Dr. Marc A. Tanenbaum, MD

Hello HFM questionner,

Hand, Foot & Mouth disease (HFM) is a viral illness and antibiotics are rarely needed unless there is a secondary bacterial infection of a skin sore. All treatment is symptomatically oriented. For the hand and foot, often no treatment is needed if the individual is comfortable. Itch occasionally is bothersome. For itch, one might take an age appropriate dose of Zyrtec or Benadryl by mouth. Often, application of your favorite non-scented skin moisturizer is beneficial for comfort. If a skin blister becomes unusually red and tender, application of OTC 1% hydrocortisone 2-3x a day will reduce the inflammation. The HF blisters spontaneously improve within 7-10 days. Achieving comfort is the goal.

For one’s mouth, comfort again is the goal. Needless to say, good oral hygiene is beneficial. Mouth blisters can occur on the inner lips, the gums, the roof of the mouth and the back of the mouth. Gentle toothbrushing, dental flossing, and mouth swishing of mouthwash or warm water is wise. Appropriate choices of foods and liquids for ingestion, e.g., sounds, bland foods should be comfortably swallowed. Avoid excessive salt as it will sting mouth blisters. Citrus juices can also stings. You can eat and drink anything that you feel is comfortable and avoid what you feel is especially uncomfortable within the mouth. For oral pain, including sore throat, one can take an appropriate dose of ibuprofen or acetaminophen. There are OTC gels that you can apply to painful mouth blisters or ulcers. Your pharmacist can recommend various options.

Other than these common sense interventions, time is your best friend. Recovery should occur within 10 days or so. Please do consult your doctor if you are very ill and cannot achieve a reasonable degree of comfort.

Good luck. This is a common illness and rarely requires prescription medications. This advice also is contingent on you having made the correct diagnosis.

Dr. T

Hello,

In regards to your question, “Why does my child's mouth hurt?

My son is 10 years old and he has mouth pain.” Most doctors would seek more specificity about the pain directly from the child at this age and with the physical exam. Although mouth pain may seem like a clear complaint, the mouth contains many structures if you think about it. The 10-year-old should be able to clarify where about the mouth he/she feels pain or minimally point to the painful area. Doctors would wonder if mouth pain means the tongue, the lips, the cheeks, the teeth, the rood of the mouth, the tonsils, the throat, etc. Doctors would also ask the child if the pain was changed or made worse with swallowing, chewing, etc. Doctors would also want to know what kind of pain the child experienced burning, throbbing, knife-like, etc. Also, how long the pain has been going on, whether it’s persistent or intermittent or changing in intensity, as well as if the child has experienced this pain before. Has there been an injury to the mouth? Doctors would also inquire about the general wellness of the child and other clues to illness, e.g., fever, cold or GI symptoms, appetite change, etc.

Next would come a physical exam including the mouth structures, but not limited to the mouth. Are sores or ulcers present? What is the status of dental hygiene? Could “mouth pain” be dental pain? Is there gingivitis (gum disease)? Is there evidence of an oral injury, perhaps a popsicle stick bruise within the mouth? So, as you can see, there is no simple answer to why is your child’s mouth hurting without more clues and a physical exam. There is a cause for your child’s mouth hurting, but without more information and a look-see, I would be only guessing. It could be as simple as mouth pain from too strenuous tooth brushing or too vigorous dental flossing.

Please think about these questions as you work with your son to better understand the mouth pain. If the cause is not obvious after working through these possibilities with your child, pay a visit to the doctor or dentist for a professional opinion.

Best of luck,

Dr. T

Hello,

This is a very unusual question. Amoxicillin is a medication only available by prescription in the USA. The prescribing physician has the responsibility and the duty to inform the patient or family of the proper dose to use and the possible side-effects to be aware of. Although I could advise you of a proper dose, my advice is to contact your prescribing physician and obtain this information. If you don’t have a prescribing physician who gave you this medication, you should not take it. If you have this medication without the involvement of a physician, simply Google your question and let the patient beware.

Regards,

Dr. T

Hello,

The simple answer is yes, however, your 2-month-old is no longer considered a newborn, but now falls into the infant category. Congratulations. By now, your baby should have had his or her first doctor visit between 3-5 days of age, then at one month and two months of age. The next well visit would typically be at 4 months of age. If your infant is suffering from “gas,”
these well visits would be an excellent time to discuss this problem as well as nutrition, development, safety, sleep and many other common questions of infancy.

Best regards and Happy Thanksgiving,

Dr. T

Hello,

If your toddler is happy, playful, eating, drinking and sleeping well (especially sleeping well), he or she does not need any help at all. The child’s immune system is working well and doing its thing. If your child is a little under-the-weather, energy wise, but otherwise well, eating, drinking and still sleeping normally, again no special help is needed.

