2021 Issue

What Parents and Guardians Need to Know About Early Vision Screenings

By Luxme Hariharan, MD, MPH, Pediatric Ophthalmologist and Global Health Specialist, Nicklaus Children’s Pediatric Specialists, Nicklaus Children’s HospitalbPublic Relations Chair, Florida Society of Ophthalmology, Miami, Florida

Did you know that the most common cause of permanent vision loss in children under four is also one that can be prevented and treated if found early enough?

Amblyopia, what you might recognize as ‘lazy eye”, is a vision issue that develops around age three, often caused by an uncorrected refractive error, which means that the shape of the eye doesn’t bend light the right way, so children see a blurred image instead of a clear one. In Florida, fewer than 20 percent of preschool children are currently screened for vision problems.

A child’s vision is still developing and connections between their retina and brain are still forming within the first few months of their lives. As children get older, they learn to focus on objects, improve their visual coordination and develop their depth perception.

When children reach the age of three, they can start to develop vision issues that are hard to detect with the naked eye. It’s around this time that amblyopia can develop. The effects of amblyopia on the eye cannot be seen by the naked eye and often times, when children start to visibly show vision issues, it can be too late to save their vision.

The number one thing parents and guardians need to know to help support healthy eye development in their young children is that early prevention is key.

The American Academy of Ophthalmology recommends children get eye screenings starting at 12-months, repeated every one to two years. The Florida Society of Ophthalmology recommends all children aged three to five are regularly screened. Early vision screening is critical in terms of preventative care and can be handled by your child pediatrician or a pediatric ophthalmologist. Treatment, which can include corrective glasses or patching, must begin right away if a child is at risk of developing amblyopia.

Every August, the Florida Society of Ophthalmology (FSO), and it’s charitable arm, The For Eye Care Foundation, Inc. (FECF), launch an awareness campaign to help share valuable information and resources with parents and guardians about the need for early vision screenings at  www.MDEye.org/Amblyopia.

All parents want their children to be safe and live healthy lives. Vision screenings are one simple and easy way to help achieve that for your children.

Tracking your baby’s development, from a few days to 4 years old.

By Wolfson Children’s Hospital

New parents keep close watch for baby’s big moments, like the first smile, but other milestones, like visually tracking an object, may go totally unnoticed. Here’s everything to look for (and look forward to) over the first four years of your child’s development.

Year 1: The building blocks

From making eye contact and moving his or her hands, to crawling and uttering that highly anticipated first word, your little one’s going to be very busy this year.

Your child’s pediatrician will examine your baby and ask about his or her physical and cognitive development at routine checkups. Physical therapist Ann Losak, PT, and speech-language pathologist Sarina Tarantino, CCC-SLP, who work with children to meet milestones at Wolfson Children’s Rehabilitation, say these are the major milestones they expect to see in a baby’s first year.

0 to 2 months:

• Kicks both legs and moves both arms equally while on his or her back and turns head to both sides
• Lifts and turns head to both sides while on his or her belly
• Makes gurgling sounds
• Interacts with caregivers by smiling, calming when they speak and moving arms and legs in excitement

3 to 6 months:

• Reaches up and bats at toys while on his or her back
• Brings knees to chest and hands to feet
• Rolls from back to belly
• Pushes up and holds head high while reaching forward for toys
• May pivot while on his or her belly to explore the environment
• May begin to push up onto hands and knees and rock back and forth, getting ready to crawl
• Can prop or “tripod” sit, using hands to hold up the upper body while in a seated position
• Notices more about his or her surroundings, like when people come in and out of the room
• Responds to his or her name
• Looks between caregiver and an activity, like a book or toy
• Coos while interacting with parents, pets and toys

6 to 9 months:

• Rolls from back to belly and belly to back
• Begins to crawl, crawling independently by 9 months
• Sits independently, and gets in and out of the sitting position
• Makes different consonant and vowel sounds
• Anticipates your actions
• Bangs objects together to make loud sounds

9 to 12 months:

• Crawls
• Pulls to stand
• Begins to cruise
• Attempts to stand without support
• May walk, though many walk later
• Uses gestures like pointing to involve you in their routines, interests and requests
• Babbles with intonations similar to an adult’s speech patterns
• Imitates simple, familiar words
• Takes turns while playing
• Follows simple directions when used with gestures

Year 2: Taking it all in stride

Once you have a toddler, physical milestones become less about rolling and sitting and more about, well, toddling.

“From 13 to 14 months old, most kids are walking, but not all,” said Losak. “They can crawl up stairs, squat and pick up a toy, and they are learning to stand up from the floor without help. At 15 to 18 months, little ones can crawl down the stairs, run, and start to kick a ball forward.”

