, also be mindful and sensitive to the fact that a parent may be feeling worried that they did something "wrong" or irresponsible that brought on her child’s skin condition. On the flip side, I also sometimes have families tell me with the best intentions that "I’m just not ever going to take them outside now," so reassurance that it is good for kids to be outside experiencing the world around them (albeit safely!) is also a good reminder.

Overall, with reassurance and good advice, heat rash is a generally a benign and time-limited condition, and families should be able to quickly return to enjoying their fun summer activities.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. E-mail Dr. Beers at [email protected].

My brother and sister-in-law are expecting their first baby – and my children’s first cousin – any day now. The whole family is anxiously anticipating this new addition, and lots of preparations are underway. A beautiful nursery, car seat, strollers, breastfeeding equipment, toys, books, and most importantly lots of love and attention are waiting for my niece. This impending joy also has made me think more about the questions I often hear from new parents – not just about the physical care of their infants, but how they can best stimulate their babies’ intellectual and emotional development. When considering the continually emerging knowledge and understanding of the affects of early toxic stress on long-term health, and the protective effects of strong relationships and attachments (Pediatrics 2012;129:e224), this is an area that we as pediatric providers should feel very comfortable giving advice and anticipatory guidance about.

I suspect we all have our own approach to answering this type of question, but here are a few things (some of which I have written about before) that I have come to believe are among the most important to emphasis.

First, and most importantly, loving positive relationships and time together are more important than things. I take care of families with lots of financial resources, and families with almost none, families with very stable homes and families with very little stability. There is no question that resources and family stability make things easier, but also no question in my mind that a strong loving attachment to a consistent adult caregiver builds a tremendous amount of resilience and confidence in a child no matter how much stuff you have. I find that this advice helps families – all of whom want to do the very best for their children – put things into perspective.

Children learn by doing things in three dimensions. Touching things, looking at real objects, and experiencing the world around them helps stimulate learning and encourages curiosity. Again, this does not require significant resources – a pile of pots and pans or a simple set of blocks can be better toys than the fanciest gift.

It is important to read together. Lots of evidence tells us that having books in the house and reading together daily is just good for kids.

It is important to play outside. Kids need to run, roll around in the dirt, look at leaves and spend time away from screens. Richard Louv wrote a wonderful book entitled "Last Child in the Woods: Saving Our Children From Nature-Deficit Disorder" (Chapel Hill, N.C.: Algonquin Books, 2008) for anyone who is interested in reading more.

Structure is good. Children who grow up generally knowing what to expect from their days feel more secure and are better able to trust and explore their environment.

As pediatricians we can play an important role in helping to support families so that every baby has a chance to grow up like my niece. The opportunity we have to teach ways of supporting development from the very earliest days of a baby’s life is unique and has a huge impact, and as research continues to show, can have effects long after children age into adulthood.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures.

My brother and sister-in-law are expecting their first baby – and my children’s first cousin – any day now. The whole family is anxiously anticipating this new addition, and lots of preparations are underway. A beautiful nursery, car seat, strollers, breastfeeding equipment, toys, books, and most importantly lots of love and attention are waiting for my niece. This impending joy also has made me think more about the questions I often hear from new parents – not just about the physical care of their infants, but how they can best stimulate their babies’ intellectual and emotional development. When considering the continually emerging knowledge and understanding of the affects of early toxic stress on long-term health, and the protective effects of strong relationships and attachments (Pediatrics 2012;129:e224), this is an area that we as pediatric providers should feel very comfortable giving advice and anticipatory guidance about.

I suspect we all have our own approach to answering this type of question, but here are a few things (some of which I have written about before) that I have come to believe are among the most important to emphasis.

First, and most importantly, loving positive relationships and time together are more important than things. I take care of families with lots of financial resources, and families with almost none, families with very stable homes and families with very little stability. There is no question that resources and family stability make things easier, but also no question in my mind that a strong loving attachment to a consistent adult caregiver builds a tremendous amount of resilience and confidence in a child no matter how much stuff you have. I find that this advice helps families – all of whom want to do the very best for their children – put things into perspective.

Children learn by doing things in three dimensions. Touching things, looking at real objects, and experiencing the world around them helps stimulate learning and encourages curiosity. Again, this does not require significant resources – a pile of pots and pans or a simple set of blocks can be better toys than the fanciest gift.

It is important to read together. Lots of evidence tells us that having books in the house and reading together daily is just good for kids.

It is important to play outside. Kids need to run, roll around in the dirt, look at leaves and spend time away from screens. Richard Louv wrote a wonderful book entitled "Last Child in the Woods: Saving Our Children From Nature-Deficit Disorder" (Chapel Hill, N.C.: Algonquin Books, 2008) for anyone who is interested in reading more.

