Healthychildren 09bts

American Academy of Pediatrics
Healthy
Summer/Back to School
2009
Children
When Parents
Are Deployed
Helping children deal
with the stress
SIDS
What every parent

needs to know
Older Children,
New Baby
Helping children make
the adjustment
Vitamins
and Minerals
What your child needs
Teenage Immunization
Keep your adolescents safe
Waiting Room Copy

Sponsored by
Summer Wellness
Welcome to the summer/back-to-school 2009 issue of Healthy Children, your
dependable guide to the issues you need to be aware of regarding your childs
health. The warm summer months are upon us, and so with more time being
spent outdoors we are especially keen to keep our children in good spirits and
in good health.
This issue offers a host of good information to help you help your children
stay healthy. Recommendations from the American Academy of Pediatrics
on vitamin D inspired an article on vitamins and minerals for children (page
24), and our adolescent-focused piece this month looks at the importance of
breakfast for teenagers a meal they often skip, but shouldnt (page 28). One
more thing adolescents shouldnt skip: immunizations. On page 22 we take a
look at the essential vaccines that this age group needs to protect them from
illness.
We also feature a closer look at what we now know about Sudden Infant
Death Syndrome (SIDS, page 12), and give guidance on how to help the children
of deployed military parents deal with the stress of being apart (page 8).
How do you help children adjust to the arrival of a new baby brother or sister?
We explore ideas for making the transition as smooth as possible (page 20).
We appreciate your readership and hope you find this issue of Healthy
Children an excellent resource for up-to-date, scientifically sound parenting
advice!
David Tayloe, M.D., FAAP

President
Healthy Children Summer/Back to School 2009
Healthy
Summer/Back to School
2009
Children
attn: Healthy Children Magazine
141 Northwest Point Blvd.
Elk Grove Village, IL 60007
[email protected]
AAP Editorial Advisory Board
Tanya Remer Altmann, MD, FAAP
Westlake Village, CA
Laura A. Jana, MD, FAAP
Omaha, NE
Jennifer Shu, MD, FAAP
Atlanta, GA
Robert W. Steele, MD, FAAP
Springfield, MO
IFC
Welcome
Table of Contents
This Just In
Ask the Pediatrician
When Parents Are Deployed
12
SIDS
16
Well Child Care
20
New Baby, Older Children
22
Teens and Immunization
24
Vitamins and Minerals
28
Breakfast: The Right Start to the Day
Paul R. Stricker, MD, FAAP

San Diego, CA
Executive Director
Errol R. Alden, MD, FAAP
Associate Executive Director
Roger F. Suchyta, MD, FAAP
Director, Department of Marketing and Publications
Maureen DeRosa, MPA
Director, Division of Product Development
Mark Grimes
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Manager, Patient Education
Regina Moi Martinez
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Kathleen Juhl
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Healthy Children is published by Vitality Communications
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Dr. David Tayloe, AAP president,

welcomes you to AAPs
authoritative resource
for parents.
The latest parenting news, research,

and health tips from our experts.
Answers to common questions.
Having a parent deployed as part of his or her military service is hard

for the family left behind, too especially children. But you can
soothe your childs fears without creating unrealistic expectations.
Weve learned a lot about Sudden Infant Death Syndrome (SIDS) since
the days when it was called crib death and considered a mystery.
Good health care for your child should include well child care
taking steps to help your child avoid illness and stay healthy. Find
out more about this important concept, including what to ask your
pediatrician.
Having a new baby brother or sister can be a strange experience for
your older child. You can help ease the transition by taking a few extra
steps.
Immunization is just as important for adolescents as it is for babies and
younger children. Find out what your teen needs.
How can you be sure that your child gets enough nutrition from his
meals? Find out what you need to know about supplementing your
childs diet.
Teenagers are often in a huge hurry to get to school in the morning,
and grabbing something on the way out isnt necessarily the best
approach.
President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . William G. Moore

Controller . . . . . . . . . . . . . . . . . . . . . . . . . . Pat Blake
Administrative Assistant . . . . . . . . . . . . . . . . . . . Pat Schrader
Copyright 2009 by the American Academy of Pediatrics. No part of this publication may be reproduced
or transmitted in any form or by any means without written permission from the American Academy of
Pediatrics. Articles in this publication are written by professional journalists who strive to present reliable,
up-to-date health information. However, personal decisions regarding health, finance, exercise and other
matters should be made only after consultation with the readers physician or professional adviser. All
editorial rights reserved. Opinions expressed herein are not necessarily those of the American Academy of
Pediatrics. Models are used for illustrative purposes only.
The American Academy of Pediatrics would like to thank

for its sponsorship of this issue of Healthy Children.
The information contained in this publication should not be used as a substitute for the medical care and
advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend
based on individual facts and circumstances.
Publication of an advertisement in Healthy Children neither constitutes nor implies a guarantee or endorsement by Healthy Children or the American Academy of Pediatrics of the product or service advertised or of
the claims made for the product or service by the advertiser.
Healthy Children Summer/Back to School 2009 3
This Just In...
The latest parenting news, research,

and health tips from our experts
Code Yellow:
Treating Preemies with Jaundice
A recent study found that early treatment to prevent jaundice in tiny
premature infants reduced the babies rate of brain injury, which is a
dangerous complication of jaundice.
Jaundice is the yellow color seen in the skin of many newborns. It happens when
a chemical called bilirubin builds up in a babys blood. Everyones blood contains
bilirubin, which is removed by the liver. Before birth, the mothers liver does this for
the baby. Most babies develop jaundice in the first few days after birth because it
takes a few days for the babys liver to get better at removing bilirubin.
But the livers of some especially premature newborns are not able to remove
bilirubin quickly enough. This causes potentially toxic levels to accumulate, leading
to a condition called hyperbilirubinemia. If not treated, it can lead to cerebral palsy,
intellectual and developmental disabilities, blindness, and hearing loss.
For years, doctors have used high-intensity light, a process called phototherapy,
to reduce bilirubin levels. Now, thanks to this recent study, researchers know more
about treating jaundice in preterm infants.
These are extremely frail infants who may have a number of health problems,
says Rosemary Higgins, M.D., of NICHD and co-author of the study. The bilirubin
level shouldnt be considered in isolation.
The findings were reported in the October 30, 2008, issue of the New England
Journal of Medicine. Researchers at the National Institutes of Healths Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
conducted the study.
QUICK TIP: If your premature baby has jaundice, talk with your
pediatrician about treatment options.
Teen Sex: Life Imitates Sitcoms