By the time your child is 2, your little explorer should have an easy time walking with few falls and a more mature gait (meaning they don’t rock back and forth while stepping). He or she can also jump in place and kick a ball with either foot.

As for communication, Tarantino said by 18 months, she hopes to see children using at least 10 words.

“This can include things they want, like ‘cookie,’ object names, like ‘cup’ or ‘car,’ and descriptions, like ‘hot.’ Toddlers should be able to wait for a snack to be prepared, show you what they want if you don’t understand their request, and begin to play pretend.”

The age 2 milestone for words is 60, but most kids will know more than 100 and will be stringing together phrases and making requests.

Year 3: A hop, skip and jump

With another year of practice, that sometimes-clumsy 2-year-old will become a coordinated and well-spoken child. And the more you chat with them, the more they’ll learn.

“A 2-to-3-year-old is expected to be about 50% intelligible,” said Tarantino. “We try to encourage parents to sit or lay on the floor with their child and play, read and be silly.”

When playing, it’s important to talk about the interaction rather than “quiz” the child during play. This helps build a stronger language connection. An example would be, “Wow! You put the block on top!” instead of, “Where is the block?”

“At 3, children can balance on one foot for a few seconds at a time and jump forward 10 to 12 inches. They can catch a large ball, so they’re getting some hand-eye coordination, and they’re starting to ride those little tricycles. In fact, they’re pretty good at most things,” said Losak.

Year 4: Well on their way

By age 4, your kiddo will be running, jumping and climbing like a champ. In fact, kids this age should be proficient at most movements, but there’s one last milestone to check for: being able to hop on one foot.

“If parents are watching their child struggle with balance and coordination activities like kicking or hopping, they should mention it to their pediatrician,” Losak said.

Same goes for if your little one is difficult to understand more often than not.

“We would expect 75% intelligibility by age 4,” Tarantino said. “By the time a child is 5, you should be able to understand everything he or she is saying.”

What if milestones aren’t met?

Every child is different, and so too are their developmental journeys. Your child’s pediatrician will check for milestone developments at routine appointments, which are scheduled frequently throughout the first year. If your child hasn’t met a milestone on time, don’t worry too much — just keep an eye on your little one, and mention it at their next checkup.

Pediatric therapists offer treatment for developmental delays, fine or gross motor challenges, and more. If your child is having difficulty with any physical, cognitive, occupational, speech or feeding tasks, call 904.202.4200 or visit wolfsonchildrens.com/rehab to learn more about Wolfson Children’s Rehabilitation.

From the moment you learned the good news, you’ve had the weight issue in the back of your mind. You were thrilled to be giving birth but a little worried about losing the weight afterward. And if this was your first pregnancy, there are a few more questions about how it all happens.

The truth is, many women do stay a few pounds heavier after birth. The entire birth process affects every part of your body and some long-term body changes are normal. The good news is you can lose most of the weight and get back to tip-top fitness.

Take It Easy

The first six weeks after giving birth are days to rest, enjoy, learn to know the new member of the family and let your body gain strength. After all, you’ve been busy for nine months creating a whole new person!

Post-partum fitness expert, Renee M Jeffreys says, “Most women’s bodies aren’t ready for serious exercise until six weeks after birth, and more if they underwent a Cesarean section.” No you won’t just be sitting around eating bonbons, you’ll be tending baby full-time, missing nighttime sleep and looking for opportunities to nap when baby does.

If you’re breastfeeding you can take encouragement from the fact that although you need to eat more to maintain your breast milk, you’ll also burn 600-800 calories a day just breastfeeding. Many women begin to lose pregnancy weight through breastfeeding alone. Once you stop breastfeeding you’ll need to adjust your calorie intake.

Another way to take care of your post-partum body is through healthy diet. Avoid those empty calorie sodas and chips and take in plenty of fiber by eating healthy snacks such as whole grain crackers, veggies and lean proteins. This is not a time to say “anything goes” diet-wise. Get off to a good start on your return to a target weight.

Step It Up

After the first six weeks you’re ready to begin a moderate exercise program. Aim for thirty minutes a day, five times a week. You may want to break that up into ten-minute segments at first. You’ll want to include walking, cycling or swimming in your regimen. Walking with baby in a stroller is the ideal exercise in these early months of baby’s life. It’s good for both of you to get out of doors and enjoy a change of scenery.

Set goals to increase your speed and distance. Using a pedometer or Fitbit to measure your steps is a good motivator. A reasonable goal is walking at a mile every fifteen minutes. If you’re able to join a postnatal exercise group, that’s a wonderful way to share your new baby experiences and get in a good exercise session at the same time. Most of these classes allow you to bring baby along.