Now, if the cough and cold (runny or congested nose) is associated with fever (>100.4 rectally or 99.4 by armpit or forehead scanner or ear thermometer), there is no need for fever medication (Tylenol or Advil) unless your child feels badly with fever. And you are the best judge of that. Feeling badly is more than just a little bit tired. Think irritable, grouchy, short-tempered, inconsolably crying.

For the last decade or more, informed pediatricians have concluded that fever in a comfortable child is the immune system at work killing viruses. But no doctor or parent wants a child to feel badly with fever. So that’s when fever meds are needed. When nasal breathing is obstructed by nasal discharge or congestion, we recommend nasal saline washes or nasal saline gel used when needed followed by nasal aspiration with a nasal bulb aspiration. There are many varieties of nasal suction devices on the market. Think cheap and effective. You don’t want the treatment to be worse than the problem. Most toddlers won’t say thank you when the aspiration is used. It’s also okay to simply use nasal saline often without suctioning to moisten and remove nasal mucus. Saline used often even without suctioning can lessen mucus. Remember the Colorado River, given enough time, created the Grand Canyon and no suctioning was ever used.

Similarly, a cool mist humidifier used when the child sleeps (nap or bedtime) can loosed nasal mucus. This should be an inexpensive cool mist humidifier, NOT a steam vaporizer which could introduce a risk of scalding the child if running too close to the child’s skin. Avoid the expensive ultrasonic humidifier! It makes water particles too small which can irritate a child’s airway in the lungs. The inexpensive cool mist humidifier makes larger water particles that moisten the upper airway only. Air below the vocal cords is already 100% humidified in all of us. No sense irritating a child’s lungs further with unneeded ultrasonic water particles. Be sure not to run the humidifier 24 hours a day to avoid mold build-up and clean it properly according to its instructions.

Remember the above advice is for significant nasal obstruction. If your child is sleeping well and not snoring loudly and has no noticeable long pauses in breathing due to the cold, it may be wiser to limit your effort to improve nasal symptoms. There is a pattern to a normal toddler cold. There can be fever the first few days, but rarely more than 3-5 days and if your child is comfortable, fever meds are not needed. If your toddler starts the cold with an abrupt high fever (103-104), you may need to call the doctor to discuss the possibility of another problem, e.g., a sinus infection or ear infection, otherwise you can give it a few days for comfortable mild fever to subside. Runny or congested nose symptoms associated with cough usually peaks by day 5-6, then subside over the next 7-14 days. It is uncommon for uncomplicated colds to last beyond two to three weeks. Colds that increase in intensity after the first week into the second week should be evaluated by a doctor for some complication of a cold like a sinus infection or a secondary problem in the lungs or ears. The typical pattern is for the cold to subside into and through the 2nd and 3rd weeks of illness.

A few words about a cough that intrudes on the child’s comfort and disturbs sleep - the child’s sleep, not the parents. You may have noticed that over the last decade cough meds for kids under 6 years of age have disappeared from the pharmacy shelves. That’s because of a few deaths that have resulted from inaccurate dosing in young children. There is no evidence and there has never been evidence of benefit from these over-the-counter (OTC) cough meds, so the FDA pulled them from the commercial marketplace. It is unlikely that the pharmaceutical industry will go through the expense of proving them effective for FDA approval. There is some evidence that once a child is over one year of age, dark honey can soothe a disrupting cough allowing the child to sleep. The study was done with Buckwheat dark honey, although it is presumed that any organic dark honey would similarly work_and we don’t really know why. We speculate that the goo of the honey given undiluted 1/2-1 tsp before bedtime might soothe the throat reducing the cough “tickle” or perhaps it’s the rich antioxidant content that improves the cough. No one knows, but undiluted dark honey has been observed to offer some cough relief in kids over one year of age. Under age one, it is not recommended. Your doctor can explain why. OTC meds that contain honey as an ingredient is NOT the same thing. That honey is diluted and no evidence exists that honey as an
ingredient in OTC cough meds is effective.

My hope for parents reading this answer will recognize that their toddler with a runny/congested nose and a cough who is otherwise well, playful, eating and sleeping well, needs no intervention at all; that low grade fever in a comfortable child with a cold can be normal the first few days of a cold; that all normal colds peak in intensity by days 5-7, then subside in intensity and are gone by 2-3 weeks; and that colds are not normal if they start with a very high fever or symptoms increase in intensity in the 2nd week of illness. Lastly, a few words about contagion. Colds mild or otherwise are contagious to others. Good hand washing by toddler caregivers is essential. Colds spread by droplets coughed through the air and by cough/nasal discharge on hands or home surfaces. Just think what does the family, not just the toddler, touch? Although Lysol and Clorox wipes work, that’s too much effort. I recommend Lysol spray multiple times a day on all the common touchy places: stairwell banisters, TV controls and remotes, keyboards, refrigerator handles, door knobs, toilet bowel levers, etc. No wiping needed. Just frequent walk-by spraying and air drying. Does this sound like a good chore for an older sib who won’t spray his/her own face? Parents already have much to do. Use Kleenex for your toddler when needed. Wash your hands after parenting care of your toddler with a cold. Try not to let your toddler cough into your face. Good luck with that! You might even consider wearing a face mask covering when working with your toddler.