Teenagers who watch sex-saturated television programming are twice as likely to get pregnant or impregnate a
girl than those who dont.
Data from a national survey of teens ages 12 to17 were used to
assess whether exposure to televised sexual content predicted
subsequent pregnancy for girls or responsibility for pregnancy
for boys. Participants in the study were monitored for three years.
Sex and the City, That 70s Show, and Friends were the shows used
in the research.
The study appears in the November issue of Pediatrics, and is
the first study to show a possible link between exposure to sexual
content on television and pregnancy before the age of 20.
4
The top 10 percent of teens who watch sexually charged

programming were twice as likely to become pregnant during
the three-year period, compared to the 10 percent of teens
with the lowest levels of exposure.
Limiting what teenagers watch, talking about how sex is
portrayed in the media, and teaching the responsibilities of
being sexually active might reduce the risk of teen pregnancy,
according to the studys authors.
QUICK TIP: When possible, watch TV with your teen and
talk about what you see.
On the Rise:
Children with Food Allergies
The number of young people who had a food allergy increased 18 percent
between 1997 and 2007, according to a new report by the U.S. Centers for Disease
Control and Prevention. In 2007, approximately 3 million U.S. children and teenagers
younger than 18 or nearly 4 percent of that age group were reported to have
a food or digestive allergy in the previous 12 months. This compares to just over 2.3
million or 3.3 percent in 1997. The findings are published in a new data brief,
Food Allergy Among U.S. Children: Trends in Prevalence and Hospitalizations.
The report found that eight types of food account for 90 percent of all food allergies:
milk, eggs, peanuts, tree nuts, fish, shellfish, soy, and wheat. An allergic persons reactions
to these foods can range from a tingling sensation around the mouth and/or hives to
rapid, life-threatening reactions.
Children with food allergy are two to four times more likely to have other related
conditions such as asthma and other allergies, compared to children without food
allergies. According to the report, more than 30 percent of children with a food allergy also
had reported a respiratory allergy, compared with 9 percent of children with no food allergy.
QUICK TIP: Children with food allergies are more likely to have respiratory
allergies.
Risky Business: Driving Without a License

One in 25 U.S. 9th, 10th, and 11th graders drive at least
one hour a week without a drivers license. This is according
to a new study, Unlicensed Teenaged Drivers: Who Are They,
and How Do They Behave When They Are Behind the Wheel?
The study was published in the November issue of the journal
Pediatrics.
Researchers surveyed 5,665 teens on driving behaviors, including whether or not they drive without a license. Unlicensed drivers were less likely to wear seat belts. They were also more likely
to drive under the influence of alcohol or drugs and report trips
without a purpose.
There was no direct correlation between license status and
car crashes. According to the researchers analysis of federal data,
however, unlicensed teens are more likely to be involved in a fatal
car crash.
Unlicensed drivers were more likely to live in rural or central city
districts and to report lower grades in school. Of the unlicensed
drivers, 28 percent had taken a drivers education class, and 50
percent reported that their parents helped them learn to drive.
The study authors recommend additional research to better understand the barriers that prevent teens from successfully
completing drivers license requirements.
QUICK TIP: Do not allow unlicensed teens to drive, no
matter how much they may want to.

Q&A
To submit questions to Healthy Children, send an e-mail to [email protected]

or write to American Academy of Pediatrics, attn: Healthy Children Magazine
141 Northwest Point Blvd., Elk Grove Village, IL 60007
Ask the Pediatrician

Solving the Riddles of Parenthood
1. Brushing Up
Q: When should I begin cleaning my babys teeth? When should she first visit a dentist?
A: Dental care is extremely important for babies, even before they begin
teething. The American Academy of Pediatric Dentistry recommends you
begin cleaning your babys teeth when she is still a newborn. Starting at birth,
clean her gums with a soft infant toothbrush and water.
As for seeing a dentist, First visit by first birthday sums it up. Your child
should ideally visit a pediatric dentist within six months of when her first
tooth comes in, but no later than age 12 months. Early examination and
preventive care will protect your childs smile now and in the future..
Unfortunately, the U.S. Centers for Disease Control and Prevention still reports
that dental decay is one of the most common chronic infectious diseases among
U.S. children. This preventable health problem begins early 17 percent of
children ages 2 to 4 years have already had decay. By the age of 8, approximately
52 percent of children have experienced decay, and by the age of 17, dental
decay affects 78 percent of children. In contrast, children with healthy teeth chew
food easily, learn to speak clearly, and smile with confidence.
QUICK TIP: Start cleaning your babys teeth and gums immediately
after birth.
invite your children to help prepare a meal around a holiday
theme. For example, on the Fourth of July, you could prepare
Q: I am looking for games my four children ages
a red, white, and blue lunch or dinner. What could be more
7 to 12 can play indoors, especially on rainy days.
fun than an appetizer of blue corn tortilla chips topped with
I dont want them to be couch potatoes, but I have a
Swiss cheese and a grape tomato? Consider a main meal of
very small budget. Any suggestions?
baked chicken, mashed potatoes with a few drops of blue
food coloring, and chilled beets. For dessert? An American
A: When the weather outside is keeping kids inside, theres
flag made from a white cake mix topped with alternative
nothing more challenging for a parent than bored children.
stripes of whipped topping, strawberries/cherries, and
Here are a few suggestions. (Before you begin, set some
blueberries (or strawberry and blueberry jam).
ground rules and make sure everyone gets to take a turn.)
77 Treasure Hunt: Hide prizes apples, coins, vouchers
QUICK TIP: Rainy days can be a good time to play games with
to skip a chore, etc. around your house. Divide your
your children.
children into two teams, draw a map, and see who wins.
2. Games Children Play
77
Dance Fever: Each kid picks a song and the others follow
their motions.
77
Simon Says: In this version, however, Simon moves quickly!
77
Story Tellers: Turn your children into their favorite storybook

characters while you read along.
77
Playing with Food: For a daring yet less energetic activity,

3. Puppy Love
In addition, consider these precautions:

Look for a dog with a gentle disposition. An older
animal is often a good choice for a child, because a
puppy may bite out of sheer friskiness. But, avoid older
dogs raised in a home without children.
77
Q: Now that the new First Family has gotten a
puppy, my three children, ages 5, 7, and 9, want a

new best friend, too. While my wife and I think
having a pooch in the family would be fun and a
good learning experience for the kids, we have never
had a pet before. What should we know before we
choose a dog? What concerns should we have?
A: Your very own dog can bring immense joy and companionship
to a family. However, be sure your children are mature enough
to handle and care for a dog. Most children are ready for the
responsibility of a pet by the age of 5 or 6. Younger children
have difficulty distinguishing an animal from a toy, and they may
inadvertently provoke a bite through teasing or mistreatment.
77
Treat your pet humanely so it will enjoy human

company. Dont, for example, tie a dog on a short rope
or chain, since extreme confinement may make it
anxious and aggressive.
77
Never leave young children alone with an animal. Many

bites occur during periods of playful roughhousing, because
a child doesnt realize when the animal gets overexcited.
77
Teach your child not to put her face close to your dog.
77
Dont allow your child to tease your dog by pulling its

tail or taking away a toy or a bone.
77
Make sure your children dont disturb your dog when

its sleeping or eating.
77
Take your dog to the vet as scheduled and keep its

immunizations up-to-date.
77
Obey local ordinances about licensing and leashing

your dog. Be sure it is under your control at all times.
77
Teach your children how to greet your dog. Your children

should stand still while the dog sniffs them; then they
can slowly extend their hand to pet the animal.
QUICK TIP: Treat a pet as part of the family.
4. Hard to Swallow
Q: My one-year-old son frequently tries to put small objects in his
mouth. Is this common?
A: You are not alone. Toddlers are notorious for swallowing foreign objects.
In fact, Childrens Hospital Boston has compiled a collection of swallowed
objects that were either ingested or aspirated and removed by Childrens
doctors between 1918 and 1962. It includes 120 items and is on display outside
Childrens Otolaryngology Clinic.
You can also check out the collection and advice from pediatricians at www.
childrenshospital.org/gallery/index.cfm?G=37.
To help your child avoid a potential emergency room visit, the AAP recommends
keeping the following household items away from infants and young children:
77 Balloons
77 Small balls
77
Coins
77
Pen or marker caps
77
Marbles
77
Small button-type batteries
77
Toys with small parts
77
Medicine syringes
77
Toys that can be squeezed to fit

entirely into a childs mouth
QUICK TIP: Do not feed children younger than 4 years round, firm food
unless it is chopped completely.

