Drowning is Not Only a Summertime Problem

By Caren Kirschner, M.D.

As pediatricians, part of our goal is to help prevent injuries and fatalities in our patients. Recently, the American Academy of Pediatrics has highlighted new information on drowning prevention. I think it is important to review some of this information with our families.

Sadly, approximately 900 U.S. children die every year from drowning. Drowning is the single leading cause of injury-related deaths among children aged 1 through 4. It is the third leading cause of injury-related death in children aged 5 through 19. It is deadly because it happens quickly and silently.

Most drowning in babies and toddlers occur in bathtubs and buckets of water. Fifteen to 30% of careful caretakers report leaving their children younger than two for a period of one to five minutes alone in the bathtub. Children can never be unsupervised when in or around bathtubs or buckets even for a second. The caretaker should always be no farther than an arms-length away, and other children like siblings should not be left to supervise. In addition, bath seats and rings are problematic because they can tip over when suction cups fail and cause bodily entrapment which can lead to drowning.

During the toddler years, most drownings occur in swimming pools. All pools, whether inground and above ground, need to be surrounded by a four-sided fence. Barrier fences should not have accessible steps or ladders. Portable inflatable pools are particularly worrisome since they generally do not have fences around them and sometimes are filled with water for weeks at a time.

It is crucially important that all children learn how to swim. It has been demonstrated that children age 2 through 4 are able to acquire the skills for swimming and most children are developmentally ready at age 4.5 years. By age 5 to 6 most, children are capable of swimming front crawl. As you may recall from your child’s well-visit, this is an issue we feel is important to discuss.

When children are playing near water of any type, a “water watcher” should be assigned. This person pays constant attention to the children with absolutely no distractions like cell phones. Adults should take turns being the “water watcher.” Many times, parents overestimate their child’s swimming ability. It is important to note that “floaties” and “swimmies” are unreliable and can impart a false sense of security. They can easily fall off or malfunction. When children are in boats, they should always wear a Coast Guard approved life jacket. These have been proven to decrease the amount of boat related drownings.

Welcome Julie Shubert CRNP, CPNP

For patients and their families who have come to the office since April, they may have met our newest nurse practitioner Julie Shubert.

Julie spent her early childhood in the Midwest but went to high school locally at Council Rock in Newtown, PA.  She has dual undergraduate degrees in Economics and Nursing after attending both the University of Massachusetts and University of Delaware. She has worked in research at the Wistar Institute and the Hospital of the University of Pennsylvania.

For the past seven years, Julie has worked for The Children’s Hospital of Philadelphia. In 2019, she graduated from University of Pennsylvania with her Master’s in Nursing and is a member of the National Association of Pediatric Nurse Practitioners. 

Julie lives in Burlington County, NJ, with her two sons and their dog Wrigley. And, yes they are a baseball family. When not working, Julie enjoys spending time outdoors, traveling, going to the shore, attending Phillies games, and of course, Eagles games!

Tips for Getting Your Child to Wear a Mask

By Yuliya Bilan Yu, MSN, CRNP

Current guidelines recommend that all children ages 2 and older wear a mask at school or daycare, or when indoors in other public places to prevent the spread of COVID-19. As a parent of two young children, I understand that it can sometimes be a challenge to get your little one to put on a mask and consistently keep in on. Fortunately, there are some things we can do to make this process a little easier.

Involve your child in making or selecting their mask and make sure it fits comfortably

Your child might be more likely to wear a mask if it has their favorite color, character, or special interest on it. There are many sites online, such as oldnavy.com and etsy.com that sell children’s masks with different patterns. To make the mask more comfortable, especially when wearing it several hours each day at school, consider getting face mask extenders or ear savers. These put pressure on the back of the head instead of on the back of the ears. Another option is using a headband with buttons that the mask attaches on. When choosing a mask, make sure that it fits snugly around the mouth and nose. Gaiters used to be recommended as a comfortable alternative for kids; however, new research shows that gaiters are not as effective in stopping the spread of disease.

