Winter 2010 Newsletter
WELCOME to our seventh issue of the Pediatric Specialists newsletter.
Winter Health
Dehydration/Oral Rehydration
DEFINITION: The most common cause of dehydration in children is gastroenteritis (often called a stomach virus or stomach bug).  Dehydration can result from an illness that causes diarrhea alone or from the combination of diarrhea and vomiting. Diarrhea is defined as more than 3 loose, watery stools/day. 
SIGNS OF ILLNESS: Symptoms of mild to moderate dehydration include fatigue, irritability, thirst, increased heart rate, decreased tears, dry mouth and tongue, decreased urination.  Please call our office immediately if there are signs of severe dehydration such as lethargy, inability to drink, deeply sunken eyes, absent tears, parched mouth and tongue, minimal urine output.  Also please call us immediately if your child has severe worsening abdominal pain, blood or mucous in the diarrhea, vomiting lasting more than 24 hours, rectal temperature over 100.4 in a child under 3 months old, vomiting more than 2x/day in child under 3 months old, or no improvement in diarrhea after one week. 
ORAL REHYDRATION: The best way to treat mild to moderate dehydration and prevent progression to more severe dehydration is to use an Oral Rehydration Solution (ORS) such as Pedialyte, Infalyte, Rehydralyte, Kaolectrolyte, or Ricelyte.  The colder the ORS, the better it will taste.  Pedialyte also comes in kid-friendly ice pops.  In a child who is vomiting, the best method is to start with very small amounts of liquid, giving 1 teaspoon every 5 minutes, then gradually increase to a maximum of 30 ml (1 ounce) every 5 minutes as tolerated.  In an infant or toddler, the goal is 4 – 8 ounces/hour, in a school age child, 8 – 16 ounces/hour.  This will replace fluids lost by diarrhea and/ or vomiting.  Even if the child is continuing to vomit, parents should push ORS in small amounts given by spoon or syringe. 
DIET:  Breastfed infants should continue nursing on demand and formula fed infants should resume their normal formula after rehydration.  Lactose-free or added fiber formulas are unnecessary.  Foods high in simple sugars (e.g. soda, juice, jello, sweetened beverages) should be avoided as they can increase diarrhea.  The traditionally recommended BRAT diet is now believed to be unnecessarily restrictive, as is the custom of withholding food for 24 hours.  An age-appropriate diet of complex carbohydrates, meats, yogurt, fruits and vegetables is recommended.
MEDICAL TREATMENT: Scientific studies have shown the effectiveness of probiotics for children with infectious diarrhea.  Probiotics are the healthy microorganisms which help maintain intestinal health.  They are found in fermented foods such as yogurt but can also be purchased in powder, tablet, or capsule form.  It is difficult to recommend a specific brand as dietary supplements are not FDA regulated, but we do recommend taking probiotics to help shorten the course of diarrhea. 
There is also a prescription medication (ondansetron) that can sometimes be used to decrease nausea and vomiting.  We recommend that children be evaluated by a health care provider before this medication is prescribed. 
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Flu Update
Again, we thank our patients for their patience during this lengthy flu season that has been difficult for us all.
At this time we are continuing to see sporadic cases of presumed H1N1 flu and expect to begin to see an increase in seasonal flu as is typical in January through March. 
We continue to recommend that all children receive seasonal flu vaccine as well as H1N1 vaccine.  Please call the office if you’d like to schedule an appointment to receive flu vaccine.  We are administering seasonal flu vaccine for any children who have not yet received flu vaccine.  We are providing H1N1 vaccine as well, but only the type which contains thimerosol preservative.  We have been informed by the Massachusetts DPH that we will not receive any further shipment of thimerosol-free H1N1 vaccine. 

Safety:
Burn Safety/Hot Water Temperature
The leading cause of deaths and injuries to children at home is accidents. Hot water burns are a frequent cause of injury in young children.  These burns occur most often in the bathroom.
Small children can get to sinks or bathtubs quickly. They can get badly burned before they can get out of the water. Infants are unable to move away from hot water if it is accidentally left on too hot or the cold water is turned off. Here are some tips:

• When using tap water, always turn on the cold water first, and then add hot. When finished, turn the hot water off first.
• Always test the water before your child gets into the tub or shower.
• Don't allow young children to touch faucet handles during the bath.
• Never leave a child alone in the bathroom for any reason.  They are at risk for getting burned by hot water or drowning. 
• Set the thermostat on your water heater to 120°F (48°C) or lower. A child can be scalded in 2 to 3 seconds in water that is only 5 degrees higher - 125°F (52°C).
• If you are unable to control the water temperature (because you live in an apartment for example), you can install antiscald devices on faucets and showerheads. An antiscald device is relatively inexpensive and can easily be installed by you or a plumber. The device will sense the water temperature and keep it from getting over 120°F (48°C).

• Do not use hot steam vaporizers. They can cause steam burns. Use a cool mist vaporizer.