On the
Home Front
Help your children deal with

the stress of deployment.
By Tamekia Reece
eployment is heart wrenching for all military

families, but especially for families with
children. As mom or dad tries to take on both
parenting roles and cope with not having a
partner for a long stretch of time, the kids have their own
stress issues. Johnny, the toddler, may not understand why
Mom isnt there to tuck him into bed. School-aged
Brittany may worry Dad will be hurt like her friends dad.
And, Billy, dealing with the usual adolescent issues, now
has to deal with his anger that Dad had to leave in the first
place, along with new household responsibilities.
Although deployments will never be easy, there are
things you can do to make it a little less stressful for your
child.
Educate Yourself
Before a parent is deployed, one of the most beneficial
things to do is educate yourself, says Col. Elisabeth
Stafford, M.D., FAAP, a clinical professor of pediatrics at
the University of Texas Health Science Center at San
Antonio. There are many programs and other resources
available to inform family members about what to expect
with deployment, possible feelings and reactions of the
homefront caregiver and children as the deployment
begins, and things to expect as the service member
returns from deployment, she says.
If youre prepared about what to expect, you wont feel
so thrown for a loop and will be better equipped to
handle it if you or your child has a difficult time with the
deployment, Dr. Stafford says.
Share and Listen

Probably the most important thing you can do to help
alleviate some of your childs deployment-related stress
is to talk with him about it and listen. Be open to
answering your childs questions in as straightforward
and age-appropriate way as possible, Dr. Stafford says.
And remember, kid see, kid do. You dont have to
suppress your feelings, but, if your children see you really
stressed and falling apart, that can stress them out and
they may echo your reaction, says Lt. Col. Molinda
Chartrand, M.D., FAAP, a developmental/behavioral
pediatrician in the U.S. Air Force.
Its okay to cry, be sad, or be worried, but talk about it
with your child. Explain youre crying because youre sad
dad is gone, but also reiterate to the child that you love
him and will always be here for him, Dr. Chartrand says.
That sends the child a dual message that its okay to have
feelings, and even though youre sad right now, youre
there to support the child.
Monitor What They See

News reports of bombings and death, especially in areas
where they know their parent is, may be stressful to kids, so
you need to monitor access to those types of things.
With older kids, Dr. Stafford says, you may not be able to
keep them from being exposed since they may have related
school projects or may hear others talking about it in school.
In those cases, parents need to take the opportunity to talk
with teenagers about what theyre reading in the newspaper,
discussing in school, or seeing on the news, Stafford says.
Quick Tips: Deployment Resources

www.deploymentkids.com
77 National Military Family Association: www.nmfa.org
77 Talk, Listen, Connect: Helping Families Cope with Military Deployment:
http://www.sesameworkshop.org/initiatives/emotion/tlc
77 Military Youth Coping With Separation: When Family Members Deploy [Video]
Military One Source (www.militaryonesource.com)
77 I Miss You!: A Military Kids Book About Deployment by Beth Andrews (Prometheus Books, 2007)
77 My Mommy Wears Combat Boots by Sharon G. McBride (AuthorHouse 2008)
77

Quick Tips:
Symptoms of
Deployment Stress
Experts say deployment stress symptoms may vary
depending on the childs age. Some symptoms may include:
77
Babies: Feeding and/or sleeping difficulties, increased

irritability, low energy
77
Toddlers and Preschoolers: Aggressiveness,

clinginess, changes in eating or sleeping habits,
crying more often
77
Elementary age: Regression (reverting back

to baby talk or bedwetting), changes in eating
or sleeping patterns, physical complaints like
stomachaches or headaches
77
Adolescents: Anger, moodiness, loss of

interest in normal activities; risky behavior
such as smoking, drinking, drug abuse,
or sexual activity.
Maintain Closeness
Although the deployed parent is far away, he or she can remain
close in the kids hearts. A stuffed animal, necklace from mom, or
a t-shirt with dads photo on it can go a long way in helping the
child feel closer to her deployed parent.
Some other ways to maintain closeness are pointing out on a
map where the deployed parent is, letting the child send e-mails,
cards and letters to the parent, letting her help prepare care
packages, and even jotting down family life and hometown
changes in a journal to keep the absent parent updated.
Keep Them Busy But Not Too Busy

If your child is used to having a play date on Tuesdays or going
to child care in the mornings, try to keep doing those things. The
family is already experiencing a huge change from a deployed
parent, so if normal routines also change or cease, stress levels may
increase more, Stafford says.
Just dont go overboard keeping your child busy. Trying to push
hurt feelings or questions from your childs mind by overscheduling
him wont work. Itll only cause him more stress and burnout.
Call in Help
If you notice your kids behavior seems very extreme, it seems
to go on for a long period of time, it gets worse instead of getting
better over time, or you or your child is very anxious, worried and
10 Healthy Children Summer/Back to School 2009
obsessed about the safety of the deployed service member and are
finding it difficult to separate from that, you should seek help
whether its from a military support group, a military
physician, your childs pediatrician or a mental health
professional, Dr. Chartrand says.
Although it can be tough to admit youre having trouble handling
your partners absence, or you may feel frustrated because you cant
miraculously make your child feel better, dont let it stop you from
getting help. Deployments are stressful for everyone, and getting the
help thats needed will benefit the entire family. c
Home, Sweet Home?

Although it may seem the childs stress should disappear
when the deployed parent returns home, it may actually
increase because the parent may return with physical or
mental health issues, or the child may not want to get too
close to the parent to avoid the pain of saying goodbye
again if the parent is redeployed, says Col. Elisabeth
Stafford, M.D., FAAP, a clinical professor of pediatrics. If you
notice your childs stress remains or increases after the
deployed parent returns, individual counseling and/or
family counseling may help.
2009 National Art Contest

Its time for children to express their artistic side for a good cause! The 2009 AAP National Art Contest will feature the
theme, Protecting Children from Tobacco Smoke.
Boys and girls who are in 3rd grade through 12th grade are all eligible to enter. Entries will be categorized by grades
3-5, 6-8, and 9-12.
Winners from each group will be invited to the presentation ceremony at the 2009 AAP National Conference &
Exhibition, to be held in Washington, D.C., on Saturday, Oct. 17. Each category will have one first-place winner and a
second-place winner.
Winners receive:
First place: $500 and up to $1,000 for travel-related expenses
Second place: $250
All winners schools will be awarded matching cash amounts. Winning artwork will be featured at the AAP Web site
and in promotional materials.
To enter, your child should submit

an original piece of artwork to:
National Art Contest
141 Northwest Point Blvd.
Elk Grove Village, IL 60007
Official entry forms and consent forms are required
along with the artwork, and are available at www.aap.org.
All entries in the contest must be postmarked by
July 31, 2009. Winners will be selected by a panel
of expert judges and will be announced during the summer.
The contest is an initiative
of the AAPs Julius B. Richmond
Center and is supported by
the Flight Attendant Medical
Research Institute.
SIDS and Our Babies

