Office Update

Office Update

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As I return to work after maternity leave, I have made the decision to consolidate my Vancouver and Richmond offices. I will continue seeing patients solely from my Richmond office as of January 3, 2022. This will allow me to better manage the needs of a growing family as well as those of my patients.

My Vancouver office patients will have the option to continue seeing me if they wish from my Richmond office. To do this, please contact my Richmond office and let my staff know that you were previously seen at my Vancouver office and they will be able to book you in for our next appointment.

The Picky Eater! How Do I Get My Child To Eat Healthy Food?

The Picky Eater! How Do I Get My Child To Eat Healthy Food?

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The Picky Eater!  How Do I Get My Child To Eat Healthy Food?

Most children demonstrate a certain level of food pickiness.  It is often a demonstration of power and control as opposed to a true distaste for all vegetables, all green foods or anything that looks funny.  Generally, as a parent ensuring your child is fed, full and happy provides you with a sense of maternal/paternal satisfaction.  The trouble is, children are smart and do realize that with their desire for control and your desire to keep them fed and full, they can BECOME picky eaters.  Often picky eating starts around 2 years of age, when children learn the word “no” and start to demonstrate preferences and the need to control their surroundings.  Children understand that they have full control of what they put into their mouths to eat and will use this as a method to demonstrate their desire for control.

So, how do you make your picky eater, eat?  These rules for meal time should apply to all children to create healthy eaters.  The first rule to remember is, in healthy children they have an innate ability to follow their own cue for hunger and fullness.  It is important to allow them to follow those natural cues when it comes to eating.  Children that over eat or are able to eat beyond fullness are shown to become unhealthy eaters as adults with an increased risk of obesity.  To make a healthy eater,

  1. Give your child a 15 minute warning before mealtime. If you tear them away from the immaculate Lego tower they have been building for 2 hours to eat dinner, they will get very upset and will not eat their meal because their focus is elsewhere.  Give them a warning so they can slowly transition to meal time and away from their current activity.
  1. You are in charge of the quality of the food you provide your child, but they are in charge of the quantity. Their portion sizes and the food that is put on their plate is up to you (and guided by Canada’s food guide) but once the plate is in front of the child, they are allow to eat as much or as little of the food that is on their plate as they desire.  Keep in mind, with the appropriate portions, your child should not get full on just the pasta, or just the bread, it should take the ENTIRE plate of food for them to get full.  They should also not get seconds until they finish what is on their plate.  This will ensure they maintain a well-rounded diet and don’t simply eat the pasta and continue to get servings of pasta despite the broccoli sitting on the plate.
  1. There should be no punishment or rewards for mealtime. Children should not be told that if they finish their meal, they get dessert or if they take just 2 more bites that they will get a prize.  Meal time should be learned to be a daily activity and not something your child has to do to win a treat.  If they learn that a treat comes after eating then that promotes the idea that meal time is a chore or an undesirable activity.  In turn, children should not be punished for not eating a certain food or not finishing their plate.  If they are punished, that will make them less likely to eat happily at the next meal and again, meal time is to be a learned daily activity and hopefully an enjoyable one not a chore.
  1. Children should be given 20 minutes to eat their meal. This is adequate time for the hungry child to eat an adequate amount of food to promote growth.  Meal time should not be prolonged as this promotes lazy eating habits and often after 20 minutes, the remaining time is with a distracted child and a parent that is trying to convince their child to eat the last few bites of food.
  1. Children should eat all of their meals at the dinner table with the family. Meal time should be a social and enjoyable time.  Children learn good eating habits through example and by making meal time social, this will promote healthy eating habits.
  1. Children should not be distracted by toys, iPads or television during meal time. If a child is distracted while being fed their food, they will not consciously understand that they are eating and will not follow their cues of hunger and fullness.  This behaviour will promote unhealthy eating habits and often creates an even pickier eater.
  1. Do not make special meals for your child. They should eat what is made for the rest of the family.  Be ok with your child not eating very much or anything at all at some meals.  Remember, your child is in charge of the quantity of food they eat off of their plate.  If at one meal, they are refusing to eat anything then allow them to sit for the allotted 20 minutes, do not punish them or offer rewards and once the 20 minutes is up, allow them to leave the table and go play.  The child will come back asking for food in 1-2 hours as their hunger cues kick in and at that time, the same rules apply as listed above and a healthy food option should be provided again.  A healthy child does not have the will power to starve themselves and so allowing them to feel hunger for a few hours before they finally eat the food provided will not harm their growth in any way.