If you’re unable to get to a formal exercise class, consider buying a postnatal exercise DVD. Be sure the program is doctor approved, such as postnatal Pilates, and enjoy at your leisure.

Patience and Persistence

The early months with a new baby are ones of intense joy and many challenges. You’re tired much of the time. So be patient with yourself and readjust your goals if necessary. But don’t give up. Do what you can each day, take joy in each new milestone of the journey and before you know it, you’ll be wearing those skinny jeans again.

Resources

Books

10 Steps to Getting Back into Shape After Giving Birth by Carrie Delvaux.

Body After Baby: A Simple, Healthy Plan to Lose Your Baby Weight Fast by Jackie Keller.

I’ve Just Had a Baby by Alison Bourne.

Tips for How to Lose the Baby Weight by Suz Redfearn.

One of the biggest questions new parents have is when should they call the doctor. We have compiled some guidelines for you, but remember that pediatricians are a resource for you, and if you feel things are not right, be sure to call your pediatrician or an ask a nurse hotline so that you get answers. As a parent, you know your child better than anyone else, and you should follow your instincts when it comes to the medical care of your little one.

I recommend that you start a medical notebook for your child and start recording information after their birth. What tests were done in the hospital, when were shots administered, what are your child’s habits and actions when healthy (eating, attention, sleep and voiding). When you call the doctor, be prepared with information. What are your baby’s symptoms and what are your concerns? What is your baby’s medical history? What changes have you observed in your child’s eating, drinking, wetting and bowel movements? Does the baby have a temperature? What treatments have you tried? Has your child been around anyone who is ill? Keep your notebook handy to write down any advice the doctor may give you. Be prepared with your pharmacy information and any allergies also.

Here are some guidelines on when to seek medical assistance.

FEVER

Call a doctor if:

• In a baby under 2 months old, a rectal temperature of 100.4 F or higher is an emergency. Take the baby to the emergency room or an urgent care immediately if your doctor is not available to see them.
• You have an infant under 3 months old and they run any fever.
• You have an infant ages 3-6 months and they have a rectal temperature over 101 degrees F or higher.
• You have a child over 6 months old and they have a rectal temperature over 103 degrees F or higher.
• If the fever lasts more than 3 days, regardless of the age of the child.

COLD SYMPTOMS:

Call the doctor if:

• The child develops an earache.
• The child develops a fever over 102 degrees F.
• The child becomes exceptionally sleepy, cranky or fussy.
• A skin rash develops.
• Breathing becomes rapid or labored. Your child’s nostrils flare or ribs sink in with a breath.  If there is a wheeze or other noise when they try to breathe.
• The cough becomes persistent or severe.

Call 911 right away if a bluish color appears around your child’s lips or nails. They are not getting enough oxygen and this is an emergency.

VOMITING AND DIAHREA:

• Call a doctor if these symptoms appear:
• Crying but no tears
• Less pee than usual — fewer than 6 wet diapers per day in infants
• Dark urine
• Dry, cracked lips and mouth
• Sunken eyes
• Crankiness
• Sunken soft spot on top of the head (in babies younger than 18 months)
• If vomiting or diarrhea last more than 24 hours

If there is a a red or black color in the poop or vomit, or flecks that look like coffee grounds, these could be blood. Seek medical attention immediately.

RASH

• If the rash lasts more than three days
• If it is a rash with a fever
• A rash that oozes or weeps
• A blistery or bubbly rash
• A rash that looks like a bull’s-eye or target
• Swollen bumps on the skin, along with trouble breathing or swelling of the face
• A rash on a child who looks sick or isn’t acting like themselves

OTHER SYMPTOMS THAT NEED IMMEDIATE ACTION

• Trouble waking your child
• Sharp or constant belly pain
• Burning when your child pees or blood in their urine
• A constant need to pee
• Seizures
• Changes in appetite over a period of time (several feedings in a row)
• If your child is floppy, crying more than usual or very hard to console.
• Tender navel or penis, especially with redness, oozing or bleeding.
• If your child has fewer bowel movements for a few days and seems uncomfortable.
• If one or both eyes are leaking mucus or are unusually red and swollen.

WHEN TO SEEK EMERGENCY CARE

• Bleeding that can’t be stopped
• Poisoning
• Seizures
• Increasing difficulty breathing
• Any change in consciousness, confusion, a bad headache or vomiting several times after a head injury
• Unconsciousness, acting strangely or becoming more withdrawn and less alert
• Large or deep cuts or burns or smoke inhalation
• Skin or lips that look blue, purple or gray
• Increasing or severe persistent pain
• Major mouth or facial injuries
• Near drowning

The choice to use store bought baby food versus. making your own (or a combination of the two) is a personal choice.  Either option will allow your child to get the nutrition they need, to grow and to thrive.