Silent and unexpected, Sudden Infant Death Syndrome (SIDS)
robs seemingly healthy babies of their lives, leaving parents and
families haunted with guilt, loss, and grief. But, over the past 15 years
with the introduction of the nations Back to Sleep campaign experts have introduced
proactive steps parents can take to reduce their babys risk, while researchers are unraveling the
mysteries of this disorder.
By Mary Best
loaked in mystery and superstition, SIDS has claimed

the lives of babies for centuries. As medical science
has advanced, scientists have ruled out a host of
theoriesfrom curses and murder to disease and
suffocation. In 1969 the National Institutes of Health applied the
term SIDS as a specific medical disease.
The reasons why a baby dies of SIDS, however, remain a
diagnosis of exclusion.
Most babies who die of SIDS appear perfectly normal, says
Rachel Y. Moon, M.D., FAAP, a pediatrician at Childrens
National Medical Center, in Washington, D.C., and a member of
the American Academy of Pediatrics SIDS Task Force. We do
know that there are demographic and environmental risks, she
adds, including African American and American Indian babies,
infants who are born to women who smoked during pregnancy,
very young women, and preterm and low birth weight infants.
But no baby is absolutely safe from SIDS, says John
Kattwinkel, M.D., FAAP, chair of the AAPs SIDS Task Force.
What the Research Says

There is good news, however. Although SIDS stills lurks in the
nightmares of new parents, researchers are uncovering scientific
evidence of its causes. The following are among the most significant.
According to research funded by the National Institute of
Child Health and Human Development (NICHD), infants who
die of SIDS have abnormalities in the brain stem, which controls
heart rate, breathing, blood pressure, temperature, and arousal.
The finding is the strongest evidence to date suggesting that
differences in a specific part of the brain may place some infants
at an increased risk for SIDS.
This research also explains why stomach sleeping and soft
bedding increases a babys risk of re-breathing his or her own air.

When they arent getting enough oxygen, most babies will do
something to change their environment theyll turn their
heads, or theyll sigh, or theyll yawn, says Dr. Moon. But babies
who die of SIDS dont wake up when they get into trouble, and
we dont fully understand why.
Another important medical study suggests SIDS babies suffer
from a triple-risk model. According to the NICHD, infants
who die of SIDS are in a critical stage in the development of
their immune, cardiovascular, and respiratory systems;
susceptible to risks during this stage because of an underlying
muscular weakness or neurological defect; and affected by an
environmental cause such as stomach-sleeping or soft bedding.
In addition, an Australian study found that bacterial
infections, such as Staphylococcus aureus, might be a cause of
SIDS. And a Rhode Island study revealed that babies whose
hearing was worse in their right ears at three different
frequencies were more likely to die of SIDS.
But while researchers make medical strides, parents need to do
their parts to reduce the risk of tragedy because SIDS can
strike anyone, anytime, anywhere.
Sadly, I know.
Losing My Will
When my doctor told me I was pregnant in the fall of 2006, I
was speechless. The only words I could utter were, holy
mackerel. Contrary to what the doctor thought, I was overjoyed
shocked, but overjoyed.
I barely remember driving home. I had left a few hours earlier
certain I had the flu, and now I was turning into our driveway
continued on page 14
SIDS is
77
A disease of the unknown. SIDS is the sudden death of an infant younger than 1 year of age. The cause of death
remains unexplained after a complete investigation. This includes an autopsy, examination of the death scene, a review of
the infants health, any other important medical history. The cause of death is considered a diagnosis of exclusion. SIDS is a
recognized medical disorder.
77
A major cause of death. SIDS is one of the leading causes of death for infants 1 month to 1 year of age. Most deaths
occur between ages 2 and 4 months; 90 percent of SIDS deaths occur before 6 months of age. Approximately 2,500
babies in the United States die of SIDS each year seven babies each day. SIDS claims more lives each year than AIDS,
cancer, heart disease, pneumonia, muscular dystrophy, cystic fibrosis, and child abuse combined. As a result of the national
Back to Sleep Campaign, launched in 1994 as a joint effort between First Candle/SIDS Alliance, the American Academy of
Pediatrics, and National Institute of Child Health and Human Development, SIDS rates have declined significantly.
According to the National Center for Health Statistics, 4,890 infants died of SIDS in 1992; in 2004, 2,246 SIDS deaths were
recorded in the United States.
77
Also called crib death. Most SIDS deaths occur while infants are sleeping, so the disorder is also called crib death or cot
death. But not all SIDS deaths occur in a babys crib. Many have died in car seats, public places, strollers, etc. Some infants
have even died in their parents arms.
77
Like a thief in the night. Most SIDS babies appear to be healthy prior to death. A SIDS death happens quickly and
silently, with no signs of suffering.
77
Non-discriminatory. While SIDS occurs in all socio-economic, racial, and ethnic groups, African American and Native
American babies are two to three times more likely to die of SIDS than Caucasian babies.
77
More harmful to boys. 60 percent of SIDS victims are male; 40 percent are female.
77
Affected by weather. More SIDS deaths occur in the colder months.
77
Devastating to parents. Nothing can be done to save the life of a SIDS baby.

SIDS is not
77
Predictable. There are no signs.
77
Painful. SIDS is not a cause of pain and suffering for the infant.
77
New. SIDS has been referenced throughout Western culture, including in the Old Testament.
77
The result of Shaken Baby Syndrome or child abuse. Experts estimate that child abuse accounts for less than 5 percent of
all the SIDS cases recorded each year.
77
An ill child. Often the only thing that can be seen medically wrong with a child prior to a SIDS death is a slight cold or the
sniffles. Some babies were unusually fussy in the hours preceding their death, but these babies had no serious medical
conditions and their deaths are a shock not only to the family but also to the physicians looking after the babies.
77
Contagious or infectious.
77
Hereditary.
77
A true syndrome. To call it a syndrome would mean it would have symptoms, and in the case of SIDS, death is the sole symptom.
77
A fatal condition of small, weak, or sickly babies. SIDS occurs to healthy and robust babies.
77
Caused by the immunizations. Most children get their immunizations at about four months of age, which coincides with the
average age of a SIDS baby. Children who were never vaccinated have also died of SIDS. Deaths due to vaccine reactions or child
abuse are not classified as SIDS deaths; however this has been implicated as a possible factor in SIDS deaths.
77
Caused by smothering. If a baby was found face down or with bedclothes over the face it might be thought that smothering was
the cause of death. Sometimes babies are covered with bedclothes, but others are found uncovered and free of bedclothes entirely.
While it is possible for an infant to smother accidentally and the incidence of smothering appears to be increasing this is still
somewhat rare. Not uncommonly the child is lying undisturbed as when last put to bed.
77
Caused by allergies.
77
Caused by poor, bad, or uneducated parents. SIDS happens to parents of all economic, social, educational, and racial
groups. Some cultures do not report SIDS deaths or have no way to classify SIDS and this often leads some to say that there are
no SIDS deaths in that area, which is misleading.
77
The cause of every unexpected infant death.
continued from page 12

searching for the right words. Any words. I parked the car,
and my husband greeted me at the door.
We need to talk, I mumbled.
We sat down on the sofa, and through a rush of tears, I blurted
out that he was going to be a dad. Ill never forget the happiness
that filled his face.
Even after telling our parents and siblings, I still couldnt
believe the news. Over the next week, I bought several home
pregnancy tests just to make sure.
Months passed. By Christmas, we had learned we were having
a boy, and test after test indicated our son was healthy. We
decided to name him after our fathers James William. We
would call him Will.
Will made his grand appearance in the world on May 8, 2006.
Even though the delivery was difficult, my healthy little miracle
weighed 8 pounds, 2 ounces, and James took us home about 36
hours later.
That summer was the happiest time of my life. James accepted
a new job, enabling me to stay home with our little prince.