Carbon Monoxide Poisoning:

Carbon monoxide poisoning is a common cause of winter injury in children.  Carbon monoxide is a colorless, odorless gas. It is made by many household appliances (furnaces, dryers, ranges, ovens, charcoal grills, camp stoves, and heaters). Many deaths are caused by trying to heat the house during a power outage. Never use a gas range or oven to heat a house. Never use a charcoal grill inside. Oil, kerosene, coal, and wood produce carbon monoxide when burned in the house or garage.
Never leave the car engine running inside the garage even with the door open. Have gas appliances and furnaces checked regularly and repair any defects. Have gas appliances installed by a professional and make sure they vent to the outside. If something goes wrong and carbon monoxide leaks into your home, it could be deadly. The alarm of a carbon monoxide detector will go off in time to get out before a normal adult starts feeling sick.
Install a smoke detector and a carbon monoxide detector on each floor in the house and in every bedroom. Your local building and safety codes may require you to have additional alarms. For extra protection, you can also put them in the dining room, furnace room, utility room, attic, garage, and hallways.
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Nutrition:
Slow Cooker Suppers

Squash and Sausage Casserole
12- 16 ounces chicken apple sausage (pre-cooked)
2-3 Cups cubed butternut squash or sweet potato
1 Cup diced carrots
1Cup sliced onion
1-2 apples, peeled, cored and diced
1/3 C dried cranberries
1 – 2 T brown sugar
1 tsp cinnamon
1 tsp allspice
1/2C chicken broth
2.5 C cooked brown rice
Mix all ingredients together in crock pot.  Cook on high 3-4 hours, or on low 7-8 hours.
Makes 4-6 servings
(Quantities are approximate; you can vary them to suit your family.  I find 2T brown sugar a little too sweet, but 1 T just right)

Moroccan Chicken with    Prunes and Couscous
(Adapted from Lora Brody’s Slow Cooker Cooking)
8 boneless, skinless chicken thighs
1T vegetable oil
1C pitted prunes
2 large onions, peeled and sliced
2tsp whole cumin seeds
1.5C chicken broth
2Tbsp minced garlic

2Tbsp minced and peeled fresh ginger
1tsp ground turmeric
1tsp ground cinnamon
¾ tsp salt
¼ tsp black pepper
1.5 C uncooked couscous

Rinse and dry chicken.  Brown pieces in oil in large nonstick skillet over med high heat for about 2 mins per side.  Transfer to slow cooker and tuck prunes among chicken pieces.  Sauté onions and cumin seeds in skillet over med high heat for 5 minutes, until onions are soft.  Pour in broth and add garlic, ginger, turmeric, cinnamon, salt, and pepper.  Bring mixture to a boil, stir well, and pour over chicken and prunes.  Cover and cook on LOW for 4.5 hours.  When ready to serve, remove chicken, prunes, and onions to platter and keep warm.  Measure 2C of cooking liquid into saucepan and bring to a boil.  Add couscous, stir, cover, and remove saucepan from heat.  Let stand for 5 minutes, then fluff with fork.  Serve couscous with chicken. 
Makes 4 – 6 servings

Staff Update
We sadly say goodbye to Britney Knighton, RN who is leaving because of her husband’s job change.  
We welcome Dawn McGrath who is joining our front desk staff, and Karen Conte, RN   to our nursing staff.
We continue to benefit from our association with Heather Stone, RD, LDN.  Heather is available to meet with patients in our office for nutritional counseling.  Appointments may be arranged by contacting her directly at 508- 577-3765.

Ask the Doctor

Question: What it the best snack to get at the movies?
Answer:   Many of us think of popcorn as a healthy snack.  If served in the appropriate quantity and popped without oil it can be a healthy, whole grain, high fiber snack.  However, eating a tub of movie theater popcorn is more like eating an 8 oz bag of potato chips at one sitting. 
Popcorn served at the local cinemas (Hoyt’s in Sharon, or Showcase at Patriot Place) have similar calorie counts.  The small popcorn is 7 cups and contains 400 calories and 27g of fat.  Buttery topping adds 230 calories and 23g of fat.  The large popcorn is 20 cups and contains 1160 calories and 77g of fat!
Of course the soft drinks or candy sold at the movies are no better in terms of nutrition, so the best snack to buy at the movies is no snack! 

Question:  What is a good age for my child to start doing chores?
Answer:  Children as young as 2 years old can start doing chores around the house.  Chores can be an important tool for parents.  They help children learn a job, give parents an opportunity to demonstrate planning skills, and create a sense of sharing between parent and child.  Basic life skills can start to be learned, even at a young age.  However, it is important to remember that perfectionism is not the goal, and there should not be too much emphasis on the chore being done perfectly. 
Below are some suggestions for chores appropriate for age:
2-year-olds:

• Setting the table (napkins, silverware)
• Sorting laundry into colored and white clothes
• Picking up toys

3- to 5-year-olds:

• Setting and clearing the table (dishes)
• Watering plants
• Feeding pets
• Making beds
• 
  Matching socks from the laundry
• Folding laundry and putting it away
• Weeding the garden

6- to 9-year olds:

• Taking out garbage, organizing recycling
• Loading/unloading washer and dryer
• Helping to prepare meals

7- to 10-year-olds:

• Raking the lawn
• Cleaning a room that is not their own (e.g. bathroom)

Suggestions:
We always appreciate your help in improving our practice and welcome any feedback you provide.  Please let us know if there is any way we can improved your experience at Pediatric Specialists. 
For the Foxboro office, please send feedback and comments to:
customerservicefoxboro@pediatricspec.com and for the Wrentham office to customerservicewrentham@pediatricspec.com.  
Feedback or submissions for our newsletter can be sent to lspitzer@pediatr
icspec.com. Also, please submit your email address if you’d like to be added to our mailing list.