Structure is good. Children who grow up generally knowing what to expect from their days feel more secure and are better able to trust and explore their environment.

As pediatricians we can play an important role in helping to support families so that every baby has a chance to grow up like my niece. The opportunity we have to teach ways of supporting development from the very earliest days of a baby’s life is unique and has a huge impact, and as research continues to show, can have effects long after children age into adulthood.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures.

My brother and sister-in-law are expecting their first baby – and my children’s first cousin – any day now. The whole family is anxiously anticipating this new addition, and lots of preparations are underway. A beautiful nursery, car seat, strollers, breastfeeding equipment, toys, books, and most importantly lots of love and attention are waiting for my niece. This impending joy also has made me think more about the questions I often hear from new parents – not just about the physical care of their infants, but how they can best stimulate their babies’ intellectual and emotional development. When considering the continually emerging knowledge and understanding of the affects of early toxic stress on long-term health, and the protective effects of strong relationships and attachments (Pediatrics 2012;129:e224), this is an area that we as pediatric providers should feel very comfortable giving advice and anticipatory guidance about.

I suspect we all have our own approach to answering this type of question, but here are a few things (some of which I have written about before) that I have come to believe are among the most important to emphasis.

First, and most importantly, loving positive relationships and time together are more important than things. I take care of families with lots of financial resources, and families with almost none, families with very stable homes and families with very little stability. There is no question that resources and family stability make things easier, but also no question in my mind that a strong loving attachment to a consistent adult caregiver builds a tremendous amount of resilience and confidence in a child no matter how much stuff you have. I find that this advice helps families – all of whom want to do the very best for their children – put things into perspective.

Children learn by doing things in three dimensions. Touching things, looking at real objects, and experiencing the world around them helps stimulate learning and encourages curiosity. Again, this does not require significant resources – a pile of pots and pans or a simple set of blocks can be better toys than the fanciest gift.

It is important to read together. Lots of evidence tells us that having books in the house and reading together daily is just good for kids.

It is important to play outside. Kids need to run, roll around in the dirt, look at leaves and spend time away from screens. Richard Louv wrote a wonderful book entitled "Last Child in the Woods: Saving Our Children From Nature-Deficit Disorder" (Chapel Hill, N.C.: Algonquin Books, 2008) for anyone who is interested in reading more.

Structure is good. Children who grow up generally knowing what to expect from their days feel more secure and are better able to trust and explore their environment.

As pediatricians we can play an important role in helping to support families so that every baby has a chance to grow up like my niece. The opportunity we have to teach ways of supporting development from the very earliest days of a baby’s life is unique and has a huge impact, and as research continues to show, can have effects long after children age into adulthood.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures.

Over recent months, children’s mental health has become a topic of increased attention and scrutiny, both in the media and in local and federal legislatures. As pediatric providers, the importance of early attention to mental health concerns comes as no surprise to us and, in fact, is something most of us address on a regular basis.

In every practice setting I’ve worked in, I have had parents reach out to me – often confused and frustrated – wondering how to help their struggling child. Unfortunately, it is also an area where many feel ill equipped to do what is needed for children and families. Lack of resources, minimal training, inadequate time, and poor access to specialty care (just to name a few) place road blocks in front of our efforts to provide comprehensive care.

Discussing concerns about behavior, poor mental health, or parenting a difficult child can be awkward for both the family and the provider, and sometimes both are unsure where to begin. On the other hand, the strong relationships developed in a primary care medical home can provide the ideal support for addressing these concerns in an effective, thoughtful, and sensitive way.

Practices and providers vary widely in their resources and comfort in addressing mental health concerns. Given the magnitude of the problem, how does a provider or a practice begin to talk about mental health with families, or how can they improve on what they are already doing? How do you elicit concerns from families? How do you handle it when families come to you?

First, and most important, arm yourself with knowledge. It is not realistic to expect that you will become a psychiatrist, therapist, social worker, and pediatrician all rolled up into one, so learn about your community’s resources. You don’t have to do this yourself – a tech-savvy office staff member or industrious visiting medical student can do the research. Good places to start include your local health department or mental health department, local medical society, or even a general online search. As highlighted recently in Pediatric News, some states have regional child psychiatry access projects, which also can be a very valuable resource.

Second, if you aren’t already doing so, prepare your practice. Start talking with office staff and your clinical team about why it’s important to discuss mental health with families. Explain to them the role they can play in helping families to understand how and why we are asking these questions. Discussing these difficult issues is made easier when asking is the norm and not done only when things seem out of control.