On September 12, I took Will for his four-month checkup and
first series of immunizations. Will and our pediatrician were like
old friends, and after their usual playtime, Dr. Patel bragged that
our little guy was fit as a fiddle.
Two nights later, we followed our regular routine a bath,
grooming, pajamas, prayers, goodnight kisses, and bedtime. I checked
on him around 11, and he was sleeping soundly on his back.
About 3:45 I woke up to check on him again, like I did every night.
When I walked into his room, I sensed something was terribly
wrong. Through the darkness, I could see he had rolled over and
was face down in his crib. To my horror, he was not breathing. I
applied CPR, woke my husband, called 911, and continued CPR.
But he was gone.
A few hours after this hellish nightmare began, the police,
detectives, EMTs, and coroner took my son away. Along with a
part of me.
More than two years later, I still suffocate from grief and guilt.
Nothing in my life will ever hurt as much as losing my son. c
Steps to Reduce the Risk of Sudden Infant Death

The following are recommendations from the American
Academy of Pediatrics (AAP) and the National Institute for Child
and Human Development (NICHD) for reducing your babys
risk of suffocating or dying from SIDS.
1. Back is best. Always place your baby on his or her back to
sleep, for naps and at night. The back sleep position is the
safest, and every sleep time counts. Side and tummy
positions are unsafe.
2. Mattress and crib safety. Place your baby on a firm sleep
surface, such as on a safety-approved crib mattress, covered
by a fitted sheet.
3. Bed behavior. Never place your baby to sleep on pillows,
quilts, sheepskins, or other soft surfaces. This includes sofas,
chairs, cushions, waterbeds, etc. Also, keep soft objects, toys,
and loose bedding out of your babys sleep area. Dont use
pillows, blankets, quilts, sheepskins, and pillow-like crib
bumpers in your babys sleep area, and keep any other
items away from your babys face.
4. Bed sharing. Keep your babys sleep area close to, but separate
from, where you and others sleep. Your baby should not sleep in
a bed or on a couch or armchair with adults or other children,
but he or she can sleep in the same room as you.
5. Breast is best. Experts recommend that mothers breastfeed
through the first year of their babys life. According to the
AAP, breastfeeding is thought to help protect infants.
6. Beat the heat. Overheating can increase your babys SIDS

risk. To help keep your baby from overheating during sleep,
dress your baby in light sleep clothing, and keep the room
at a temperature that is comfortable for an adult.
7. Smoking prohibited. Do not allow smoking around your
baby. Dont smoke before or after the birth of your baby,
and dont expose your baby to secondhand smoke.
8. Pacifier pleasers. Research published in the Archives of
Pediatrics & Adolescent Medicine indicates that pacifiers may
help reduce the risk of SIDS. Use a clean, dry pacifier when
placing your infant down to sleep, but dont force the baby
to take it. If you are breastfeeding, wait until your baby is
one month old before using a pacifier.
9. Air supply. According to another study published in the
Archives, having a fan in the room where your baby sleeps
was found to reduce the risk of SIDS by 72 percent. More
research is needed to confirm these results, and fans cannot
take the place of your baby sleeping on her back.
10. False confidence. Avoid products that claim to reduce the
risk of SIDS because most have not been tested for
effectiveness or safety. If you have questions about using
monitors for other conditions talk with your pediatrician.
11. Tummy time. Provide tummy time when your baby is
awake and someone is watching its a good way to help
baby strengthen muscles. Change the direction that your
baby lies in the crib from time to time.
Spread the Word
This places the child at much greater risk for SIDS.

This risk can be greatly reduced by talking with those who
care for your baby, including childcare providers, babysitters,
family, and friends, about placing your baby to sleep on his or
her back at night and during naps.
According to the American Academy of Pediatrics, 32

percent of infants are in childcare full-time, two-thirds of U.S.
infants younger than 1 year spend their days in non-parental
childcare, and infants of employed mothers spend an average
of 22 hours per week in childcare.
Sadly, the increased risk of an infant dying of SIDS while
someone else is caring for him or her is as much as 18 times
higher than when he or she is with his or her parents.
Approximately 20 percent of SIDS deaths occur while an
infant is under the watch of a nonparental caregiver. About
one-third of SIDSrelated deaths in childcare occurs during
the first week, and one-half of these occur on the first day.
Why? No one is certain, but it is believed that childcare
providers sometimes place infants on their tummies to sleep,
even though they are accustomed to sleeping on their backs.

To Learn More
77 American Academy of Pediatrics: www.aap.org
77 American SIDS Institute: www.sids.org
77 Association of SIDS and Infant Mortality Programs:
www.asip1.org
77 CJ Foundation for SIDS: www.cjsids.com

77 First Candle/SIDS Alliance: www.firstcandle.org
77 National Institute for Child and Human Development:
www.nichd.nih.gov/sids/sids.cfm
Well-Child Care
a Check-Up
for Success
By Tracy A. Mozingo
You visit the pediatrician when your child is sick, but well-child care is an
important part of keeping children healthy, too.
aking your child to the doctor for an allergic reaction,

an ear infection, or labored breathing is only one type of
visit. When I take Josh, my 1-year-old son, to the
pediatrician, Im relieved when the visit is one of his
well-baby check-ups. Many parents view this well-child visit as a
time for scheduled vaccinations and to see how much your child
has grown in the past few months.
However, well-child care also is a chance to raise questions and
concerns about your childs development, behavior, and general
well-being questions that are difficult to discuss during sick
visits. For instance, pediatricians are used to discussing common
concerns with parents such as eating, sleeping, toilet training,
social behaviors, as well as attention and learning problems.
Having regular well-child visits with your childs doctor and
raising the concerns that matter most to you are key ingredients
in helping the doctor know you and your child, and in forming a
reliable and trustworthy relationship The American Academy of
Pediatrics (AAP) Department of Research recently conducted 20
focus groups with parents and 31 focus groups with pediatricians
and pediatric nurse practitioners to gather recommendations
about how to make the most of the well-child office visit. From
these sessions, four themes emerged:
77
Pediatricians and parents share the goal of healthy children.
77
Pediatricians want the well-child visit to best serve the

needs of children and their families.
77
Pediatricians are experts in child health, but parents are

experts on their child.