The best time to start with solid food is the same whether the food comes from the supermarket in a jar or as raw ingredients that you mash. When your baby is sitting up with little support, able to maintain good head control, shows an interest when you are eating and can close their mouth and turn their head when they have had enough or not interested, the baby is ready. This is usually when they are about 6 months old, but babies vary. Take your cues from your child and their doctor.

Pros of Homemade Baby Food:

• Saves money
• You control the quality
• Convenience
• Flexibility
• More choice in what is in the food
• Preservative free
• Environmentally friendly

Cons of Homemade Baby Food:

• Takes time to plan and make
• Organic produce can be costly
• Requires freezer and/or refrigerator space
• Spoils quicker than store bought food
• You must be careful about food quality.

You may be wondering how to start. Start with simple, bland foods with a pureed consistency.  Some doctors recommend that you start with vegetables instead of something sweeter like fruit. Easy to digest foods are squash, sweet potatoes, pears, avocados and bananas. Peel the fruit or vegetable if appropriate. Remove stems, pits and seeds. You may bake, steam, roast or microwave until tender. Baby food needs no added spice, butter, salt or pepper. You can thin the item with a little water, breast milk or infant formula to help puree it or mash it to the desired consistency. It is best to add one food at a time and wait 3-5 days before introducing something new. Do not give up if your baby doesn’t instantly like it.  Put it in the rotation of foods and try again later.

After introducing several foods to your child, you can start giving her combinations. Apples and sweet potatoes, plum and pear, peas and carrots – whatever you think they would like. When your baby is ready to try meats, be sure to remove the skin, fat, bone and connective tissue, and cook fully.

As you add in new foods, strive to feed a rainbow of colors. Eventually, your baby will be able to eat what you eat diced in tiny pieces. Your doctor is a great source for answers to any feeding questions you have. Happy Feeding!

As they test their independence, setting and enforcing limits lays the groundwork for good behavior.

Rachel Ehmke

When and how should you begin to discipline toddlers?

Kids begin knowing what “no” means at around seven months on average, and, once they can speak, many go through a stage where it becomes their favorite word to use. Unfortunately, parents can also count on kids going through a stage where they gleefully ignore when mom or dad says no and other attempts and discipline. That’s because it is natural for them to start pushing boundaries — testing their independence and trying to explore the world on their own terms.

Why discipline is important

A big part of discipline in the early years is simply keeping kids safe. We don’t touch the oven. We don’t pull on the cat’s tail. We don’t run into the street. But by setting consistent limits early, parents are also laying the groundwork for good behavior in the future.

Setting limits has other benefits, too. Telling children which behaviors you do — and don’t — want to see actually makes kids feel more secure, because it reminds them that you’re in charge and guides them to the areas where they should be developing their skills and independence (such as playing with the plastic tea set and not trying to touch the real one).

Rules are also a way to help kids begin to consider the perspective of others or at least set the stage for empathy. Two-year-olds might be too egocentric to comprehend how others feel, but they can begin to learn that sharing is a nice thing to do and practice handing grandma a toy.

But how should parents share rules with children, and how can those rules be enforced — particularly when children are very young and might not understand the concept of consequences?

Setting routines 

Kristin Carothers, a clinical psychologist, says that parents are probably already setting limits without realizing it. “One of the most naturalistic ways to create boundaries is around having set routines for your kids,” says Dr. Carothers. “They might not know what time it is, but they know the bedtime routine — we have our bath, we read our book, we go sleep in our own bed.” By creating a familiar routine, parents are teaching children what to expect next, so there are no unpleasant surprises, while also establishing a clear boundary about when the bedtime begins.

Discipline toddlers in the moment

Of course, much of life isn’t planned for, so parents need strategies for how to correct behavior and reinforce boundaries in the moment. “If there’s a rule you want followed, like not hitting, then that is something you have to correct in the moment when you see it,” says Dr. Carothers. But how you correct it matters.

Parents often say, “Don’t do that” or “No,” but Dr. Carothers says that it is actually more helpful to tell children what you do want them to do, instead. “Kids know what ‘no’ means, but they don’t necessarily know what to do next after we say no, so you always want to make sure that you have an alternative for them,” she explains. Saying, “Keep your hands to yourself” or “Use gentle hands” makes that clear.