A psychiatrist I work with recently made a terrific suggestion – put signs up in your office explaining that your practice is concerned with patients’ physical and mental health. Let families know how you hope to help, depending on your practice’s state of readiness to do so – by doing universal mental health screening, asking about behavioral concerns at all well visits (for example, "Does anything about your child’s behavior or mood concern you?"), or simply just making yourself available for questions.

Of course, these discussions can take time. Don’t hesitate to say to a parent, "I really want to make sure we have time to discuss this in depth, so I’m going to ask you to schedule a separate appointment." This also gives you the opportunity to ask the parent to gather additional information, such as letters from teachers, completed attention-deficit/hyperactivity disorder (ADHD) assessment tools, copies of report cards, or anything else that may give you a better picture of what is going on in order to allow for the most appropriate treatment and/or referral.

Not every child will need to see a psychiatrist or even a therapist, and with a careful history you can "triage" what can be addressed in primary care and what needs to be co-managed or referred elsewhere.

The best way to make sure that you are catching mental and behavioral health concerns early is to perform universal screening on all children in your practice – using a standardized screening tool – at regular intervals. Some pediatricians are doing this quite smoothly, others may have work to do before implementation is feasible in their own practice setting, but it is a good long term goal. The American Academy of Pediatrics offers some resources to make this easier.

Despite all the road blocks that currently exist, these are problems that aren’t going away on their own. By addressing them proactively, both families and providers will be happier and less frustrated, and ultimately children will get better care.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. This column, "Practical Parenting," appears regularly in Pediatric News. E-mail Dr. Beers at [email protected].

Over recent months, children’s mental health has become a topic of increased attention and scrutiny, both in the media and in local and federal legislatures. As pediatric providers, the importance of early attention to mental health concerns comes as no surprise to us and, in fact, is something most of us address on a regular basis.

In every practice setting I’ve worked in, I have had parents reach out to me – often confused and frustrated – wondering how to help their struggling child. Unfortunately, it is also an area where many feel ill equipped to do what is needed for children and families. Lack of resources, minimal training, inadequate time, and poor access to specialty care (just to name a few) place road blocks in front of our efforts to provide comprehensive care.

Discussing concerns about behavior, poor mental health, or parenting a difficult child can be awkward for both the family and the provider, and sometimes both are unsure where to begin. On the other hand, the strong relationships developed in a primary care medical home can provide the ideal support for addressing these concerns in an effective, thoughtful, and sensitive way.

Practices and providers vary widely in their resources and comfort in addressing mental health concerns. Given the magnitude of the problem, how does a provider or a practice begin to talk about mental health with families, or how can they improve on what they are already doing? How do you elicit concerns from families? How do you handle it when families come to you?

First, and most important, arm yourself with knowledge. It is not realistic to expect that you will become a psychiatrist, therapist, social worker, and pediatrician all rolled up into one, so learn about your community’s resources. You don’t have to do this yourself – a tech-savvy office staff member or industrious visiting medical student can do the research. Good places to start include your local health department or mental health department, local medical society, or even a general online search. As highlighted recently in Pediatric News, some states have regional child psychiatry access projects, which also can be a very valuable resource.

Second, if you aren’t already doing so, prepare your practice. Start talking with office staff and your clinical team about why it’s important to discuss mental health with families. Explain to them the role they can play in helping families to understand how and why we are asking these questions. Discussing these difficult issues is made easier when asking is the norm and not done only when things seem out of control.

A psychiatrist I work with recently made a terrific suggestion – put signs up in your office explaining that your practice is concerned with patients’ physical and mental health. Let families know how you hope to help, depending on your practice’s state of readiness to do so – by doing universal mental health screening, asking about behavioral concerns at all well visits (for example, "Does anything about your child’s behavior or mood concern you?"), or simply just making yourself available for questions.

Of course, these discussions can take time. Don’t hesitate to say to a parent, "I really want to make sure we have time to discuss this in depth, so I’m going to ask you to schedule a separate appointment." This also gives you the opportunity to ask the parent to gather additional information, such as letters from teachers, completed attention-deficit/hyperactivity disorder (ADHD) assessment tools, copies of report cards, or anything else that may give you a better picture of what is going on in order to allow for the most appropriate treatment and/or referral.

Not every child will need to see a psychiatrist or even a therapist, and with a careful history you can "triage" what can be addressed in primary care and what needs to be co-managed or referred elsewhere.

The best way to make sure that you are catching mental and behavioral health concerns early is to perform universal screening on all children in your practice – using a standardized screening tool – at regular intervals. Some pediatricians are doing this quite smoothly, others may have work to do before implementation is feasible in their own practice setting, but it is a good long term goal. The American Academy of Pediatrics offers some resources to make this easier.