77
A team approach can best develop optimum physical,

emotional, and developmental health for the child.
Making the Most of Doctor Time

In our study that included parent and pediatrician focus
groups, we found that both groups felt an ongoing, continuous
relationship between family and pediatrician was a first
requirement for high quality care, said Lane Tanner, M.D.,
FAAP, associate director, Division of Developmental and
Behavioral Pediatrics at Childrens Hospital and Research Center
in Oakland, Calif. That continuity of care helps build trust, and
that can lead to better communication at the well-child visit.
Creating a list is another way to ensure you get all the
information you need. Jotting down three to five questions and
bringing them to the visit will help you focus on your issues of
concern and start the dialogue with your pediatrician.
Any question that reflects your concern about your childs
development, behavior, sleep, eating or relations with other
members of the family is appropriate, suggested Martin T. Stein,
M.D., FAAP, professor of pediatrics at the University of
California San Diego Rady Childrens Hospital. Asking what
you can do to help your childs development and learning is
probably the best question.
Other ideas include researching Web sites, pamphlets, and
books that describe age-specific developmental skills and typical
issues your child may be experiencing. Knowing what to expect
makes the new feel more familiar (and less scary).
Talk to others who may care for your child the other
parent, a grandparent, child caregiver and ask for their input.
Healthy Children Healthy Children Summer/Back to School 2009 17
They may notice something different to offer a new perspective,

Dr. Stein offered.
According to Dr. Tanner, parents shouldnt hesitate or feel
embarrassed to share information that further opens the doors of
communication. As your childs most important advocate, you
have valuable information that will help your doctor better
understand your child and your family, he said.
An Ounce of Prevention
Immunizations are a big part of the preventive care visit, but
talking about other topics can be helpful. Pediatricians also
address safety in the home and at the playground, optimal
nutrition, toilet training, and environmental concerns such as
lead paint exposure.
A lot of first-time parents like me may not realize that they can
ask about any and everything related to the care of their child
medical or not.
I recommend talking about what you see as either a special
trait or a concern about your child, Dr. Stein explained. This
helps your pediatrician get to know you and your child on a more
personal level. And pediatricians also like to know how much you
appreciate their care. This helps build a stronger bond with your
family. We can all use positive feedback!
A Healthy Future
The AAP developed a set of comprehensive health supervision
guidelines for well-child care, called Bright Futures, for
pediatricians to follow. Its mission is to promote and improve the
health, education, and well-being of infants, children, adolescents,
families, and communities.
Some pediatricians send out reminder cards for these planned
appointments, much like dentists offices do for semiannual
cleanings. This was one of the recommendations that emerged
from the focus groups.
Well-child care is so important, stresses Dr. Tanner. Taking
your child to the doctor when he or she is feeling under the
weather is simply not enough. The AAP recognized the need for a
schedule of visits to the pediatrician because when you know a
visit is approaching, you can prepare for topics of discussion.
Starting the dialogue can lead to a healthier life for you child
overall, and that is the ultimate goal.
For a complete schedule of recommended well-child visits, see
the Schedule of Well-Child Care Visits below. c
Schedule of Well-Child Care Visits
4 years
3 years
30 months
24 months
18 months
15 months
12 months
9 months
6 months
4 months
3 to 5 days
1 month
2 months
Visits can include physical measurements, patient history, sensory screenings, behavioral assessments,
and planned procedures (immunizations, screenings and other tests) at the following suggested intervals:
And once every year

thereafter for an
annual health
supervision visit that
includes a physical
exam as well as a
developmental,
behavioral, and
learning assessment.
Source: American Academy of Pediatrics Bright Futures Recommendations for Pediatric Preventive Health Care 2008
Make Time for a Medical Home

A medical home is the place where you put your primary trust in your childs healthcare.
Simply put, its the pediatricians office where you take your child for continuing healthcare. Your childs
complete records are on file here, and you can find help for all other healthcare services including referrals
when needed.
According to the American Academy of Pediatrics, a medical home provides primary care that is accessible,
continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. The goal is
to provide good preventive care for children, to make sure they get the most appropriate treatment based on
their health history. For children who have chronic conditions, such as asthma or diabetes, this is particularly
important.
You can learn more about the medical home at www.medicalhomeinfo.org.
Newborns
The New Kid
Love eventually conquers all, but expect battles

ahead when you add another child to your brood.
By Cari Jackson
ts easy to lose yourself in daydreams of

having a perfect growing family. You bring
your newborn home, and your older
child immediately takes to cooing over his
little sister. From that point forward, you see
happy family time, meltdown-free.
Fat chance. Imagine if you said, Im
bringing home a new wife, says Cheryl
Hausman, M.D., FAAP, medical director
of the Children Hospital of Philadelphias
University City Primary Care Center.
This isnt much different. Your child will
most likely feel anger and jealousy toward
this intruder. Each child expresses it in
different ways and to varying degrees, and
some children suppress these emotions
altogether. But expecting your child to
welcome a new baby with complete and
unwavering loyalty, Dr. Hausman says, is
an unreasonable expectation.
While jealousy will also appear in older
children, Ben Siegel, M.D., FAAP, Professor
at Pediatrics at Boston University School
of Medicine, says the reaction may be
particularly strong in egocentric toddlers.
Up to 2 1/2, everything revolves around
the child, Dr. Siegel says. There will be
anger, and though he dislikes the term,
there could also be regression. You might
say goodbye to potty training and hello
again to your toddlers desire to breastfeed.
There may be aggression, biting, and
kicking, says Dr. Siegel, incoming chair of
the AAP Committee on Psychosocial
Aspects of Child and Family Health.
Children of all ages fluctuate along an
emotional scale similar to the Kbler-Ross
stages of grief. This scale includes denial,
anger, bargaining, depression and acceptance, and is named after the

psychiatrist who created itDr. Elizabeth Kbler-Ross. And you
dont stay in acceptance at the very end, warns Dr. Hausman,
herself a mother of six. Just because a kid says Im ready one day,
doesnt mean theyll feel that way the next.
The goal isnt to stop these emotions you cant. Parents can
only give children the tools to work through these very real and
understandable feelings.
Lay the Foundation

As soon as parents plan to have another child, they can
introduce the idea through conversations and play. Tell children,
Youre going to have a new brother or sister one day because we
love kids and we want more than one, says Dr. Hausman. She
advocates honesty early on. Children will notice changes brewing,
and without the proper information, their imaginations may
conjure fantasies far worse than reality.
For children under 5, parents can play with baby dolls,
describing what babies do. Kids learn about the world and
experience their emotions through play, Dr. Siegel explains.
Parents can read childrens books about new babies (see sidebar).
Whether or not a toddler under 2 1/2 appears to understand, these
activities plant a seed of awareness.
Preschools play an important role. Let teachers know about the
new sibling. Teachers can use the opportunity to talk with
everybody about it, Dr. Siegel says. There should be a connection
in school to the home, because so much play takes place there.
Where there is play, there is emotional development.
Once a mother is pregnant, children older than 4 or 5 will ask a
lot of questions: how did the baby get in there? How is it going to
get out? Siegel encourages parents to take their first opportunity
for sex education. Tell them, When Mommy and Daddy love
each other, they make a baby. Explain to older children that the
baby comes out through the birth canal. You might even show
them pictures, to which a kid (and plenty of adults) will reply,
Ick. The important thing is to answer questions honestly, but
not with so much detail that you overwhelm the child with too
much information for her age.
Team Family
Every family member should play a role in decision-making.
Include children by inviting (but not demanding) their help
decorating the nursery, picking out clothes, or choosing a name.
Toddlers under 2 1/2 will not want to share, but parents can ask older
children, What special toy of yours would you want to give the baby?
Reinforce a childs self-esteem by using special language my
big boy, my grownup girl. Now is not the time to push children
into major changes, like toilet training. Complete that process
months before the baby arrives, or else wait until several months
later to begin it.

