Earlier this year there was a massive Tylenol recall. The recall included Infant Tylenol drops, Children’s Tylenol, as well as many other children’s medications. I’m not exaggerating when I say massive, but generic medications (liquid acetaminophen made by Walgreens or CVS, for example) were not included. The recall was a great reminder that generics are just as good as brand-name medications.

The recall also serves as a great reminder that giving medications to children is never risk-free. Recalls like this remind us to use medications only when absolutely necessary. There is always risk when you intervene.

Tylenol (acetaminophen) is a great medication. It has a place in our medicine cabinets and in keeping children comfortable in the face of fever or pain. Teething, viral infections, ear infections, and minor injuries are great times to use Tylenol. But prior to shots is not. Or afterward, as it turns out. After shots, Tylenol will help prevent fever, but may also prevent the desired immune response. There is new data to support this that has changed the way I think and counsel families about Tylenol. Now when parents ask, I say,”If it were my child, no Tylenol before shots.”

Fever is a “normal” immune response to a trigger (medical school and residency taught me this). But being a mom has certainly shown me that fevers in my babies don’t feel “normal.” When we pediatricians say it’s “normal,”we neglect to connect with the experience of parenting a feverish child. I understand why so many parents reach for the Tylenol. I did; after F’s 2 month shots, he developed a low-grade fever and cried his little face off. I gave him Tylenol twice that night. I wouldn’t have, had I known this:

Fever is a part of the body’s natural inflammatory response to infectious triggers (viruses or bacteria). And to shots. Scientifically speaking, post-shot fevers demonstrate the immunization given is working!

So what if giving Tylenol (a fever-reducer) reduces the immune system’s response? Some Czech Republic doctors wanted to find out.

They published their findings in The Lancet. They wanted to evaluate a baby’s immune response after the standard 2 month-old immunizations. Researchers sorted babies into two groups, one in which the babies received the 2 month shots, and another in which the babies received the 2 month shots and then received Tylenol every 6-8 hours afterward for 24 hours. They looked at the outcomes of fever in both groups and observed the desired immune response (blood tests) in all babies. Since shots are given to trigger the immune system to remember a particular insult, if the baby’s immune system doesn’t respond and develop antibodies to the vaccine, the shot isn’t as effective. They wanted to know if Tylenol dulled the effect of the shots.

The Study Results:

High fever over 39.5ºC (103ºF) was uncommon in both groups (≤1% of all infants).

Low-grade fever around 38 ºC (100 ºF) was very common (in 42% of infants receiving Tylenol, and in 66% of kids without Tylenol).

Babies who received Tylenol had a reduced immune response. The study found antibody concentrations were significantly lower in babies who received the Tylenol compared with those who didn’t. This was true to all vaccine types tested. Even after booster shots later on (at 4 and 6 months, for example), the lower antibody concentrations existed in the group that originally got the Tylenol for 3 different vaccines.

Powerful stuff. The fact is, fever is a common and expected response after immunizations and shots. Tylenol will help prevent fever in some, but may also prevent the desired immune response. This study found that around 1/2 of all 2 month-old infants (42-66%) had temperature elevation in the first 24 hours. Most babies tolerate temperature elevation without complaint. Others may be sleepy, cranky, or decrease their feeding. Although Tylenol will reduce the likelihood that your infant has a mild temperature, this reduction in inflammation may reduce the effectiveness of the shot.

Mama Doc Tips: How To use Tylenol After Shots:

Never give Tylenol before shots. You may decrease your baby’s (or child’s) immune response to the shot for no reason. It’s okay for your baby to have a fever. It’s a safe and normal response to immunization.

Think about using Tylenol only when necessary. If your baby seems remarkably fussy, uncomfortable or has a high fever (over 103ºF) after shots, consider using Tylenol. If your baby or child has a low-grade temperature (100-101 ºF) after shots, avoid using Tylenol as it may interfere with the immune response.