Despite all the road blocks that currently exist, these are problems that aren’t going away on their own. By addressing them proactively, both families and providers will be happier and less frustrated, and ultimately children will get better care.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. This column, "Practical Parenting," appears regularly in Pediatric News. E-mail Dr. Beers at [email protected].

Over recent months, children’s mental health has become a topic of increased attention and scrutiny, both in the media and in local and federal legislatures. As pediatric providers, the importance of early attention to mental health concerns comes as no surprise to us and, in fact, is something most of us address on a regular basis.

In every practice setting I’ve worked in, I have had parents reach out to me – often confused and frustrated – wondering how to help their struggling child. Unfortunately, it is also an area where many feel ill equipped to do what is needed for children and families. Lack of resources, minimal training, inadequate time, and poor access to specialty care (just to name a few) place road blocks in front of our efforts to provide comprehensive care.

Discussing concerns about behavior, poor mental health, or parenting a difficult child can be awkward for both the family and the provider, and sometimes both are unsure where to begin. On the other hand, the strong relationships developed in a primary care medical home can provide the ideal support for addressing these concerns in an effective, thoughtful, and sensitive way.

Practices and providers vary widely in their resources and comfort in addressing mental health concerns. Given the magnitude of the problem, how does a provider or a practice begin to talk about mental health with families, or how can they improve on what they are already doing? How do you elicit concerns from families? How do you handle it when families come to you?

First, and most important, arm yourself with knowledge. It is not realistic to expect that you will become a psychiatrist, therapist, social worker, and pediatrician all rolled up into one, so learn about your community’s resources. You don’t have to do this yourself – a tech-savvy office staff member or industrious visiting medical student can do the research. Good places to start include your local health department or mental health department, local medical society, or even a general online search. As highlighted recently in Pediatric News, some states have regional child psychiatry access projects, which also can be a very valuable resource.

Second, if you aren’t already doing so, prepare your practice. Start talking with office staff and your clinical team about why it’s important to discuss mental health with families. Explain to them the role they can play in helping families to understand how and why we are asking these questions. Discussing these difficult issues is made easier when asking is the norm and not done only when things seem out of control.

A psychiatrist I work with recently made a terrific suggestion – put signs up in your office explaining that your practice is concerned with patients’ physical and mental health. Let families know how you hope to help, depending on your practice’s state of readiness to do so – by doing universal mental health screening, asking about behavioral concerns at all well visits (for example, "Does anything about your child’s behavior or mood concern you?"), or simply just making yourself available for questions.

Of course, these discussions can take time. Don’t hesitate to say to a parent, "I really want to make sure we have time to discuss this in depth, so I’m going to ask you to schedule a separate appointment." This also gives you the opportunity to ask the parent to gather additional information, such as letters from teachers, completed attention-deficit/hyperactivity disorder (ADHD) assessment tools, copies of report cards, or anything else that may give you a better picture of what is going on in order to allow for the most appropriate treatment and/or referral.

Not every child will need to see a psychiatrist or even a therapist, and with a careful history you can "triage" what can be addressed in primary care and what needs to be co-managed or referred elsewhere.

The best way to make sure that you are catching mental and behavioral health concerns early is to perform universal screening on all children in your practice – using a standardized screening tool – at regular intervals. Some pediatricians are doing this quite smoothly, others may have work to do before implementation is feasible in their own practice setting, but it is a good long term goal. The American Academy of Pediatrics offers some resources to make this easier.

Despite all the road blocks that currently exist, these are problems that aren’t going away on their own. By addressing them proactively, both families and providers will be happier and less frustrated, and ultimately children will get better care.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is chair of the American Academy of Pediatrics Committee on Residency Scholarships and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures. This column, "Practical Parenting," appears regularly in Pediatric News. E-mail Dr. Beers at [email protected].

There is a growing body of evidence that good (and enough) sleep is closely related to improved health and behavioral outcomes. (Of course, that is something we all know from our sleep deprived years in residency.) Whether it is attention-deficit/hyperactivity disorder (ADHD), abnormal weight gain, or even cardiovascular disease, getting enough sleep makes children healthier. That is easier said than done, of course. Given the number of things to get done in any given day – homework, after-school activities, dinner, and bath – it is a wonder any child gets to bed before midnight. Additionally, just as good sleep makes children happier and healthier, it also makes parents happier and healthier and is a common concern for families.

A recent study in Pediatrics examines the impact of genetic and environmental influences on infant sleep (Pediatrics 2012;129:1091-6).