Prepare your child for wearing a mask

Consistently keeping a mask on may take repeated preparation and practice.

Talk to your child why it is important to wear a mask and try to make the explanation positive. For example, you might say “Masks help keep us safe from the virus. When we wear a mask, the virus can’t jump from person to person.” You can also make comparisons to other healthy habits in your daily life that help prevent illness, such as handwashing or wearing weather-appropriate clothes.

Point out to your child how you wear your own mask and watch their reaction. Also note how your child reacts to others wearing a mask. Some children might find strangers wearing a mask a little scary. If this is the case, you can show your child pictures of other people wearing masks and talk about it. This will help them see it as more normal and put them more at ease in different social settings. You can also involve your child’s favorite toys and stuffed animals in wearing a mask. Younger children often appreciate a playful approach to mask wearing.

Once your child is comfortable wearing their mask for a little while, try to extend the time while they are engaged in their favorite activity, such as going for a walk or watching a favorite show. It can take some time to adjust to the longer mask-wearing periods and this is normal. If your child feels anxious or uncomfortable wearing a mask for an extended time, teach them relaxation techniques such as taking deep breaths or relaxing all the muscles in their body. Also encourage them to talk about their feelings and concerns.

Consistency, breaks, and rewards

You might find it helpful to set clear rules for your child about when, where, and why they need to wear a mask. Some children understand this better with visuals, such as pictures or videos. Reviewing the rules each time the family goes out could also work.

Young children often need frequent breaks when wearing a mask. Talking to a child about breaks ahead of time can help them keep the mask on for the expected timeframe. For example, you might say, “We are going to keep our masks on at the store while we get a few grocery items and after that we will go outside and can take off our masks.” Staying well hydrated is also important in preventing illness, so let your child know it is ok to take off their mask to quickly drink some water when feeling thirsty.

For many children, rewards can go a long way in getting them to wear a mask. Let your child know what they can earn for doing a good job in keeping their mask on. You may need to set this up ahead of the outing or bring something with you that could be given as a reward.

For more resources and information on masks, check out:

https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html

https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Cloth-Face-Coverings-for-Children-During-COVID-19.aspx

Meningitis B Vaccine Recommended for College Students

By Timothy Flynn, M.D.

In the past decade there have been at least 14 outbreaks of a particular bacteria called serotype B Neisseria meningitidis (meningitis B) on college campuses throughout the country.  These outbreaks tend to be relatively small, but young adults who become infected can become critically ill and some suffer long term health consequences or even die. Students who live on campus are most at risk for getting sick. The meningitis B vaccine is required by one local college and recommended by several others in the Philadelphia area. 

It is important to realize that the meningitis B vaccine is different than the meningitis vaccine that children get at ages 11 and 16 years old. The vaccines are different and the childhood vaccine does not protect young adults from the type of bacteria that causes these outbreaks. 

If you have questions about the status of your child’s vaccinations or to schedule a meningitis B vaccine please call our office. 

Treating Depression in Kids and Adolescents

By Caren Kirschner, M.D.

Over the last several years, we have been screening all of our adolescent patients for depression with a validated depression screen call the PHQ-9. It is not surprising that a large proportion of our patients screen positive. The rates of pediatric and adolescent depression have been increasing over the last decade. Unfortunately, the pandemic has only intensified this trend.

Our kids are dealing with so many overwhelming stressors, including the deaths of family members or friends, parental job loss/financial strain/poverty, social isolation, and school and extracurricular disruptions. These stressors may trigger depression under certain circumstances.

Depression is a mental health illness that can be no less painful or difficult as many physical illnesses. It affects all aspects of a child’s social, behavioral, educational, and physical well-being and development. And most devastatingly it can be associated with suicide.

The good news is that depression is very treatable.