Fever is “normal” but unsettling. Talk with your child’s pediatrician about ways to support your child when they have a fever.

There is a lot of information (and opinion) about how to get your infant to sleep through the night. Cry it out/don’t cry it out, rocking/no rocking, co-sleeping/crib sleeping, white noise/no noise, breastfeeding or bottle-feeding. Everyone has an idea about what works. Like I said earlier, there is very little data to support one technique over another.

Auspiciously, there is new data that may help us know what NOT to do. Researchers found 3 things to avoid while helping your baby learn to sleep through the night.

A new study refutes an urban legend: feeding rice cereal keeps babies asleep.

The findings may also help us understand how to improve our home environment to ultimately improve infant/toddler sleep. Researchers in Boston followed over 1600 mothers until their babies were 2 years of age. They evaluated the amount of sleep babies got at 6 months, 1 year, and 2 years of age. Study results included:

No rice cereal before 4 months.  Feeding rice cereal early in infancy doesn’t help babies/toddlers sleep longer. Many parents hear that rice cereal will satiate a baby to the point that they’ll avoid overnight feeds. The study found babies who were fed rice cereal before 4 months of age slept LESS. I recommend no solids until about 6 months of age. Not because rice cereal is necessarily harmful, rather it likely isn’t helpful and what’s the rush? Wait until the baby is able to sit up independently, then give it a go.

No TV. Research (and instincts) tell us television isn’t good for infants & toddlers. In this study, babies who were placed in front of the TV, slept less at age 1 and 2 years of age. The AAP recommends no TV until age 2. Some families find that impossible. Whatever you do, this study may encourage you to wait until your baby is sleeping through the night.

Avoid depression. Postpartum depression was associated with less sleep in babies and toddlers. Nearly 80% of women who give birth have the “baby blues,” but some women go on to suffer from postpartum depression. Prompt diagnosis and help can improve a mother’s enjoyment of the baby, her suffering, and the baby’s sleep. If you’re worried about your mood or sadness, or another mother’s mood, you can get help. Postpartum depression can be treated. Call the doctor for an appointment to discuss. Or talk with your infant’s pediatrician. It’s always okay to ask for help.

Also, two wildcard non-issues: breast-feeding (versus formula) & maternal smoking seemed to have no effect on sleep duration in the 1 and 2 year-olds.

There you go, the anti-advice. Just 3 things to try not to do. All in the never-ending quest for a good night of sleep.

I keep saying less is more. So often, with children, the less we do, the better. Pediatricians often pride themselves on being smart enough to know when to do…..nothing.

Take pink eye, for example. You know, the gnarly ooey-gooey, eyes-sealed-shut-yellow-crusty-”sleep”- in-the-eye that never goes away? The highly contagious infection where your child looks uber-crummy and straight-up, infectious? When it happens, you create a self-imposed lock-down-blinds-drawn-cancel-all-plans-covert-stay-home and watch a movie to hole-up the contagion. You or your child may want to hide from the world until it improves.

In my practice, pinkeye is one of the those infections that inspires me to wash my hands over and over and over again.  It is really contagious. And the best thing you can do when you see a glimpse of it, anywhere, is wash.your.hands.

So you haul in to see your pediatrician. Question is, what does your doc do for your child? School is asking for a note to come back and you’re there for a quick-fix thinking, “Just give me something to make this go away. And fast.” And like always, it depends on a number of things.

Your pediatrician will want to determine if the “pink eye” is caused from a bacterial or a viral infection. Studies vary but as a general rule, up to 50% of infections can be viral. So not all need antibiotics. At a glance, it can be hard to tell. Doctors use the history they take, the other associated symptoms (runny nose, cough, fever, ear pain), and the duration of symptoms to guide them. But without a culture, sometimes it can be difficult to know if a child needs antibiotic drops. And we hate to give antibiotics when we really don’t need them. Doctors can turn to some new research to help.