The investigators asked parents of more than 1,900 pairs of twins to complete a questionnaire about their children’s sleep habits both during the day and at night. They concluded that there are BOTH genetic and environmental influences on sleep – again, this is perhaps not a great surprise for those of us who have talked to countless numbers of parents about this issue, but it is helpful to have some evidence behind this observation. I have cared for many families who could easily address their children’s sleep problems with some simple environmental changes and others who seemed to be doing everything "right" who still struggled. This study helps me to both assure parents that environmental changes do matter, but also to reassure them that there are some babies who just have a harder time with sleep. While this study looks only at infant sleep, sleep concerns are present at all ages.

The authors note a few environmental conditions associated with more disrupted or less sleep – in some cases up to 2 years of age. These include increased television viewing, early introduction of solid foods (less than 4 months), maternal depression, and attending a child-care center outside the home. Additionally, good "sleep hygiene" is recommended, including no television in bedrooms, early bedtimes (before 9 p.m.), consistent routines, avoidance of caffeinated drinks, and going to sleep alone (in other words, not in the parents’ bed). It is worth noting, as the authors do, that some of these are changes that might be harder for families with low socioeconomic status who may be sharing living space or have other influences that make consistent routines challenging.

Knowing this, how much sleep should children get? A review of the literature published earlier this year reported average sleep duration at different ages, including data from different countries and cultures (Sleep Med. Rev. 2012;16:213-22).

For infants, the average total amount of sleep was 12.8 hours, for toddlers and preschoolers it was 11.9 hours, and for older children it was 9.2 hours. These are only averages, of course, but if a child who is getting a dramatically different amount of sleep, parents may need to make some changes.

Improved sleep benefits everyone in the house. When needed, I encourage parents to think through what changes they would like to start with and then think about how they can implement them – recognizing that they are probably tired and frustrated with the problem. Some things are relatively easy (just unplug that television and remove it from the room) and others are more challenging (a child used to going to bed anytime between 9 p.m. and 1 a.m. isn’t just going to start hopping into bed each night at 8 p.m. on the nose), but taking an individualized approach improves chances for success and will hopefully lead to a better rested family.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is a member of the Pediatric News editorial advisory board, chair of the American Academy of Pediatrics Committee on Residency Scholarships, and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures.

There is a growing body of evidence that good (and enough) sleep is closely related to improved health and behavioral outcomes. (Of course, that is something we all know from our sleep deprived years in residency.) Whether it is attention-deficit/hyperactivity disorder (ADHD), abnormal weight gain, or even cardiovascular disease, getting enough sleep makes children healthier. That is easier said than done, of course. Given the number of things to get done in any given day – homework, after-school activities, dinner, and bath – it is a wonder any child gets to bed before midnight. Additionally, just as good sleep makes children happier and healthier, it also makes parents happier and healthier and is a common concern for families.

A recent study in Pediatrics examines the impact of genetic and environmental influences on infant sleep (Pediatrics 2012;129:1091-6).

The investigators asked parents of more than 1,900 pairs of twins to complete a questionnaire about their children’s sleep habits both during the day and at night. They concluded that there are BOTH genetic and environmental influences on sleep – again, this is perhaps not a great surprise for those of us who have talked to countless numbers of parents about this issue, but it is helpful to have some evidence behind this observation. I have cared for many families who could easily address their children’s sleep problems with some simple environmental changes and others who seemed to be doing everything "right" who still struggled. This study helps me to both assure parents that environmental changes do matter, but also to reassure them that there are some babies who just have a harder time with sleep. While this study looks only at infant sleep, sleep concerns are present at all ages.

The authors note a few environmental conditions associated with more disrupted or less sleep – in some cases up to 2 years of age. These include increased television viewing, early introduction of solid foods (less than 4 months), maternal depression, and attending a child-care center outside the home. Additionally, good "sleep hygiene" is recommended, including no television in bedrooms, early bedtimes (before 9 p.m.), consistent routines, avoidance of caffeinated drinks, and going to sleep alone (in other words, not in the parents’ bed). It is worth noting, as the authors do, that some of these are changes that might be harder for families with low socioeconomic status who may be sharing living space or have other influences that make consistent routines challenging.

Knowing this, how much sleep should children get? A review of the literature published earlier this year reported average sleep duration at different ages, including data from different countries and cultures (Sleep Med. Rev. 2012;16:213-22).

For infants, the average total amount of sleep was 12.8 hours, for toddlers and preschoolers it was 11.9 hours, and for older children it was 9.2 hours. These are only averages, of course, but if a child who is getting a dramatically different amount of sleep, parents may need to make some changes.