There is one terrible “cold” you can prevent and that’s influenza by getting a flu shot for you and your toddler. In fact, all persons 6 months of age and older without a medical contraindication should get a flu shot before the end of October. The flu is not really a cold; it’s more like a train wreck, compared to a cold which is like running into a cotton ball. Help your toddler immune system and your’s recognize the flu virus and be prepared to fight it off by getting a flu shot. And then there’s COVID-19, which can be asymptomatic in some and not in others, can cause a cold in some or a terrible respiratory illness in others and we can’t predict in whom COVID will cause what. As you know, children 12 and older can get a COVID-19 vaccine. We are hopeful that by the end of November or December, children 5 and older will be able to get a COVID vaccine as well, then later as further evidence of safety and benefit come in, even kids 2 and older, perhaps 6 months and older.

Just like you put your kids in federally approved car seats and buckle yourselves up a car to reduce the chance of serious injury in a motor vehicle accident, and you don’t text while driving because you know it’s in your best interest and that of your passengers in your car, it’s time to be proactive for your kids to get a flu shot and a COVID-19 if eligible. You don’t need a law or mandate to use common sense. You can get additional information about colds, cough and fever, as well as current COVID-19 guidelines as well as immunization information at the American Academy of Pediatrics family website www.healthy children.org. It has a great search window.

Have a good Autumn and Winter,

Dr. T

Hello,

In response to your question, "What is the best medicine for bronchitis for kids?" I find the answer to be rather complex and dependent on what you hope the medicine will do. Firstly, almost all bronchitis in children is viral and will not require antibiotics. Secondly, viral bronchitis can be mild and require no therapy if the child is comfortable and breathing normally.

Although there are many cough and cold products available to treat symptoms of a cold or bronchitis, most are not needed and some can be harmful. Over the last few years, cold and cough medications for children under the age of 6 years have been removed from pharmacy shelves. The FDA withdrew approval for these medications a few years ago because there were a few deaths in kids under age 6 from incorrect dosing and there has never been sufficient evidence of effectiveness. The pharmaceutical industry can bring these medications back to commercial use if they provide the FDA evidence of safety and effectiveness. It is very unlikely they will go through this expense as they've known for many years that there is no evidence of benefit. The medications remain available for persons over age 6 without evidence of benefit as their approval was historically "grandfathered" by the FDA and overdose tragedies in older persons are extremely rare.

I like to explain to families that "cough" is G-d's gift to humanity to prevent "drowning" from airway mucus from any cause. So, we expect a cough with bronchitis, even some fever and malaise. But "comfortable cough" is what's expected. Cough that keeps one up at night or causes chest pain is not acceptable and you should talk to your child's doctor. Uncomfortable
cough associated with labored breathing or out-of-breathness or breathlessness also is not acceptable and requires communication with your doctor. Comfortable fever for a few days is common. Some appetite loss is expected and the ability to take fluids is important. Terrible headaches and body aches are NOT the norm.

Bronchitis, like a cold and most illnesses, has a beginning, a middle where symptoms peak and an end. Usually fever, when present, is gone by the 3-5 day, congestion and cough peak in frequency and intensity by day 3-7, then diminish over the next 2 weeks. Yes, coughing can take about 2-3 weeks to go away. A person with viral bronchitis usually feels better within a week or so, even though the improving cough may take another 1-2 weeks to completely go away. Cough lasting longer than 3-4 weeks in an otherwise well child should be called to the doctor's attention.

So, best medications include Tylenol or ibuprofen in the appropriate dose for fever that makes your child feel bad. Comfortable fever requires no medication unless your doctor advises otherwise. Adequate hydration is important, so frequent fluids when awake are useful. Nutritious fluids (soups) hydrate and provide some needed nutrition as well. A soft, nutritious diet until the child feels better and a normal appetite returns is also important.

When cough disturbs sleep many pediatricians suggest dark honey at bedtime for kids over one year of age. Ask your doctor for an appropriate dose. Sleeping with the head of the mattress elevated 10-15 degrees can be helpful allowing mucus to flow better. A cool mist humidifier near the child also can help mucus remain loose and flow better. We don't recommend expensive humidifiers ($90 or so) because they can create water particles that are too small and can get into the lower airways irritating the lungs. Steam vaporizers can be effective, but present a danger of burning the child directly from the steam jet or if the child overturns the unit on him/herself.