The study was recently published in Archives of Pediatrics and Adolescent Medicine.

The intent of the research was to help pediatricians identify viral infections over bacterial. And ways to avoid unnecessary intervention (antibiotics).

4 Ways To Know Your Child Is Less Likely To Have A Bacterial Eye Infection:

• If the child is over age 6 years old.
• If it’s summer! Bacterial infections were less likely between April and November (translation, less likely to be bacterial in the summer).
• If the child only has watery discharge (not ooey-gooey yellow/green stuff).
• Child is not waking up in the AM with “eyes glued shut.”

Phew. Now you know. This may help you feel better if the pediatrician suggests not to use antibiotics. Good to know while washing your hands…

Less is more.

Celebrating with family and friends is one yummy thing in life even in the face of family dynamics-drama.  I know it doesn’t feel yummy for everyone.  I’m not trying to sound Pollyanna-ey.  I’ve had the dark years of holidays, too.  When the being together made me feel lonelier than truly connected.  But, that’s not where I find myself now, fortunately.  The people in my life who are less than 3 feet tall also decorate these times together and make it better and better.  Who knew you could get so excited about a little, “gobble, gobble.”

The smallest in our family also make holidays more complicated though.  It’s the over the river and through the woods part that can be really tough.

I get piles of questions in clinic about traveling with kids. I wanted to get one thing out there:

If it were my child, I would not use Benadryl on the airplane, car or train to knock my kid out.  I never have and hopefully never will.  Yes, I heard about the 2-year old getting kicked off the Southwest plane in October for being too loud.  I hear you in not wanting to be the ditto on that story.  I know how painful flying can be with a squirming, screaming infant or toddler and the surrounding public.  With F (my first born), we took more than 10 commercial flights in his first year. I remain stunned at how rude the public can be when they feel inconvenienced by flying and sitting around children.  Nonetheless, I still wouldn’t push the syringe full of Benadryl to make it better.

My rationale is part philosophical and part safety based.  Benadryl is a medicine designed to help children with symptoms of allergies.  It’s an anti-histamine (it works against histamines produced by cells in the body as a response to an allergic trigger).  But when you give an oral medicine, it enters the blood stream and has effects all over the body.  With Benadryl, those effects are often on the brain, gastrointestinal system and skin.  One of the side effects from Benadryl is that it’s sedating, hence why people talk about using it for travel.  Crash out, knock out, eyelid closed, tired in some kids. Trouble is the response to Benadryl is inconsistent between kids and can be dangerous.  Children can get dry mouth, stomachache, nausea, vomiting or rarely an allergic response to the med, heart palpitations, rash or other neurologic changes.  And, some kids go absolutely nutty.  A paradoxical (opposite) response, some kids get totally wired and a little crazy on it, too.  The crazy-hyper-nutty is not dangerous, but can be disastrous in a travel setting.

The last place you want to be with an unexpected or undesirable medication side effect is on the airplane at 35,000 feet.

Your pediatrician cannot predict what kind of response your child will have to a new medicine they have never tried.  Period.

The bottom line is this:  we work hard to avoid using medication in children unless they absolutely need it.  Using a medicine for parental convenience is not an indication to medicate your child. I just can’t advise that you put medicine in your child’s mouth for ease of travel or convenience.  Especially since we never know which child (and why) will have side effects.  Side effects to medications represent a huge number of visits to pediatricians and emergency rooms, especially for kids under age 5, as it’s often their first-time exposure to a medication.

Some Points on using Benadryl in Children:

• Benadryl is an anti-histamine, designed to help children suffering from mild allergy symptoms (itchy nose, sneezing, itching of skin, hives).
• Never ever use Benadryl in a child under age 1.  This sedating effect could be more sedating than you would want.
• Using a medication for your convenience is never an indication for medication in a child.
• Some children have a paradoxical effect (opposite from the desired effect) and get wired, hyper and a little nutty.
• Always talk with your pediatrician before giving any medicine (OTC or prescribed) in a child less than 2 years of age
• Some pediatricians may disagree with me and advise you to use Benadryl for travel.  If you decide to use Benadryl for travel, try a dose at home first.  Don’t attempt a new med at the airport or on the plane for the first time.