The key to a healthy eater is to promote their ability to understand hunger and fullness while at the same time, sticking to basic rules of meal time behaviour and choosing quality food for your child.  A picky eater does not have to be a picky eater for very long.

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.

Constipation – What is concerning? Why are so many kids constipated?

Constipation – What is concerning? Why are so many kids constipated?

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CONSTIPATION – What is concerning?  Why are so many kids constipated?

Constipation is a very common issue amongst toddlers.  Being a picky eater and loving carbohydrates, bananas, apples and milk is a very common trend in this age group.  This diet, however very easily causes children to become constipated.  Constipation is defined in a variety of ways, however in general terms if the stool is hard, the child is straining (pushing very hard while stooling), the child is in pain while stooling, the child is stooling infrequently (every 2-3 days) then they are constipated.

Constipation is a difficult issue to manage as many toddlers and children are very picky eaters making it difficult to get them to eat less constipating foods.  It is important however to get a good handle on their stooling pattern as constipation can become very difficult to treat if it is present for a long time.  Chronic constipation can lead to:

1) Dilatation of the rectum/lower bowels which causes a loss of sensation for the need to stool;

2) Further worsening of the constipation due to retained stool;

3) Overflow diarrhea (when liquid stool from above passes around the retained hard stool and comes out); and

4) Occasional accidents

The first step towards dealing with constipation is dietary management.  A diet rich in fibre and water is the main step towards improving constipation.  Generally foods that are non-constipating are fruits and vegetables.  There are a few fruits to be aware of that are constipating.

Bananas and apples in particular are constipating and often these are the two most loved fruits among kids.  With the picky eater, you can often offer a smoothie in the mornings rich in fruits and vegetables to try and increase their intake.  Putting some prunes, or prune puree into this smoothie is also very helpful for constipation.

The next step is to have a regular stooling routine.  Make your child sit on the toilet for 10 minutes at the same time every day to allow them adequate time to attempt a stool.  It is often best to schedule this time after a meal as your bowels are pushing food along after a meal and this helps with the process of stooling.

There are over the counter medications that can help soften stools for your child.  Talk to your medical professional for information regarding these medications as not all of these are safe or suitable for kids.

The goal for your child is regular, daily, soft, non-straining, non-painful stools.  I often tell parents that poop should be soft like toothpaste.  i.e. It has a shape when you squeeze it out of the tube, but it is soft and pasty in texture.  If your child has been constipated chronically (for a few months now), then it will take at least 6 months to retrain the dilated rectum/bowel back to its original state.  This means maintaining 6 months of regular, soft, non-straining, non-painful poops through diet and other means.  If there is even 1 day in that 6 months of a hard or infrequent stool, then that 6 month count restarts.

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.

For The 12 Month Old

For The 12 Month Old

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FOR THE 12 MONTH OLD

Your child is a whole year old now!  At this point they are starting to be able to walk a few steps independently.  Watch them carefully though, as this new mobility could lead to an increased risk of falling into things.

They will now start saying a few actual words like “mama” or “dada” or “baba” (to ask for the bottle).  Many parents will talk about their baby’s first word and associate it with a definitive date or time that it happened.  However, it is not uncommon for parents to not know when their baby said their first real word.  This is because babies will often start babbling nonsensically at 7-9 months with “mamama” or “bababa”, etc.  However, real speech is generally considered to occur when a child says words predictably, and with purpose and meaning.  So if your child says “mamama” to pillows and pieces of furniture, chances are those are not real words.  You will know when they actually are calling for you with “mama” and “dada”, when they only use those words to refer to you rather than stuffed animals, vacuums, and other inanimate objects.

At this age, babies should be anxious or nervous around strangers as they become more aware of the world.  They will always want to cling to their parents and start making good eye contact with people.  They will point at things they intentionally want, and can clap and wave with prompting.

Baby will now be able to start feeding themselves with utensils.  It will be messy, but they can do it.  Without the utensils, feeding themselves with hands should be an easy task.  They should be able to pick up small things like pieces of food with their well-developed pincer grip.  As we mentioned last week, a pincer grip can be best visualized by imagining a small crab picking up an object.

Food-wise, baby should now be eating whatever the rest of the family is eating.  No special meals are necessary.  Just make sure the food is chopped up into small enough pieces that they will not present a choking hazard.