Nasal saline spray, drops or gel can help nasal secretions remain loose and flow more successfully. Nasal suction/aspiration similarly can unclog the nasal airway. Of course, most kids hate the suction bulb so choose your battles wisely. You don't want the treatment to be worse than the symptom.

Don't forget to educate your child on proper cough and hand hygiene, age permitting. Covering one's mouth with one's hand is 20th century technology. Today we encourage coughing into one's elbow to reduce hand contamination. Frequent use of a hand sanitizer can reduce spread in the home or at school in children old enough not to put their "sanitized" wet hands in their mouths. Lysol spraying the "touch" places in the home (a few times a day) often can also reduce family viral spread: stairwell banisters, TV remotes, keyboards, refrigerator handles, door knobs, toilet flush levers, etc. This can be a great job for well persons and older sibs who won't spray their faces to help make parent work a little easier.

Lastly, we can't forget about COVID-19_also one virus among many that can cause bronchitis. As parents, you should already be immunized against COVID-19. If you are not, it's not too late to get immunized. Similarly influenza can cause bronchitis. So, when the flu shot becomes available this Autumn, both you and your child (over 6 months of age) should get immunized against the flu. Children 12 years and older should get the COVID-19 vaccine as well and hopefully this Autumn, kids under age 12 years will be able to get a COVID vaccine as well. More important than any "medication for bronchitis" are COVID-19 and flu shot to PREVENT bronchitis and other complications that you've heard about in the media.

This link from the American Academy of Pediatrics Family Website can tell you more about cough:
https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/symptomviewer.aspx?symptom=Cough&_ga=2.176103586.1624770254.1627745502-222233170.1619280832&_gl=1*pjbumk*_ga*MjIyMjMzMTcwLjE2MTkyODA4MzI.*_ga_FD9D3XZVQQ*MTYyNzc0NTUwMS43LjEuMTYyNzc0NTY0MC4w

Also, more important than medicine for your child's bronchitis is your ability to tell a comfortable child with cough and normal breathing from a child with uncomfortable cough and troubled breathing:
https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/symptomviewer.aspx?symptom=Trouble%20Breathing&_gl=1*uodpdc*_ga*MjIyMjMzMTcwLjE2MTkyODA4MzI.*_ga_FD9D3XZVQQ*MTYyNzc0NTUwMS43LjEuMTYyNzc0Njk3NC4w&_ga=2.147833783.1624770254.1627745502-222233170.1619280832

I hope you have found this helpful and encourage you to have your family immunized against COVID-19 and influenza for this winter viral sick season.

Best regards,

Dr. T

Hello,

In answer to your question, "Does ear pain cause a baby to cry uncontrollably?" in my experience, I would say yes, it can. However, it is just one of many possible causes of uncontrollable crying. An appropriate dose of Tylenol or Ibuprofen (depending on age) should interrupt crying from earache. This probable relief should give you time to call or visit your baby's pediatrician.

If your baby is 3 months of age or older, please visit the American Academy of Pediatrics Family Web Page,
https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/symptomviewer.aspx?symptom=Crying%20Child%20-%203%20Months%20and%20Older&_ga=2.33892129.1624208114.1625862786-222233170.1619280832&_gl=1*fkb5i*_ga*MjIyMjMzMTcwLjE2MTkyODA4MzI.*_ga_FD9D3XZVQQ*MTYyNTg2Mjc4NS4yLjAuMTYyNTg2Mjc4NS4w
or, if younger than 3 months, visit
https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/symptomviewer.aspx?symptom=Crying%20Baby%20-%20Before%203%20Months%20Old&_gl=1*1efd2sy*_ga*MjIyMjMzMTcwLjE2MTkyODA4MzI.*_ga_FD9D3XZVQQ*MTYyNTg2Mjc4NS4yLjEuMTYyNTg2MjkzNi4w&_ga=2.34089633.1624208114.1625862786-222233170.1619280832
to learn more about infant crying.

Dr. T

Hello,

In answer to your question,"How do I know if my baby formula needs to be changed?" it all depends on what you mean. If your full-term baby is on a standard infant formula and is doing well and thriving, there is no reason to change it. If you have a premature 1-month-old on a formula designed for premies, you should ask your pediatrician at your regular well baby
checkups criteria for switching to a standard baby formula.