I’ve been caught in a recurring cloud this week even though the sky has been essentially spotless. It’s been one of those weeks where I find myself spinning around to grab the cup of milk or the steering wheel, muttering, “What am I doing?”

I am back perseverating on how to do this right. Life, I mean.

The issue of balance between work and parenting while trying to contribute to the world and use my skills (read: loaded issue) bubbles up at times. I never quite know what will trip me up, triggering a re-evaluation. But it comes up. Quarterly, let’s say, like state taxes…

There are days I am astonished by my opportunities and the children I get to take care of. And days where I am so delighted by my kids, I cry when I leave for work. And days I question if I have the stamina to endure. Last night by the end of clinic, I was so tired and my eyes so bloodshot (no idea why), that my medical assistant took my temperature. It was normal. But, point is, it happens; I do get really tired.

The real trouble is this: I liked my day in clinic yesterday and the things I discovered: the broken bone I found in a 2 week old, the teenager I helped with depression, the 20+ checkups I completed. But tired and missing my boys, yes. See, this would be far easier if I was only pulled in one direction. It’s not how it works for me; I have tugs on each limb.

The endless tug-o-war between arguments for those that stay at home and those that work while raising kids, goes on and on in my head. Specifically though, the retreat back to this issue of balance between work and home–and my current decision to work (a lot)–was spawned by 4 things:

• A blog post I read, now 2 months ago, has lingered. The post really was about how we all come to our own decisions. Yet the message on Twitter that led me to it said, “Family comes first for some who have finished residency.” The post details how some docs choose to stay home with their children, even after completing rigorous training. The post wasn’t written by the OB/GYN who decided to stay home with her children, rather it was written by a working colleague. I read it just before I headed out for one of my long clinic days where I work well past 8pm. It ruined my day. And I’ve been thinking of it since. My rebuttal, now months and many moons later, would be entitled, “Family comes first for some who have finished residency,” except it would describe what I do, too. See, my family does come first even when I’m at work. (I can get a little feisty)
• Recently, I talked with a friend who is now a stay at home mom. After a whole conversation where my work didn’t come up as we chatted about our kids she asked, “Are you and Jonathan okay?” The tone of the question seemed to imply pity for my circumstance of working while raising our boys. I was taken back. See, we were, we are, we will be okay. We exceed okay. We’re ecstatic about our lives and opportunity. The question, gowned in judgment, made my heart hurt and made me question, yet again. Although pity is possibly not what she implied, it’s how I took it and how I remember it. And its lingered.
• For the last 2 weeks, while I am writing and working in my office (at home), I’ve been overhearing O downstairs playing. He’s 20 months and his language is launching, rocket style. In tough moments (you know, like wanting a toy) he’s been instantly calling out, “Mommy!” It takes a lot in me not to go running…
• While on vacation earlier in July, we saw an old family friend. She asked about work–my practice, writing and blogging, etc. I told her how much I was working, quantifying it in hours. Her response, “Does that leave you any time to parent?” Of course it does. It just doesn’t leave me time to sleep. Her comment pierced me. And it lingers.

So I’ve been stuck in this confusing cloud. But today, for the first time in weeks, I got a refreshing new perspective.

It was O’s well child check up this AM. I took the morning off (minus a 7am interview) and spent it with the boys.  I did mom type things, a trip to F’s school, a stop at the park, got the car washed, and went to the grocery. Then O and I sailed into the pediatric clinic for his check up.