The AAP supports prenatal pediatric visits. Parents, sans kids,

can use this visit to discuss how else they can help their older
children, as well as address any other worries they may have.
D-Day
While it wouldnt be appropriate for younger children, you may
invite a child older than 5 into the delivery room. If your doctor
and the hospital allow it and if your child appears emotionally
ready, the event could be a powerful bonding experience. If the
father needs to be at the mothers side, make sure someone else
can attend to the child at all times.
If your child wont be present, bring him to meet his new sibling
as soon as the baby is born. The shorter the separation between
the older child and the family, the more reassuring it will be.
Home Again
While a newborn demands an exhausting amount of attention,
especially from a nursing mother, it is crucial to give older children
special attention during this period. Continue to use special language
big brother,my big boy to bolster his self-esteem.
Enlist the childs help in burping the baby, bringing diapers, or
singing to the baby. Both parents should plan special outings just
with the older child.
Call upon extended family and friends to spend time with the
older child. Children have the capacity to develop attachments to
multiple people, Dr. Siegel says. The greater the number of
attachments, the easier the transition.
Maintain family rituals. If somebody used to read at night, if
theres playtime at night, that has to continue, Dr. Siegel says.
Continuity is key.
Children may experience feelings that they dont recognize.
Parents come in all the time and theyll say, Oh, he loves giving
hugs to the baby, Dr. Hausman says. But those hugs can be too
much for the infant. So, never leave your child alone with a newborn.
If your child is acting out, you cant let the behavior slide, but
you also have to understand the context, Dr. Hausman says. Have
discussions around the behavior, and use timeouts, especially in
response to aggression.
Always ask for rather than demand babysitter services of teenage
children. Offer compensation, either in a babysitters salary or with
privileges. And if they dont want to do it, respect their wishes.
Neverending Story
The dismay and the beauty of this transition period is that it
never ends. As the new baby grows and gets into the older childs
toys, an older child who has been patient up to this point may lose
it. Everyone in the family is constantly adapting to new roles.
The process of working it out is what families are all about,
Dr. Hausman says. Enjoying that is the best piece of advice I
could give. c
Teens and
Immunization
By Sam Gaines
Immunizations dont end with childhood. Heres what you need

to know to stay on top of the schedule and keep your adolescents
healthy and well.
abies? Of course. Toddlers? Naturally. When it comes to

immunization, though, most of us just dont think of
older children adolescents, in particular in terms
of their vaccination needs. But immunization is just as
important for a pre-teen or teenager.
Research published in the American Medical Associations
Archives of Pediatric and Adolescent Medicine in March 2007
found that teenagers age 14 and older were much less likely to see
a pediatrician than their younger-adolescent counterparts. In fact,
adolescents age 11 to 14 had three times more visits to
pediatricians than the older teens.
Some people dont realize that their kids should be seen
annually once they reach school age, says Ari Brown, M.D.,
FAAP, a pediatrician in private practice in Austin, Texas. Dr.
Brown is also the author of Baby 411. And of course, no one likes
getting shots, including teens. But the reality is that they need to
be protected against things like bacterial meningitis, tetanus, and
whooping cough, among others. Its much less painful to get a
shot than to suffer from these diseases.
Staying on Schedule
The CDCs recommended vaccination schedule doesnt end at
age 11. It continues through the later teen years, even if many
parents dont continue bringing their children to the pediatrician
for immunizations and a well-child visit (see article beginning
on page 16).
Immunization rates are 80-95 percent at school entry, says
Harry Keyserling, M.D., FAAP, professor of pediatrics at Emory
University School of Medicine. We know that as children get
older, the vaccine uptake is not that high. Dr. Keyserling points
to the typically slow uptake of new vaccines as a factor with
adolescent immunization. But we anticipate that immunization
rates of the recently recommended vaccines will increase over
the next few years.
Doctors know that staying on schedule with immunizations
isnt easy once children reach their teenage years. Parents just
dont think of this as part of the routine with their teenagers,
says Charles Wibbelsman, M.D., FAAP, chief of the Teenage
Clinic at Kaiser Permanente in San Francisco. A lot of teens may
go several years before coming in to see their pediatrician. Most
of those who do come in for a physical exam are athletes who

need them to participate in their sports. Thats a good thing, but

we also know were not seeing the teens who may be engaging in
riskier behaviors and we need to, for their benefit.
An additional factor, especially now, are the rising copayments associated with regular office visits. Just an office visit
can be a considerable expense for many families now, Dr.
Wibbelsman says. Thats something we need to be aware of as
pediatricians, and talk with our patients about.
The Teen Vaccines

One of the vaccines scheduled for children in the 11- to
12-year-old age group is a very familiar one for most parents:
Tdap, the tetanus/diphtheria/pertussis vaccine. This booster
dose builds on the childhood DTP/DTaP vaccination, and even
adults should receive this immunization in order to help
protect their children. Its also an important vaccine for teens
(ages 13 to 18) who have not received the Tdap vaccine
previously.
Three additional vaccines are vital for children at this age:
Meningococcal: This vaccine prevents the potentially deadly
bacterial meningitis and is vital for college freshmen, teens
entering the military, or those going to a sleepaway summer
camp. It spreads wherever people live in close quarters with
each other. The vaccine is routinely recommended for
children ages 11 to 18 who have not been vaccinated
previously, and is also recommended for some younger
children in high-risk categories.
Human papillomavirus (HPV): There are more than 100
types of HPV, and many of these types show no serious health
concerns. In fact, HPV is the most common sexually
transmitted infection (STI); about 20 million Americans are
infected. The HPV vaccine protects against four types of HPV.
Two of these types are linked to more serious health
conditions, such as cervical cancer. One of the newer vaccines
to gain FDA approval, the HPV vaccine is the first anti-cancer
vaccine. It is very important, says Carrie L. Byington, M.D.,
FAAP, professor of pediatrics and vice chair of research
enterprise at the University of Utah School of Medicine.
Parents need to understand what an opportunity this vaccine
is. You want your child to have protection from cervical
cancer. (See sidebar, Keeping HPV at Bay, on page 24.)
Influenza: As with most other age groups, adolescents need

protection from the flu. The influenza viruses can make you
and your children very sick. Every year, more than 200,000
Americans have to be hospitalized because of the flu and its
complications, and 36,000 die. An annual influenza vaccine is
an important part of protecting your children.
See Vaccination, page 29
Talking to Your Doctor