Hi,

The short answer to your question "Is bottled water safe for baby formula," is yes, although it probably isn't necessary if you have properly treated metropolitan city water. See
https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/symptomviewer.aspx?symptom=Bottle Feeding%20(Formula)%20Questions&_ga=2.49494246.113575225.1625247341-222233170.1619280832&_gl=1*tpy20d*_ga*MjIyMjMzMTcwLjE2MTkyODA4MzI.*_ga_FD9D3XZVQQ*MTYyNTI0NzM0MC4xLjAuMTYyNTI0NzM0MC4w
"#6. *Water to Mix With the Formula: *

Most city water supplies are safe for making 1 bottle at a time. Run the cold tap water for 1 minute. Don't use warm tap water. (Reason: To avoid potential lead exposure). Heat cold water to desired temperature. Add this to powder or formula concentrate. Exceptions:

- Untested well water or
- City water with recent contamination or
- Developing countries with unsafe water supply or
- Your child has decreased immunity.
- For these conditions, use distilled water, *bottled water*, or filtered tap water.
- Another option is to use city water or well water that has been boiled. Boil for 10 minutes. Add 1 extra minute per each 1,000 feet (305 meters) of elevation.
- *Bottled* water costs more than distilled water.
- If making a batch of formula, distilled, *bottled *or boiled water is needed."

Regards,

Dr. T

Hi there,

Let’s reframe the question: What’s the appropriate Serving Sizes for Toddlers? I recommend you go to the family web page of the American Academy of Pediatrics, www.healthy children.org, and in their search window, search for “serving sizes for toddlers.” You will see that 2 to 3 four-ounce servings of whole cow’s milk at meal times should suffice.

Best regards,

Dr. T

Hello,

Thank you for your question, “My toddler daughter has a poor appetite. What causes poor appetite in toddlers?” Do you remember that old TV commercial, “is it real or is it Memorex?” It’s not that a toddler can’t have a poor appetite suggestive of a problem, but more likely than not “poor appetite” is in the eye of the beholder.

If a parent suspects there might be a toddler appetite problem, he or she, or better yet, they, should discuss with the child’s pediatrician or family doctor. Toddlers are normally seen for well care at 18, 24, 30 and 36 months of age. This issue can be raised at any of these well checkups or at anytime as a “problem” visit. In addition to taking a diet history and examining the child, the doctor will look at the child’s growth curve or growth pattern as indicated by the child’s history of height and weight measurements since birth when seen for checkups and problem visits. If the child is growing at a normal rate or speed for height and weight, almost always there is no problem.

Children can be chunky, slender or average build and all grow at a normal rate of height and weight gain. Gaining weight at a faster rate than average for age can be a problem as obesity (over-weightness) is our country’s number one health problem. Gaining weight at a slower than normal speed or rate can also be a problem. Slow weight gain compared to height gain suggest inadequate calories or some health problem converting nutrition to calories and growth.

So let’s presume that you raise this issue with your child’s doctor who advises you that your child is gaining weight and height at a normal speed (rate) for age. This should sound reassuring, yet you still feel your child’s appetite is not normal. At this point the doctor or his staff, or a dietician the doctor recommends, should review a typical 3-day diet record with you of what your child typically consumes. The doctor is looking for an adequate nutritional variety and appropriate caloric intake for age for your child. Presuming that this dietary record is also reassuring, your doctor will probably make the following points:

1] A toddler’s appetite is often sporadic and not the same day to day.

2] Toddlers will almost always take what they need nutritionally over a span of a few days, if not every day.

3] Don’t accept the first 10-15 NO’s from your toddler. Just place the food in small quantities of a healthy safe variety on the surface in front of your child with a smile on your face and exert no pressure.

4] This is the tag line on toddler nutrition for the 21st century: “Parents provide; children decide.”

5] There are many parent/physician tricks to amplify the above general principles, but let’s leave them to your doctor, the staff or your dietician to review with you.

So, bottom line, if you know that your child is growing well and is generally healthy, has had healthy well checkups, has a normal growth curve, is fully immunized, and you are placing small quantities of a safe and healthy food variety in front of your toddler, and the child picks at it sporadically in different amounts over a few days, is pooping and peeing well, is happy and sleeping comfortably, you should presume that all is normal. I would also recommend that you visit the family website of the American Academy of Pediatrics, www.healthchildrenorg. Use its search window to read about toddler nutrition.
I hope you have found this general advice of value.

Regards,

Dr. T

Hello,

Thank you for your question, "What does RSV cough sound like in toddlers?"

A study in the European Journal of Pediatrics, "*Typical RSV cough: myth or reality? A diagnostic accuracy study*" from January, 2021, doi:10.1007/s00431-020-03709-1, found that Senior physician staff and aediatric nurses performed better than various bedside tests in diagnosing RSV by the sound of cough, but were not better that antigen tests by nasal swab. Pediatric residents in training needed at least 3.5 years of work experience to be able to make an RSV diagnosis based on cough sound. Even so, the residents were only 66% correct, and that's with training. None could validly distinguish RSV from other germs based on cough sounds. So, there is no reason to expect a parent to reliably identify RSV as a cause of cough in a toddler.