O’s pediatrician did his check-up. Then she asked how I was. I launched into the aforementioned topic. I was describing how many people over the last 6 months have warned me. They say things like, “Your boys will only be young once” or “Your boys want you around now but won’t want you around later.” I explained to her how it has me all caught up and spider-webbed. That the comments and quandary have been angst inducing and guilt-inspiring. And how I am always chewing on the fact that no one says this to the husband.

But then, just as I was tearing up and re-entering the cloud, a sunbeam shot through. O’s pediatrician (a mom of three) said, “Oh no, that’s not true. Your boys will always want you around, when they are teenagers and grown-ups, too.” She went on to explain her specifics and rationale. Her experience and her success. And her regrets.

All the sudden the cloud was gone. I was affirmed and understood again. And appreciative she made the decision to go to work.

So I’m off the tug-o-war for a bit. Hope you are, too. See you next quarter.

Raising children in a world full of accessible opinion is a funny thing. Everyone seems to have an idea about how to do this right. Stay home, work full time, work part time, return to work, cry to sleep, not cry to sleep, pacifier, no pacifier…the recipe for each of us is different, of course. Often we’re all right in what we’re doing from picking out baby food to enrolling our child in preschool. But it doesn’t always feel that way when a barrage of comments and advice from relatives, friends, and people in the supermarket hit us in the shins. What people say about how we care for our children hurts far more than salt in a wound. Editorials on our parenting can seriously linger.

Recently I talked with Liz Szabo at USA Today about this issue. She wrote a popular article called, Why do mothers judge one another and their parenting? where she quoted me and a number of other moms & doctors about our experiences. There is a video interview from New Day NW at the end of the post where I discuss competitive parenting, too.

Most people who read it tell me it makes them feel better.

I’m half way through the book Instinctive Parenting by Ada Calhoun. The introduction and first few chapters are mesmerizing. I found myself nodding, laughing, gasping out loud– it seemed she and I were so aligned. She made me feel like we really all can do this perfectly. Armed with instincts, we really can help our children thrive. But then about 10 chapters in it started to feel like even in a book about trusting yourself, not the voices in the news/baby books/neighborhood/playground, she had a story to tell. And something about it felt as if it was instructive, too. Not steeped in judgment, but instructive. As if in parenting, to steel ourselves into trusting our own instincts we may have to believe in the demonization of the other side or opinion. Maybe it’s simply instinctual to feel righteous about how you do it. Maybe it inspires the confidence we all need?

Here’s how I see it:

• Competitive parenting abounds. We all know what it feels like to be judged or evaluated in what we do. Yet, we become righteous towards others when we’re successful in a task/method and feel everyone else should do the same. This makes sense and is how we “get through.” But often there is far more than one “right” way to do things.
• As a pediatrician I see parents for checkups every day I’m in clinic. Every parent has some concern about how to care for, protect, and raise their child. Don’t let other parents fool you; we all have questions about how to do this well.
• Besides a few important safety measures (back to sleep for infant sleep, using car seats properly) most parenting issues have multiple right answers. That is, there are many ways to all of this right. I agree with Ada, trusting your own instincts, not the instincts of others, is the best way to proceed.
• Listening to our friends and family who are raising children may be far more important than telling. Employing a virtual muzzle to stifle opinions might help all of us! As my mother in law said yesterday, “If someone isn’t asking for advice, whatever advice you provide will be perceived as criticism.”
• Often when we become judgmental of other parents, it’s because we’re evaluating our own choices.
• A big debate and source of sour feelings come around the decision to stay home versus work while raising families. This decision and tension is usually more challenging for women.  From the time you return to work (or don’t) from maternity leave, there will be people telling how to do it right.  Only you will know the perfect balance of work and time at home for yourself. Your recipe for balance will likely not be the same of even those you respect or emulate. Often you won’t know what is perfect straight away. Have patience with your decisions; you can always change your mind.