Improved sleep benefits everyone in the house. When needed, I encourage parents to think through what changes they would like to start with and then think about how they can implement them – recognizing that they are probably tired and frustrated with the problem. Some things are relatively easy (just unplug that television and remove it from the room) and others are more challenging (a child used to going to bed anytime between 9 p.m. and 1 a.m. isn’t just going to start hopping into bed each night at 8 p.m. on the nose), but taking an individualized approach improves chances for success and will hopefully lead to a better rested family.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is a member of the Pediatric News editorial advisory board, chair of the American Academy of Pediatrics Committee on Residency Scholarships, and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures.

There is a growing body of evidence that good (and enough) sleep is closely related to improved health and behavioral outcomes. (Of course, that is something we all know from our sleep deprived years in residency.) Whether it is attention-deficit/hyperactivity disorder (ADHD), abnormal weight gain, or even cardiovascular disease, getting enough sleep makes children healthier. That is easier said than done, of course. Given the number of things to get done in any given day – homework, after-school activities, dinner, and bath – it is a wonder any child gets to bed before midnight. Additionally, just as good sleep makes children happier and healthier, it also makes parents happier and healthier and is a common concern for families.

A recent study in Pediatrics examines the impact of genetic and environmental influences on infant sleep (Pediatrics 2012;129:1091-6).

The investigators asked parents of more than 1,900 pairs of twins to complete a questionnaire about their children’s sleep habits both during the day and at night. They concluded that there are BOTH genetic and environmental influences on sleep – again, this is perhaps not a great surprise for those of us who have talked to countless numbers of parents about this issue, but it is helpful to have some evidence behind this observation. I have cared for many families who could easily address their children’s sleep problems with some simple environmental changes and others who seemed to be doing everything "right" who still struggled. This study helps me to both assure parents that environmental changes do matter, but also to reassure them that there are some babies who just have a harder time with sleep. While this study looks only at infant sleep, sleep concerns are present at all ages.

The authors note a few environmental conditions associated with more disrupted or less sleep – in some cases up to 2 years of age. These include increased television viewing, early introduction of solid foods (less than 4 months), maternal depression, and attending a child-care center outside the home. Additionally, good "sleep hygiene" is recommended, including no television in bedrooms, early bedtimes (before 9 p.m.), consistent routines, avoidance of caffeinated drinks, and going to sleep alone (in other words, not in the parents’ bed). It is worth noting, as the authors do, that some of these are changes that might be harder for families with low socioeconomic status who may be sharing living space or have other influences that make consistent routines challenging.

Knowing this, how much sleep should children get? A review of the literature published earlier this year reported average sleep duration at different ages, including data from different countries and cultures (Sleep Med. Rev. 2012;16:213-22).

For infants, the average total amount of sleep was 12.8 hours, for toddlers and preschoolers it was 11.9 hours, and for older children it was 9.2 hours. These are only averages, of course, but if a child who is getting a dramatically different amount of sleep, parents may need to make some changes.

Improved sleep benefits everyone in the house. When needed, I encourage parents to think through what changes they would like to start with and then think about how they can implement them – recognizing that they are probably tired and frustrated with the problem. Some things are relatively easy (just unplug that television and remove it from the room) and others are more challenging (a child used to going to bed anytime between 9 p.m. and 1 a.m. isn’t just going to start hopping into bed each night at 8 p.m. on the nose), but taking an individualized approach improves chances for success and will hopefully lead to a better rested family.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. She is a member of the Pediatric News editorial advisory board, chair of the American Academy of Pediatrics Committee on Residency Scholarships, and president of the District of Columbia chapter of the American Academy of Pediatrics. She said she had no relevant financial disclosures.

As I return from the West Coast after two cross-country flights with my family, I am reminded of all the challenges young children face while flying. We regularly travel with our children and have learned many lessons along the way – by doing research, by surviving en-route successes and disasters, and by observing other families’ inspired solutions. Parents frequently ask their pediatrician for advice before traveling; if you haven’t flown recently (or at all) with small children yourself, what can you tell them?

First, be sure that children are healthy and up to date on their immunizations before travel. Any needed shots should ideally be given at least 4-6 weeks before leaving to ensure time for an adequate immune response. If a family will be traveling out of the country, it is important to research the specific areas they will be visiting for any additional medical concerns or requirements that may exist (for example, malaria prophylaxis). The Centers for Disease Control and Prevention website is a wonderful and quite detailed resource for both providers and patients. I highly recommend consulting it before travel anywhere out of the country, even if the destination is somewhere a family has been before; recommendations can and do change.

It is also important to remind the family to carry on an adequate supply of any chronic and emergency medications they might need. Additionally, I encourage families to check the airline’s website for guidelines on traveling with a car seat, which I strongly recommend doing. Riding in cars without the proper child restraints isn’t any safer away than it is at home.