Milk should no longer be provided in a bottle.  They can safely drink homo milk, but no more than 2 cups of milk total per day.  Your child may insist on milk from a bottle rather than a sippy cup, because that’s what they’re used to.  But despite their crying and protests, you can rest assured that they will eventually get over it even if you cut them off cold turkey.

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.

For the 9 Month Old

For the 9 Month Old

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FOR THE 9 MONTH OLD

Congratulations!  Your baby is now 9 months!  They are getting more and more fun, interactive and their personalities are surely developing and surprising you daily.  Now, you are likely noticing a lot of exciting new milestones.  Your little one is likely commando crawling or even crawling on all fours.  They are reaching for everything and moving around the room like never before.

Be aware, they can now grab things that you do not notice at first sight.  They have a pincer grasp (i.e. pointer finger and thumb grasp) and can pick up even the smallest of items.  Be careful!  This means they are at an increased risk of choking on items as they are finding things while they roam around.  Rule of thumb, if an item can fit through a toilet paper tube, it is a choking hazard.

Your baby is likely now also more scared or nervous around strangers.  This is normal.  Expect it and love the fact that you are the one they turn to for love, comfort and security.  Your baby should also be babbling by 9 months.  A lot of Mamama, Bababa, Papapa, and Dadada should be expected.  Don’t worry, you are not alone – most parents have a hard time telling if their baby is saying Mama or Dada to them or just in general.

Your baby should be eating solids 3 times per day.  They are also likely transitioning from purees to more textured foods (foods that are chopped up finely into small pieces).  They also can be eating snacks throughout the day.  It is appropriate to be drinking formula or breastfeeding multiple times through the day still.

Remember to give solids before milk because it is important to transition baby to a diet where most of their calories are coming from solids.  Water throughout the day from a sippy cup is also important to promote hydration and prevent constipation.  By 12 months, they should be eating the same foods as their parents (i.e. 3 meals per day, 2-3 snacks per day and 2 cups of milk per day).

Enjoy watching your baby’s discovery of the world around them as they get more mobile and more curious!

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.

GERD – Is it Spitting Up? Is it Vomiting? Should I be Worried?

GERD – Is it Spitting Up? Is it Vomiting? Should I be Worried?

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GERD – IS IT SPITTING UP? IS IT VOMITING? SHOULD I BE WORRIED?

All infants from 0-6 months have a certain amount of gastroesophageal reflux (milk coming back up after reaching the stomach).  A large portion of infants spit up milk after they are fed.  Often milk comes up when being burped or sometimes a mouthful of milk spills out of baby’s mouth within an hour after feeds.  Occasionally if there is a large air bubble in the stomach or if the baby is overfed, they can also forcefully vomit after a feed.  These are all events that are not out of the ordinary for a normal baby.

When to worry?  Not uncommonly, babies can become uncomfortable after feeds because of the reflux.  It is thought that the acidity of the stomach contents causes irritation of the lower esophagus making baby uncomfortable.  Often if this is occurring, babies will arch their backs, turn red in the face and cry within the first 1-2 hours after a feed.  They may or may not be a baby that spits up.  If it is really bad, they may appear uncomfortable amidst the feed and not appear keen to continue feeding.  In this situation there are non-medicinal and medicinal management options.

These include:

1) Burping the baby frequently.  In the middle of the feed, pull baby off the breast or bottle and burp them to help get any extra air out.  Too much air in the stomach will promote reflux of stomach contents during and after a feed.  Continue to burp baby after a feed as per usual.

2) Put baby on their tummy for a few minutes before a feed.  This can help expel extra air already in the stomach before a feed.

3) Keep baby upright for 20-30 minutes after a feed.  This will allow time for the milk to move past the stomach and into the upper intestine and leave less volume to potentially reflux up into the esophagus.

4) If your milk flow is very fast at the beginning of your breastfeeding, then consider pumping off the first few milliliters of milk before feeding or leaning back while you breastfeed to slow the flow of the milk.  This will help decrease how much air baby swallows while trying to feed from the fast rate of your milk flow.

If all of these measures do not appear to improve baby’s discomfort after feeds, you can speak to your physician about prescribing an acid reducer such as ranitidine for your baby.  Babies usually grow out of reflux by 6 months of age.  Anatomically they have less reflux of stomach contents, they are starting solids at this time and they are starting to spend more of the day upright and less on their backs.