There are numerous evidence-based studies that show that most kids who are treated effectively can achieve remission. The two evidence-based therapies include psychotherapy and medication. For example, The Treatment of Adolescent and Depression Study (TADS) looked at 439 adolescent aged 12-17 over 12 weeks diagnosed with depression. Those treated with medication and cognitive behavior therapy (CBT) had a 71% recovery rate. The patients treated with medication alone had a 60.6 recovery rate vs CBT alone of 43.2%. The placebo group only had a 34% recovery.

In general, there is a lot of misinformation spread about mental health and its treatments. We understand that parents are concerned about having their children taking certain medications. The truth is that there are excellent studies that have shown that many medications we use to treat depression are safe and extremely effective when prescribed appropriately and in conjunction with psychotherapy.

Both Dr. Flynn and myself have both undergone training at The Reach Institute. This is an organization that serves to give pediatric primary care providers intensive specialized training in the diagnosis and management of mental health care. Please schedule an appointment with us if you have concerns about your child’s mental health so we can work together to get them the care they need.

Returning to Sports after a COVID-19 Infection

By Timothy J. Flynn, M.D.

Coronavirus affects people of all ages. Most children who are infected have mild symptoms and recover completely. However, some children can get seriously ill or may have symptoms that persist for a prolonged period of time. For example, loss of taste and smell can persist for months in some cases. Although uncommon, some children will have a feeling of shortness of breath that persists for weeks even after the infection is otherwise gone. 

One area of ongoing investigation is the possibility that COVID-19 may affect the heart, possibly by causing myocarditis, an inflammation of the heart muscle tissue. Certain viruses can cause myocarditis in children. It is possible that COVID-19 affects some children’s heart muscle either by causing myocarditis or some other problem. 

Research into the effects of COVID-19 infection in athletes is still in the early stages; however, based on what is known so far, preliminary guidelines have been created to help medical professionals decide when athletes infected with COVID-19 can return to play. Everyone with a positive COVID-19 test should refrain from exercise for 10 days. Further evaluation is generally not needed for children who had no symptoms or fewer than 4 days of fever. Children who had more serious or prolonged symptoms (including 4 or more days of fever) should see a doctor to discuss if more testing is needed and to create a return-to-play plan.

Is My Child Ready for Potty Training?

Child on potty
Yumi, Yuliya’s daughter, is within the age range when most children begin to learn to use the potty.

By Yuliya Bilan Yu, MSN, CRNP

You might be wondering if your child is ready to start potty training or if there’s a “right age.” No two children are alike, and rather than going by chronological age, it is best to look at different signs of readiness, such as being able to:

  • follow simple instructions
  • understand and use words about using the potty
  • make the connection between the urge to pee or poop, and using the potty
  • keep a diaper dry for 2 hours or more
  • get to the potty, sit on it for enough time, and then get off the potty
  • pull down diapers, disposable training pants, or underpants
  • show an interest in using the potty or wearing underpants

Most children begin to show these signs between 18 and 24 months of age, but some might not be ready to start until after their second birthday or later. Complete toilet training, that includes both daytime and nighttime dryness, as well as bowel control, might not be achieved until 4 years of age. Meanwhile, the process itself can take anywhere from a few months to over a year, so it is important to be patient and try to maintain a positive attitude.

There are different approaches to potty training, with some parents preferring to keep children in diapers or pull ups in between attempts to use the potty. You can start this method by having your child get his or her diaper changed while sitting on the potty and talking about the experience. While your child sits on the potty, praise him or her or engage in a fun activity, such as singing or reading books together. Your goal is to create a positive association for the potty. So if your toddler is resisting this part or the experience is turning out to be stressful, he or she might not be emotionally ready yet, so it is best to take a break for a few weeks before trying again.

Child on potty
Leanna, our MA Jen’s daughter, is encouraged to use the potty at home.

Other parents prefer to discontinue diapers altogether and use cloth training pants or have the child wear real underwear, with the idea that having a sensation of wetness can help increase awareness of urination. In reality, at some point you’ll likely be somewhere in between the two methods. Your choice of an approach largely depends on your family’s preferences and your child’s personality. Regardless of the method of potty training, it is important to never shame your child for having accidents or mishaps, and you should be on the lookout for any possible discomforts that could arise with this change in their routine, such as constipation. A diet with plenty of fluids and fiber, such as fresh fruits and vegetables, will help keep your child regular and make potty training a more positive experience. Another point to keep in mind, is that your child’s feet should be well supported, with knees higher than the potty or toilet, to allow for a comfortable bowel movement.