There are no set guidelines for how young an infant can be before flying – one of the most common questions I am asked – but I think it is quite reasonable to recommend waiting at least 1-2 weeks to ensure that a newborn is healthy and does not have as-yet-undetected cardiac (or other) anomalies. I typically also discuss the risks of infection with parents of very young infants – both the risk of acquiring illness during travel and the importance of identifying local medical facilities as a part of pretravel preparations. The younger a child is, the more stringent I encourage parents to be about frequent hand washing/sanitizing and limiting exposure to other travelers.

We found that keeping our baby in a cloth carrier on our chest was a very effective way of discouraging friendly strangers from touching them or coming close into their faces. It made lugging around all the supplies they needed a bit easier as well. I don’t think this is a reason to discourage travel at a young age, but parents should be aware of the risks and be cautious.

During air travel, motion sickness and eustachian tube dysfunction are the most common complaints, so it is helpful to be prepared for them.

Eating large amounts or unfamiliar and overly exciting food immediately before flying can put anyone at higher risk for stomach upset, so I recommend traveling with plenty of milk for younger infants, plus a stash of healthy snacks and baby food or a sandwich. Giving a child lots of junk food and candy to keep them happy in flight can definitely backfire and leave the parent grabbing for the airsick bag. Again, it is helpful to check the airline’s websites for guidelines on traveling with liquids for children. This is typically allowed for small children, within certain limitations.

For most children, eating small but more frequent and familiar meals is all they need to prevent motion sickness; however, some will still have trouble. Children older than age 2 years can take an antihistamine such as dimenhydrinate (Dramamine; 1-1.5 mg/kg per dose) or diphenhydramine (0.5-1 mg/kg per dose up to 25 mg) at 1 hour before travel and every 6 hours during the trip. Note, however, that these medications are not approved by the Food and Drug Administration for the treatment of motion sickness in children; additionally, some children have paradoxical reactions, so if a family plans to use these medications, they should give a trial dose sometime before travel.

For eustachian tube dysfunction, drinking from a bottle or straw during takeoff and landing, chewing gum (for older children), or using a pacifier (for young children) is helpful. Middle ear disease is not a contraindication to flying; however, it may make a child more prone to pain during ascent and descent.

Overall, the better prepared a family is to travel with their child, the more enjoyable the trip will be, and everyone will land ready to have a good vacation.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center in Washington. 

As I return from the West Coast after two cross-country flights with my family, I am reminded of all the challenges young children face while flying. We regularly travel with our children and have learned many lessons along the way – by doing research, by surviving en-route successes and disasters, and by observing other families’ inspired solutions. Parents frequently ask their pediatrician for advice before traveling; if you haven’t flown recently (or at all) with small children yourself, what can you tell them?

First, be sure that children are healthy and up to date on their immunizations before travel. Any needed shots should ideally be given at least 4-6 weeks before leaving to ensure time for an adequate immune response. If a family will be traveling out of the country, it is important to research the specific areas they will be visiting for any additional medical concerns or requirements that may exist (for example, malaria prophylaxis). The Centers for Disease Control and Prevention website is a wonderful and quite detailed resource for both providers and patients. I highly recommend consulting it before travel anywhere out of the country, even if the destination is somewhere a family has been before; recommendations can and do change.

It is also important to remind the family to carry on an adequate supply of any chronic and emergency medications they might need. Additionally, I encourage families to check the airline’s website for guidelines on traveling with a car seat, which I strongly recommend doing. Riding in cars without the proper child restraints isn’t any safer away than it is at home.

There are no set guidelines for how young an infant can be before flying – one of the most common questions I am asked – but I think it is quite reasonable to recommend waiting at least 1-2 weeks to ensure that a newborn is healthy and does not have as-yet-undetected cardiac (or other) anomalies. I typically also discuss the risks of infection with parents of very young infants – both the risk of acquiring illness during travel and the importance of identifying local medical facilities as a part of pretravel preparations. The younger a child is, the more stringent I encourage parents to be about frequent hand washing/sanitizing and limiting exposure to other travelers.

We found that keeping our baby in a cloth carrier on our chest was a very effective way of discouraging friendly strangers from touching them or coming close into their faces. It made lugging around all the supplies they needed a bit easier as well. I don’t think this is a reason to discourage travel at a young age, but parents should be aware of the risks and be cautious.

During air travel, motion sickness and eustachian tube dysfunction are the most common complaints, so it is helpful to be prepared for them.

Eating large amounts or unfamiliar and overly exciting food immediately before flying can put anyone at higher risk for stomach upset, so I recommend traveling with plenty of milk for younger infants, plus a stash of healthy snacks and baby food or a sandwich. Giving a child lots of junk food and candy to keep them happy in flight can definitely backfire and leave the parent grabbing for the airsick bag. Again, it is helpful to check the airline’s websites for guidelines on traveling with liquids for children. This is typically allowed for small children, within certain limitations.