When to worry about vomiting?  If your baby is vomiting persistently with increasing force, severity and frequency, they must be seen immediately by a medical professional.  If the vomit ever contains blood or bile this is an abnormal event.  Bile is army green in colour and it is not normal for an infant to produce vomit this colour.

I hope this information is helpful to you but of course if you have any concerns you should be sure to schedule a visit with your doctor or pediatrician.

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.

For the 6 Month Old

For the 6 Month Old

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FOR THE 6 MONTH OLD

Wow!  6 months!  Don’t be alarmed if your baby is starting to wake up at night time again for feeds.  This means your baby is likely ready for solids and that milk is not sustaining them through the night anymore.  You know your baby is ready for solids when they start showing interest in food.  Sit them at the dinner table with you and see if they watch you eat, reach for your food or even scream at you to give them some of your food.  If you notice your baby is doing these things, then they are ready for solids.  It is safe to start solids as early as 4 months as long as your baby is showing interest in eating.  Most start with rice cereal because it is iron fortified, easy to digest and convenient, but you can start with anything.  You can pick any food and puree it (however, avoid honey because of the risk of poor pasteurization and botulism).  It is best to start with iron rich foods because if your baby is exclusively breastfed, their iron stores will be low as breastmilk does not have iron in it.  Start with solids at the dinner time meal so your baby has more food in their belly when they go to bed.  This will hopefully get them to sleep through the night again.

We used to recommend avoiding highly allergenic foods such as egg white, seafood and peanuts when introducing solids.  We no longer recommend this as it is likely that this avoidance may have actually promoted allergies to these products.  At this time, we recommend introducing any and all solids (except honey) to your baby.

There are no hard and fast rules regarding starting solids.  There are however, a few guidelines to follow.  Introduce a new food every 3-4 days.  This is done so that if your baby has an allergy to something, you will know exactly what it is.  If you start multiple foods on one day and your baby has a reaction, you will have to avoid all of those products until we figure out exactly what they are allergic to.  Give solids before you give your baby milk.  The reason for this is because you are  now starting the transitional process to having your child eat solids as their primary calories and only having milk as an add on.  You want your baby to eat as much solids as they want and then top them up with milk.  By the time your child is 1 year old, they should be eating 3 meals, 2 snacks and 2 cups of milk per day, like you or I.  They should be eating the same foods as you and you should not be making them any special foods by 1 year of age.

It is safe to start cow’s milk by 10 months of age.  If you want to go back to work early or wean off breastfeeding around this time, it is ok to transition to cow’s milk.  Formula is still safe and ok to use at this time as well, however if you want to save your money, homo milk will also do the trick.

If your baby can and will use a sippy cup, start it sooner than later.  Children often get attached to the bottle as opposed to the milk and you may run into difficulties in the future trying to wean them off of the bottle.  Switch them sooner to avoid a hard time for yourself in the future.

At this point, your 6 month old will likely be able to sit up independently.  They can roll over in both directions (front to back and back to front).  They are likely putting everything including their hands and feet in their mouth.  They are passing items between their hands.  They are drooling up a storm and may even have some teeth coming through.  You’ll see them always smiling, laughing and giggling during this milestone.  Enjoy the last few months of stationary baby before they become mobile!

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.

For the 4 Month Old

For the 4 Month Old

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FOR THE 4 MONTH OLD

You’ve made it 4 months!  You are probably super comfortable with being a Mommy or Daddy by now.  This article will be a shorter one because not too much changes at this milestone.

Your baby is feeding every 3-4 hours and breastfeeding is probably taking about 10-15 minutes each time.  Your baby is likely sleeping longer stretches overnight or even through the night and you are finally getting some real sleep.

At this stage, more tummy time is better.  They should have good control of their neck and be able to push up with their arms from their tummy laying position.  In addition, your baby should be starting to show signs of rolling over.  To help them with this, you can put your baby on their belly and put toys all around them.  Babies will typically roll from front (tummy) to back first, which is why putting them on their tummy is suggested.  Don’t expect them to roll over back to front first, because that’s harder than rolling over front to back.

Placing toys away from them at arm’s length will help them reach for things and help with fine motor skill development.  In addition, you’ll probably notice your baby will start holding toys between their hands and start putting things in their mouth.  This is the time to be careful about what you place around them and make sure nothing can pose a choking or swallowing hazard.  General rule of thumb, if an item can fit through a toilet paper tube, it is too small and poses a choking risk.