While potty training might seem like a challenging journey, keep in mind that, as with other skills, your child will one day master it. Should you have any questions or concerns in the time being, we are here to help guide you through the process.

COVID-19: Thoughts and Observations from a Pediatrician

By Caren Kirschner, M.D.

It has been over six months since the COVID-19 pandemic has cruelly hit our community and completely changed all of our lives in both big and small ways. We have all experienced repercussions of this virus in countless ways. The effects have been scary and sometimes devastating.

  • Some of our patients have contracted the virus, but thankfully recovered.
  • We have had heart-breaking discussions with some of our patients who have lost friends or loved ones way too soon.
  • We have had telahealth visits where we have seen sick relatives suffering in the background.
  • Some of our parents have lost their jobs or had to resign due to loss of childcare.
  • Our patients’ entire educational system has been drastically changed with little planning.
  • Our kids have had to forgo so many special events including birthday celebrations, graduations, proms, entire high school sports seasons, plays, dances, musicals, and concerts.

The list goes on and on. And sadly, all of this and the need for our kids to socially distance from not only their friends but also their family members has led to a significant increase in incidences of anxiety and depression.

I believe it is important to acknowledge all of this and outwardly recognize how difficult this pandemic has made life over the last year.

But through all the heartache, we have also been incredibly impressed and humbled by the amazing resilience and fortitude of our patients and their families. We have so many parents who have been the frontline workers keeping us healthy, safe, fed, and functional at their own risk. Just this week, I had a long talk with a parent who heroically took care of multiple COVID patients in a hard-hit nursing home, at great cost to her physical and mental health.

So many of our adolescent patients have continued their part-time jobs at supermarkets, pharmacies, nursing homes, restaurants, and camp/childcare positions without ever taking time off. They worked but then came home to quarantine, missing the normal social gatherings of teenage life. This is not easy, and they have no idea how amazing they are.

And when I ask most of my younger school-age patients how school is going, the majority respond that it is going well. They love their teachers even if they only get to see them on computer screens. They are making the best of it, and that in itself is inspiring. And even our youngest patients have made us so proud. I can not express how much love we feel when we witness one of our three-year-olds walking into the exam room proudly (and correctly) wearing their favorite face mask. They too are heroes for this by keeping us safe.

We want to truly thank all of you for continuing to trust us in caring for your kids during these unprecedented times. We promise to continue to strive to provide the safest possible environment in our office in order to provide the best possible care.

Unfortunately, the pandemic is not over. In order to ensure the safety of our patients and our staff, we will continue to require that everyone in our office over the age of two wear a face mask properly — covering your mouth and nose.

And when not in our office, we strongly recommend that everyone wears a mask when they are with any non-household members and can not maintain a six-foot distance. It is important to follow the CDC recommendations of social distancing and avoid crowds. We all need to continue to practice good hand hygiene and avoid touching our face as much as possible. None of the recommendations are easy, but they are critically important in order to protect ourselves, our families, our friends, and our community at large.

Lastly, it is also still important for our kids to stay home if they are ill. We will continue to see our patients when they are sick at designated times or via telahealth. We are now able to perform rapid COVID testing under certain circumstances. We can also send the more sensitive PCR swab to an outside lab. Depending on certain factors, we may decide it is best to send patients to an outside hospital for drive-through testing. It is important to know that a negative test can not definitively rule out an infection with COVID-19. That means that if your child is ill, we may still recommend your child quarantine for 10 days even with a negative test, especially if we can not find an alternate diagnosis and/or there is a known exposure. Please know that we do not make these decisions lightly, but we are obligated to follow the public health guidelines.

We wish you, your families, and friends continued good health.