More important than the sound of cough, in my opinion, except for an inspiratory whoop that could represent Pertussis or whooping cough, is the effort of breathing associated with a cough. Cough is God's gift to mankind to prevent choking on respiratory mucus associated with illness. No cough, no clearance of mucus with resulting "drowning" on one's own mucus. The cough in itself is not dangerous. It's the effort of breathing with cough-associated illness that's important to recognize whether the cause is RSV, another virus, bacterial pneumonia or asthma. You will find this of interest:
https://www.healthychildren.org/English/tips-tools/symptom-checker/Pages/symptomviewer.aspx?symptom=Cough


Since a comfortable cough can be therapeutic in RSV or other viral illness by clearing mucus, let's discuss comfortable cough. In my mind, comfortable cough is painless, doesn't interrupt sleep, and is not associated with out-of-breathness, breathlessness, or windedness. Cough is a normal part of a cold and viral bronchitis, usually peaks in intensity by the 5-6th day, and diminishes over the next two weeks. An uncomplicated cold or bronchitis with cough usually lasts less than a month, often 2-3 weeks. Coughs that don't meet this pattern should be discussed with one's doctor. So, my recommendation is don't make decisions about the cause of a cough based on sound, but rather based on your toddler's total comfort, ability to rest and sleep, duration of illness and comfort breathing.

You might not remember that we can immunize against a number of causes of cough in a toddler: Influenza, Pertussis (whooping cough), Measles, Diphtheria, some bacterial pneumonias, and soon we should be able to include COVID-19. All these vaccines as well as the other routine childhood vaccines are very important. Of course, you can call your doctor if you are anxious or uncertain about these issues. I do recommend using the search window on www.healthychildren.org, the Academy of Pediatrics Family Web Site for more useful information.

Regards,

Dr. T

Hello,

Thank you for your question, "What can I do if my (2 week old) baby doesn't want to drink milk?"

As you may know, 2-week-old infants and more specifically, all infants under 12 months of age, should not be offered cow's milk. I am sure you've heard that breast milk is best for babies, but if you have chosen for personal reasons not to breastfeed your baby, infant formula is the best alternative to breast milk for infants. Formula has been developed to simulate the nutritional value of breast milk.

Newborns following home birth or discharge from a birthing facility are usually asked to see their pediatrician or primary physician in the next few days, usually by day 5 of life. If the baby's weight loss has stabilized and all is well otherwise, the baby is next asked to return at 2 weeks of age to confirm healthy growth and nutrition. Sometimes infants are not asked to return until one month of age for their first well checkup appointment.

Since your infant is 2 weeks old, you are just at the right age of life to discuss your baby's nutrition and feeding with your baby's doctor. If your baby is sensitive to the formula you offer and is rejecting it, your doctor could recommend alternative formulas to try. Sometimes a baby will have issues with sucking and swallowing, having nothing to do with the formula being used. In this case, if suspected, the doctor can refer the baby to an infant feeding specialist, usually a pediatric occupational therapist or a speech and language specialist (SPL). Yes, although SPL specialists may seem an unusual choice for swallowing problems, they are often expert in mouth and muscle function and coordination, and can be helpful in treating
swallowing problems.

Treating infant swallowing problems presumes an otherwise normal exam and normal anatomy from mouth to abdomen. Sometimes a special imaging test is required to observe the baby's swallowing and passage of formula to the stomach - a barium swallow X-ray. This can be done with minimal radiation to the baby and confirms normal anatomy.

A feeding expert can be very helpful in teaching the infant proper swallowing habits to ensure normal nutrition and growth. My recommendation is to bring your concern to your baby doctor's attention. Be sure the baby's weight is doing well according to your doctor's growth measurements. Take note of how often your baby urinates and poops and share this information with your doctor. Expect to see the doc every few days until the issue is resolved and good growth is confirmed.

If you are offering your baby cow's milk, please do discuss this with your doctor. Cow's milk is perfect for baby cow's, but not for little humans. I recommend this information to you:
1]
https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/The-First-Month-Feeding-and-Nutrition.aspx
and
2]
https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Signs-of-Feeding-Difficulties.aspx
and
3]
https://www.healthychildren.org/English/ages-stages/baby/formula-feeding/Pages/Forms-of-Baby-Formula.aspx
and
4]
https://www.healthychildren.org/English/ages-stages/baby/formula-feeding/Pages/Why-Formula-Instead-of-Cows-Milk.aspx

Best regards,

Dr. T

The answer is yes, although this is unusual. More typically, appendicitis progresses steadily with central tummy pain around the navel changing over hours to days to severe pain in the child's right lower abdomen (your left side facing the child), very poor appetite to no appetite, vomiting, fever, and a sick looking child. Uncommon presentations of appendicitis in a child can include diarrhea, back pain, chest pain/cough, bladder/urinary pain, and even left-sided lower abdominal pain, depending on where the tip of the child's appendix is located internally - rectal colon, ascending right-sided colon, near the diaphragm, bladder, or left side of the pelvis. With increasing irritation to the lining of the abdomen, the peritoneum, the child will have tummy pain when walking, hopping, coughing, and riding in a car when the car jostles hitting potholes, and such. The child will often walk hunched over grabbing the tummy at this stage.