Your baby should also become more interactive at this milestone.  They should be smiling, laughing, giggling, and looking to their parents.  They should be making lots of noises with “Ooo” and “Ahh” sounds and enjoying their interaction with you.  Enjoy this time with baby now, and stay tuned for my 6 month article next week when we deal with the idea of starting solid foods!

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.

For the 2 Month Old

For the 2 Month Old

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FOR THE 2 MONTH OLD

You’ve made it 2 months with your bundle of joy!  By now, you probably have a predictable schedule.  Things are seeming to get a bit easier and your baby is interacting with you a bit more, smiling and watching as you walk around the room.  At this point, you can breathe a sigh of relief.  Your baby should stay on a regular schedule of feeds every 2-4 hours throughout the day now.

Your baby is now safe to sleep longer stretches overnight, usually 4-5 hours.  But remember, they should still be sleeping in their crib without any padding, pillows or stuffed animals.  Be sure your baby is getting tummy time at least 3 times per day for 10 min each time.  This will promote neck strength and promote gross motor skills as well as help prevent flattening of the head.  Feel free to review my last two articles on Safe Sleep and Preventing a Flat Head for a quick refresher if needed.

In BC, 2 months is when baby gets their first set of vaccinations.  It is usually 3 shots in the thighs and 1 oral vaccine.  You can get these done at your local public health nurse’s station or your family doctor or pediatrician if they offer vaccines in their office.  Remember to keep track of your child’s vaccines.  It is ok to get the vaccines a week past the scheduled 2 month visit, however I would not suggest delaying the immunizations by much longer as it is easy to get behind on vaccinations, but troublesome to catch up.

Usually babies tolerate the 2 month vaccinations well.  They are often a bit fussy afterwards and may not feed as well as before and can even have a slight fever.  These symptoms usually only last 1-2 days.  You can give Tylenol prior to the vaccinations in anticipation of discomfort and fever or give it as needed based on how your baby behaves following.  Be sure to follow the Tylenol dosing on the bottle or ask your physician or pharmacist for appropriate dosing based on your baby’s weight.

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.

 

 

Preventing a Flat Head

Preventing a Flat Head

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PREVENTING A FLAT HEAD

Everybody wants their baby to have a beautiful round head.  A flat head is not only a problem in the future if your child decides to shave their head, but there can actually be other significant issues that may arise.  Imagine if you took a perfectly round ball of clay and drew a line down the middle separating it into two sides.  If you took a flat palm and squished down on the back of one side to mimic a flat side of the head, what happens to the front of that side?  The front naturally gets pushed forward and causes the ball of clay to become asymmetric.  Something similar can happen with the head of babies, potentially distorting the natural symmetry of the face permanently.  Here are a few tips to prevent flattening of your baby’s head in the first 4-5 months of life.

Firstly, tummy time while awake for 10 minutes three times per day.  This will promote neck strength and keep your baby off the back of their head.

Secondly, during the first 4-5 months of life, parents are recommended to have babies sleep on their backs.  Your baby will always look towards the more interesting side of the crib, usually towards the side where there’s more movement.  Always placing your baby with their head pointing in the same direction can cause regular nightly pressure on the same side of the head, leading to a flat spot.

So to help prevent this, alternate the position in which your baby’s head faces each night.  For example, place your baby with their head pointing to the left side of the crib on Monday, Wednesday, and Friday.  Then on Tuesday, Thursday, and Saturday, do the opposite and place your baby with their head pointing to the right side of the crib.  Sundays can be determined by a coin toss or a simple game of rock, paper, scissors between parents.  If you worry about forgetting which side your child was facing the night before, tape a sign to the crib with the following on it “<– M, W, F  //  T, Th, Sa –>, Sun (??)”.

Keep in mind, this prevention tip only works in the first 4-5 months.  This is because after this time, babies can start rolling over on their own and therefore will not necessarily stay in the same place you left them.

If you find your baby is always looking in one direction regardless of how they are held or placed in bed, then this is a warning sign that they may need to be seen by a health care professional for assessment of torticollis or twisted neck.

**Disclaimer – Any information found in these blog posts is only for informational purposes and not intended to replace the diagnosis and care of a physician.  Should you have any specific concerns about your child, please consult with your family doctor or pediatrician.