For most children, eating small but more frequent and familiar meals is all they need to prevent motion sickness; however, some will still have trouble. Children older than age 2 years can take an antihistamine such as dimenhydrinate (Dramamine; 1-1.5 mg/kg per dose) or diphenhydramine (0.5-1 mg/kg per dose up to 25 mg) at 1 hour before travel and every 6 hours during the trip. Note, however, that these medications are not approved by the Food and Drug Administration for the treatment of motion sickness in children; additionally, some children have paradoxical reactions, so if a family plans to use these medications, they should give a trial dose sometime before travel.

For eustachian tube dysfunction, drinking from a bottle or straw during takeoff and landing, chewing gum (for older children), or using a pacifier (for young children) is helpful. Middle ear disease is not a contraindication to flying; however, it may make a child more prone to pain during ascent and descent.

Overall, the better prepared a family is to travel with their child, the more enjoyable the trip will be, and everyone will land ready to have a good vacation.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center in Washington. 

As I return from the West Coast after two cross-country flights with my family, I am reminded of all the challenges young children face while flying. We regularly travel with our children and have learned many lessons along the way – by doing research, by surviving en-route successes and disasters, and by observing other families’ inspired solutions. Parents frequently ask their pediatrician for advice before traveling; if you haven’t flown recently (or at all) with small children yourself, what can you tell them?

First, be sure that children are healthy and up to date on their immunizations before travel. Any needed shots should ideally be given at least 4-6 weeks before leaving to ensure time for an adequate immune response. If a family will be traveling out of the country, it is important to research the specific areas they will be visiting for any additional medical concerns or requirements that may exist (for example, malaria prophylaxis). The Centers for Disease Control and Prevention website is a wonderful and quite detailed resource for both providers and patients. I highly recommend consulting it before travel anywhere out of the country, even if the destination is somewhere a family has been before; recommendations can and do change.

It is also important to remind the family to carry on an adequate supply of any chronic and emergency medications they might need. Additionally, I encourage families to check the airline’s website for guidelines on traveling with a car seat, which I strongly recommend doing. Riding in cars without the proper child restraints isn’t any safer away than it is at home.

There are no set guidelines for how young an infant can be before flying – one of the most common questions I am asked – but I think it is quite reasonable to recommend waiting at least 1-2 weeks to ensure that a newborn is healthy and does not have as-yet-undetected cardiac (or other) anomalies. I typically also discuss the risks of infection with parents of very young infants – both the risk of acquiring illness during travel and the importance of identifying local medical facilities as a part of pretravel preparations. The younger a child is, the more stringent I encourage parents to be about frequent hand washing/sanitizing and limiting exposure to other travelers.

We found that keeping our baby in a cloth carrier on our chest was a very effective way of discouraging friendly strangers from touching them or coming close into their faces. It made lugging around all the supplies they needed a bit easier as well. I don’t think this is a reason to discourage travel at a young age, but parents should be aware of the risks and be cautious.

During air travel, motion sickness and eustachian tube dysfunction are the most common complaints, so it is helpful to be prepared for them.

Eating large amounts or unfamiliar and overly exciting food immediately before flying can put anyone at higher risk for stomach upset, so I recommend traveling with plenty of milk for younger infants, plus a stash of healthy snacks and baby food or a sandwich. Giving a child lots of junk food and candy to keep them happy in flight can definitely backfire and leave the parent grabbing for the airsick bag. Again, it is helpful to check the airline’s websites for guidelines on traveling with liquids for children. This is typically allowed for small children, within certain limitations.

For most children, eating small but more frequent and familiar meals is all they need to prevent motion sickness; however, some will still have trouble. Children older than age 2 years can take an antihistamine such as dimenhydrinate (Dramamine; 1-1.5 mg/kg per dose) or diphenhydramine (0.5-1 mg/kg per dose up to 25 mg) at 1 hour before travel and every 6 hours during the trip. Note, however, that these medications are not approved by the Food and Drug Administration for the treatment of motion sickness in children; additionally, some children have paradoxical reactions, so if a family plans to use these medications, they should give a trial dose sometime before travel.

For eustachian tube dysfunction, drinking from a bottle or straw during takeoff and landing, chewing gum (for older children), or using a pacifier (for young children) is helpful. Middle ear disease is not a contraindication to flying; however, it may make a child more prone to pain during ascent and descent.

Overall, the better prepared a family is to travel with their child, the more enjoyable the trip will be, and everyone will land ready to have a good vacation.

Dr. Beers is assistant professor of pediatrics at Children’s National Medical Center in Washington.