When you ask if appendicitis can come on slowly in your 8-year-old, I presume you might be asking can lingering tummy ache in an otherwise well-looking child be appendicitis. Again yes, although in my experience this is unusual. A more common explanation for lingering tummy ache in an otherwise well child is constipation, especially if this pain is intermittent. A good appetite almost always is a clue against appendicitis as are episodes of wellness between tummy aches.

Other important causes for lingering, intermittent tummy aches can include bullying, abuse, and other subtle and hard to recognize psychological stresses.

If your child is well with lingering or intermittent tummy aches, you will need the help of a physician and an examination to figure this out.

Best regards,

Dr. T

Hello,

"Can anxiety cause stomach pain in kids?" Yes, of course. However, stomach pain is very non-specific and can be caused by a large variety of conditions. If this is a long-term issue lasting more than two weeks, you will need the help of a physician to figure this out. The age of your child and the pattern of the stomach pain is a very important clue. You may want to keep a symptom diary to include the time of day of pain occurrence, the intensity of the pain according to the child on a scale of 1 to 10 with some descriptive adjectives (if possible by the child) of the pain, e.g., burning, sharp, achy, cramp, lightening, dull, etc., the location of the pain, how long it lasts, the relationship to meals, what makes it worse, what makes it better, etc. It's important to know if the pain occurs overnight, especially if it wakes the child.

Observing the child's poop prior to flushing down the toilet would be wise. Is it large, hard, loose, abnormal color, etc. The child may not want you present while pooping, but it should not be embarrassing to your child to have you view the poop prior to flushing.

You also will want to record a typical 3-day record of your child's diet for the doctor's review. Now, you probably know that intense pain in the child's right lower abdomen could be appendicitis and a visit to the emergency room or urgent care would be wise, but intermittent recurrent stomach aches of mild to moderate intensity can be evaluated by your child's doctor.

To evaluate the role of anxiety as a cause of stomach pains, a conversation with your child's teacher could be helpful. Ask a general question and be prepared to simply listen to the teacher's feedback. Also a gentle inquiry of your child about his social situation, bullying, texting issues and even sexting might prove revealing. If your child has a cell phone, reviewing the phone history could be helpful. You can explain that parents have the legal right to do this if needed.

Look for patterns. Stomach pains on school days but not on weekends or holidays is very suspicious for school anxieties. Be aware of test grades and homework grades.

The fact that you are asking the question if anxieties can cause stomach pains is highly relevant that you think it's a possibility. A sensitive conversation between parent and child could be very revealing. A question like, "If you had a magic wand, what one thing would you change about your school day?" could prove a good opener to a meaningful conversation.
I hope this information helps.

Regards,

Dr. T

Hello,

In response to your question, "what causes baby throat infections," the simple answer is viruses. Babies do not get Strep throats. Possibly they can get rare conditions such as Diphtheria or HIV (acquired from the birth canal) although infant immunization almost always prevents Diphtheria and protected sex and prenatal screening can prevent HIV. Viruses are transmitted in the usual way via saliva mouth to infant face, or mouth to hand to face, or other respiratory fluids from nose or airway between individuals. In general, covering one's mouth with one's elbow when coughing, and hand washing or hand sanitizer can prevent such spread.

Detecting a "sore throat" in a baby is not always easy. Painful swallowing or refusal of feedings could be a sore throat. Usually, there are other viral symptoms in addition, e.g. runny nose, weepy eyes, cough, congestion, and sometimes fever. If there is a voice change, this usually represents involvement of the vocal cords or tonsil enlargement. A baby can be hoarse with or without a sore throat. A parent usually can tell if their baby is ill and advice from a physician or nurse is needed even if the parent is uncertain if the baby has a sore throat. Your doctor wants to know what you observe that makes you feel your baby is ill. Telling your doctor that your baby has a sore throat is often misleading, but mentioning that the baby cries with swallowing or winces in pain, or rejects feedings is much more meaningful. I recommend that parents visit the family website of the American Academy of Pediatrics for general advice and answers to common quiestions_www.healthychildren.org.

Dr. T

Hello,

The simple and straight answer to your question "does a flu shot weaken the immune system" is no. This vaccine and all vaccines exercise the immune system. In other words, vaccines cause the body to create antibodies to components of germs but not the actual living germ itself. The flu shot does not contain living flu germs (viruses) but only components of the flu virus to stimulate the immune system to make antibodies just like the flu virus does when the living virus enters the body, but without causing the disease influenza. The immune system is not weakened; it is activated. Hundreds if not thousands of germs enter our body every day, activating our immune system's defenses. If this were not the case, we would not survive but a few days without a functional immune system. Our immune system is never inactive. It is "looking out" for us every moment of every minute or every hour of our lives.