Stumbled upon an article summary last week, “Bad Behavior Linked to Poor Parenting.” I am going to call this BBLtPP. I clicked on the link with butterflies, hoping not to find something like: We’re following a pediatrician with 2 sons, one doctor husband, and one overweight Labrador who live in Seattle. She writes a blog. It’s her parenting we’re worried about…

But I clicked on the link and it didn’t exist; I got an error message. Then again, nothing. Clicked a few minutes later. Nothing. The page on MSNBC for some reason had vanished.

Thank goodness.

I hate seeing reports like this in the media. They propel this myth that there is one way to do this, this raising of child. When American Idol advertised for “Mom Idol” last night, I wondered was Mom Idol going to sing or just win for being the best all-around-rock-n-roll-Mom? I’m certain not to win in both categories. I’m sure I’m doing something wrong. Parent teacher preschool conference next week, so I’ll let you know. But really, what defines ideal motherhood and who is the one doing the defining?

The immense task and joy of raising, loving, feeding, and enriching a child’s life while gaining incredible perspective along the way, seems utterly un-definable at times. Articles like BBLtPP strike deep stomach drops and fear in many of us. I know this. My patients tell me about these types of articles. Then they ask questions like, “Do you feel it’s wrong if I give her peaches before avocados? “ Seemingly basic question but it’s loaded with self-doubt. There is a particular look in their eyes. It’s: “I’m a bad parent, aren’t I?” But their mouth forms the words “a-v-o-c-a-d-o” and “p-e-a-c-h-e-s.”

This idea that there is a right way to parent and a wrong way to parent is nothing I learned in medical school or pediatric residency. Rather, it’s something I’ve learned at the mommy group I went to a few times, or the playground I visit, or via the snide comments I got while feeding my son a bottle of formula in Seattle. The limited and rigorous idea that there is an essentially scripted good way versus bad way to parent needs no further emphasis in the media.

There are safety concerns and gross errors in parenting. I’m not entirely naïve, of course. I have cared for many children who are the victims of the lack of parenting: assaulted children, abused children, abandoned and neglected ones. I am not saying there are no lines in this sand. There really are right (evidence and life saving) ways to have your baby sleep, safer ways to feed and avoid choking, safer ways to play, and safer ways to protect and buckle your child into a car. But those tasks and preventative measures for preserving and promoting health aren’t the essence of parenting.

Parenting is all the other things in between.

The mortar, really. The sticky stuff wedged between all the tasks and lists we check off throughout the day and night with our children. At the risk or sounding all Hallmark, I’d say it’s the really good stuff. Parenting is the consistency, the listening, the remembering. The non-conditional love part. Parenting comes when you enjoy or laugh with your child, when you are respond to their cry, when you remember who they are and how to help them regain their idea of themselves. It’s when you advocate for them in difficult situations. Or in easy ones. When you provide them a trusted and reliable model and space to be. When you provide them a platform to grow and develop. Parenting is grossly individual.

I watch parenting happen every day when I’m in clinic. And at home. It happens all the time. But I still don’t have a manual.

My sons are growing me up, too. Just as they gain inches and pounds, I gain insight, wisdom, and conscience for the world.

Most of us perform constant self-evaluation. The ubiquitous monologue running, “Am I doing this right? Am I a bad parent if I _________?” Rarely, I suppose the answer is yes. More often, no.

We constantly self-monitor, self-reflect and project ourselves against our peers and family, co-workers and neighbors.

Oh, crud. Just tried the BBLtPP link again and it goes through when you hit refresh. The first sentence reads, “Poor parenting causes boys, but few girls, to be particularly prone to bad behavior, a new study suggests.”

Now it’s stacked against me! Good grief. You read it if you’d like, but I don’t think I’ll pick apart the study for you. Instincts on my back, I believe the four of us will find our way in this house. Mom Idol or not, with help from my dear friends and family, I’ll hopefully avoid showing up in the study labeled “bad parent” while F and O grow me up, too.