For children around three years old, parents might have the child do a time out for something like aggressive behavior. Dr. Carothers explains time out as being “time out from your positive attention.” So you might say, “We keep our hands to ourselves. You hit your brother, so now you have to sit in this chair.” For kids who are young, time out shouldn’t be longer than three minutes. Then, after the time out is finished, you can tell the child what he should do next: “You can ask your brother for the toy” or “You can touch your brother gently.”

Parents can also start setting natural consequences for a child’s misbehavior. For example, if a child jumps on the couch, a natural consequence could be having her practice sitting calmly on the couch. If she writes on the wall, then you could have her wash the wall. Of course she might not actually get the wall clean, but just the act of trying to wash the wall reinforces your rules.

 Keeping expectations realistic

For some situations, relying on your ability to respond in the moment might not be enough. For example, toddlers will run into the street if they see something interesting and not realize the potential danger. “We can’t expect a toddler to set that limit for himself,” explains Dr. Carothers, “so you as a parent need to do the intervention on the opposite side.”

For walking on the sidewalk, that means you need to hold your toddler’s hand at all times to keep him safe. Dr. Carothers also encourages parents to say something like, “Good job holding mommy’s hand! Thank you for staying close to me,” which lets your child know that these are the types of behaviors that you like to see.

How is the baby sleeping?  How are you sleeping?

I remember being asked this question over and over again as I ventured down the path of new motherhood and then again with a newborn and a toddler. So many things venture into a baby’s ability to sleep for longer periods of time. My 10 lb. newborn had her days and nights mixed up when we brought her home, and the first week one of us stayed up until 2 or 3 am with her. Once we got her schedule switched, she slept through the night at 3 weeks. Her 7 lb. little sister only wanted to sleep while being bundled in a blanket and held, and she never went to bed or stayed in bed easily. Same parents, same room, same routine – different children. We have some recommended strategies for you to try to help you on your way to a good night’s sleep.

HOW MUCH SLEEP DO BABIES AND TODDLERS NEED?

Newborns need 16-20 hours/day. They are awake an hour or two between periods of sleep.

Infants need between 13 and 15 hours per day. This sleep is with morning and afternoon naps, and nighttime sleep.

Toddlers need around 12 hours of sleep, accomplished with an afternoon nap and nighttime sleep.

WAYS TO IMPROVE THE SUCCESS OF GETTING YOUR CHILD TO SLEEP

• Feed your baby right before bedtime so they are not hungry when you put them down.
• Put child in bed when sleepy but not asleep. This way they will learn to fall asleep on their own.
• Place babies under one on their back.
• Maintain a nighttime routine, such as feeding, bath, story, etc. and stick to it as closely as you can.
• Put the baby to bed at the same time every night.
• Limit daytime naps to no more than 3 hours.
• If you have an infant, put the baby to nap in places where there is noise and movement, so they don’t get used to complete silence with every nap.
• Do not put a bottle or cup in bed with your baby or toddler.
• Consider the use of a pacifier, but only after your child has become an established breast feeder, if you are breastfeeding.

SIGNS OF TIREDNESS

If your child is exhibiting these signs of tiredness, they may need additional soothing (rocking, singing, a quiet story, a backrub) before going to sleep. The signs of tiredness in children of various ages include:

• newborns – staring, jerky movements of the arms and legs, clenched fists, frowning, yawning, irritated behavior including crying
• older babies – loss of interest in toys or playing, fretfulness, yawning, separation anxiety, irritated behavior including crying, eye rubbing, a change in physical activity
• toddlers – clumsy physical movements, tasks take longer to perform, irritated behavior including crying, emotional tension.

WHY SOME CHILDREN RESIST SLEEP

Some of the reasons why older babies and toddlers may not want to take a nap include:

• They don’t want to be by themselves.
• They don’t want to miss out on any activity.
• They are too excited, restless or anxious and can’t relax.
• Their daytime routine doesn’t always include naps.
• They are hungry or thirsty or have some other physical discomfort.

SUGGESTIONS FOR DAYTIME NAPS

Suggestions to help your child settle for a nap include:

• Make sure your child has plenty of fresh air and physical activity.
• Establish a routine so your child expects to have a nap at certain times.
• Give your child time to relax beforehand with gentle activities.
• Make sure they are comfortable, fed and wearing a fresh diaper.
• If your child is a toddler or mobile, put them in a place that is quiet and dark.
• Provide your child with an opportunity to settle themselves. Then, if they are anxious without you, stay in the room for a few minutes.
• After 12 months some children may be comforted by a special object or toy. However, first check recommendations for safe sleeping and avoiding SUID (sudden unexpected infant death).
• Leave their bedroom door open so they can hear you moving around the house.
• Even if they do not sleep, the rest and quiet time alone is still beneficial