Regards,

Dr. T

Hello,

In answer to your question "how effective is the flu shot," I can say that it is effective enough to keep most people out of the hospital and intensive care units and off the ventilator. Over recent years, the flu vaccine has proven about 50%-60% effective in preventing influenza illness, but much more effective in preventing serious illness. So, after receiving a flu shot, even if one gets the flu, it is usually much milder than what would have been if one did not get the vaccine. This COVID-19 year we are very fortunate to have minimal influenza in most communities due to the great majority of the population wearing face masks, social distancing, and washing hands or using hand sanitizer appropriately. Better to have gotten the flu shot and gotten mild flu, than to never have gotten the shot at all.

Dr. T

Hello,

"What are the symptoms of viral fever in kids?" An interesting question. Doctors have been looking for decades for clinical symptoms to reliably distinguish viral fever from bacterial fever in order to know how to advise families and whether to treat with antibiotics or not. Treating viral illness with antibiotics is useless and fraught with risks. Diagnosing viral illness in kids from symptoms alone is highly dependent on professional judgment and experience. Sometimes a laboratory test is needed. For example, a sore throat might be caused by any number of viruses, but a bacterial sore throat - a Strep throat - requires a throat culture for a certain diagnosis. A throat culture involves swabbing the back of the throat with a Q-tip and sending the specimen off to a laboratory or doing a rapid Strep assay at the time of the pain visit. A Strep throat requires treatment with an antibiotic. A viral throat infection does not.

Having pointed out the value of judgement, there are symptoms associated more with viral causes than with bacterial germs. Illnesses with fever associated with cough, runny nose, weepy eyes and are more likely viral than bacterial. Viral fevers usually last no longer than 3-4 days. Needless to say, if a parent has a question about a child's fever, the child's doctor should be called. More information about fever in children can be obtained by visiting the family website of the American Academy of Paediatrics, www.healhychildren.org.

Regards,

Dr. T

Hi,

A good question, but one that needs some clarification." A five year old with high fever." First question: what is high? Answer: a high fever is one over 103 or 103.5. Second question: how does your five-year-old feel with this fever? He/she is allowed to feel tired, but should not feel bad, e.g., headache, body aches, other pains. In addition, the child should be lucid and aware when awake and have some appetite and thirst. Since your child is 5 years old, no only do you have your powers of observation to inform you, your child has language to share with you how he/she feels. In modern times, we understand that fever is part of our immune system's armamentarium to fight infection. Fever combats viral infection, but physicians and parents do not want children to suffer. I hope that you would agree that feeling tired is not suffering as defined above.

But to answer your question, here are some home remedies to fight fever based on basic physical principles of thermodynamics. Don't over-insulate the child. Only a light sheet and/or light blanket. The process of evaporation of liquid from the skin carries away heat, so a tepid sponge bath periodically can permit evaporation and fever reduction. No cold water or ice water baths because too rapid heat loss can result in muscle tremors and body heat production. No alcohol bath because of a danger of alcohol absorption and toxicity and precipitous cooling with subsequent tremors and heat production. Just in case it's not obvious to my readers when you choose to perform a tepid sponge bath, the water should not cover the child's legs. Remember a sponge bath works by evaporation, so the more skin exposed to the air, the better.

Now, as for home remedies, meaning medications by mouth, I can only recommend acetaminophen or ibuprofen as recommended by your child's doctor. In my opinion, you cannot expect other ingested compounds to directly benefit fever. You will have to worry about toxins and product purity. Over-the-counter fever treatments other than acetaminophen, ibuprofen, and other NSAID products, like Naprosyn are not FDA inspected or monitored. Let the buyer beware.

Lastly, it's important to remember that fever is a symptom and not a diagnosis. Your child's doctor during the first 5 years of his/her life should have educated you as to when a fever might represent a more worrisome condition than a mild common viral illness. Fever that lasts longer than 3-4 days should be evaluated by your child's doctor by phone or by visit. Hopefully, your child has had all the recommended childhood immunizations through age 4 or 5 years making fever much less likely to represent a serious bacterial (pneumococcal, Haemophilus influenza type B, Whooping Cough, Diphtheria) or serious viral illness (Measles, Chicken Pox, Rubella). An unimmunized or partially immunized 5-year-old should see a physician for proper evaluation and advice.

So in short, your simple question is not so simple after all. I hope his information has proven helpful. I would also like to direct you to the family website of the American Academy of Pediatrics, www.healhtychildren.org. Their search window is extremely user friendly.

Marc Tanenbaum