About Teen Vaccines
Its important for parents to make all their routine
well-child visits so their children dont fall behind with
immunizations, says Harry Keyserling, M.D., FAAP, a
member of the AAP Committee on Infectious
Disease.
If there are financial considerations that are
preventing you from taking your teen in for well-child
visits and immunization, talk with your pediatrician. I
try to make it as easy as possible for parents to come
in, and to let them know that they may qualify for
Vaccines for Children if their child needs a shot
which is a huge cost savings. (More information on
the Vaccines for Children program is available at
www.cdc.gov/vaccines; search for Vaccines for
Children.)
When you see your pediatrician, ask directly, What
vaccines does my child need at this point? says
Carrie Byington, M.D., FAAP, of the AAP Committee on
Infectious Disease. If you have questions about
adolescent vaccines, ask. Some parents find it helpful
to write down questions before the visit. You want to
talk to your pediatrician about developmental and
behavioral issues for adolescent children, too, says
Charles Wibbelsman, M.D., FAAP, of the AAP
Committee on Adolescence.
One more recommendation: Bring your childs
immunization records. Often, health insurance
changes for families because of a job change,
relocation, or other reason, says Dr. Wibbelsman. It
saves a lot of time. Even though your teen is no
longer a baby, keep those records where theyre
within easy reach.
Some clinics and health care organizations now
keep automated records, which minimize delays in
checking records. Also, check to see if your state
keeps an immunization registry, says Dr. Wibbelsman.
Keeping HPV at Bay

Some parents have understandable concerns about
giving the HPV vaccine to their daughters. Is my daughter
at risk in the first place? Will it encourage sexual activity?
Dont condoms protect against HPV?
Unfortunately, myths about HPV and the vaccine
persist. These include:
Myth #1: Theres no need to get the vaccine when
youre very young. The idea here is to prevent
cervical cancer in the first place, which the vaccine
does, not to treat the disease. Protection is most
effective when girls in the 11 to 13 age group receive
immunization. But even older teens who havent yet
received the vaccine can benefit from the protection.
Myth #2: The HPV vaccine may encourage my
daughter to have sex. There is no evidence that the
vaccine triggers or encourages sexual behavior in
adolescents. Its best to keep in mind that the vaccine
protects against cervical cancer and two types of genital
warts. Many other factors that have nothing to do with
HPV or the vaccine affect teenage sexuality. The best
way to help your daughter deal with the pressures and
challenges of sexuality is to talk with her honestly on an
ongoing basis.
Myth #3: Since HPV is sexually transmitted and
my daughter is not sexually active, she doesnt
need the vaccine. She may not be sexually active
now, but at some point she likely will be and the
vaccine will protect her when that day comes. Even if
she waits until marriage to become sexually active, her
husband could be a carrier and not even know it,
potentially exposing her to HPV.
Children
By Trisha McBride Ferguson
Vitamin D:
On the Double
Why experts suggest increasing your childs intake
of this essential vitamin.

f you think your child is getting enough

vitamin D by just drinking milk, youre
probably wrong. Recent studies show that
most children arent getting enough of this
essential vitamin. In October 2008, the American
Academy of Pediatrics (AAP) responded by
doubling the amount of vitamin D it
recommends for babies and children to 400
International Units (IU) per day.
Why Vitamin D?
Quick Tips: Adding it Up

Heres a look at some food sources of Vitamin D:
Food
Cod liver oil, 1 tablespoon
IU per serving* Percent DV**

1,360
340
Salmon, cooked, 3.5 ounces
360
90
Mackerel, cooked, 3.5 ounces
345
90
Tuna fish, canned in oil, 3 ounces
200
50
Sardines, canned in oil, drained,

250
70
Most often associated with milk and sunlight,

1.75 ounces
vitamin D hasnt been top-of-mind for parents
Milk (nonfat, reduced fat, and whole),
98
25
in recent years. Common wisdom says that if

Vitamin D-fortified, 1 cup
youre child drinks milk and plays outside, hes
Margarine, fortified, 1 tablespoon
60
15
getting what he needs, right? Surprisingly, not
necessarily. Were seeing evidence of vitamin D
Ready-to-eat cereal, fortified with
40
10

10% of the Daily value for
deficiency in infants and children of all ages as

vitamin D, 0.75-1 cup
well as adolescents and adults, says Carol
Egg,
1 whole
20
6
Wagner, M.D., FAAP, professor of pediatrics at

(vitamin
D
is
found
in
yolk)
the Medical University of South Carolina. We
know more about vitamin D than we did even
Liver, beef, cooked, 3.5 ounces
15
4
five years ago. Because of lifestyle changes and
Cheese, Swiss, 1 ounce
12
4
sunscreen usage, the majority of the population
*International Units
shows signs of deficiency as determined by
**Daily Value based on recommended 400 IU for children.
measured vitamin D levels in blood.
Vitamin D helps ensure the body absorbs and
Source: National Institutes for Health, Office of Dietary Supplements
retains calcium and phosphorus, both critical for
building bone. A vitamin D deficiency can lead
children, and adolescents, including those who are breastfed.
to rickets, a bone-softening disease that continues
Breastfeeding is the best source of nutrition for infants, explains
to be reported in the United States mostly in children in the first
Dr. Wagner, a member of the AAP Section on Breastfeeding
two years of life. At greatest risk for rickets are infants exclusively
Executive Committee and co-author of the AAPs clinical report
breastfed who do not receive a daily vitamin D supplement.
on vitamin D. However, it is important that breast-fed infants
There is epidemiologic evidence that vitamin D not only
receive supplements of vitamin D. Until it is determined how
makes for strong bones, but may play a role in preventing some
chronic diseases later in life, including those involving the immune much vitamin D a nursing mother should take, we must ensure
and cardiovascular systems, explains Frank R. Greer, M.D., FAAP,
that the breastfeeding infant receives an adequate supply of
professor of pediatrics at University of Wisconsin School of
vitamin D through a supplement of 400 IU per day. Once the
Medicine and Public Health.
child is weaned, a vitamin D supplement is needed throughout
Based on these findings the AAP has changed its previous
childhood and adolescence as well, she adds.
recommendation of 200 IU per day to 400 IU a day beginning in
For formula-fed babies, the requirements are the same. Unless
the first days of life. We are doubling the recommended amount of the child is drinking 32 ounces of infant formula per day, a
vitamin D children need each day because evidence has shown this
vitamin D supplement is required.
could have life-long health benefits, says Dr. Greer, chair of the AAP
Committee on Nutrition and co-author of the AAPs clinical report
Giving Supplements
on vitamin D. Supplementation is important because most
When it comes to giving your child a vitamin D supplement,
children will not get enough vitamin D through diet alone.
theres nothing new about the process. Any chewable
multivitamin supplement for kids that contains 400 IU of Vitamin
Supplements for All
D is acceptable, says Dr. Greer. There are several liquid vitamin
The AAP recommends vitamin D supplements for infants,
See Vitamin D, page 29
Adolescents
The Case for
Eating Breakfast
The first meal of the day may be the most important
especially for children and teens. Heres why.
By Winnie Yu
he morning alarm sounds,

and your sleepy-eyed teen
rolls over, hits the snooze
button, and dozes off to
revisit the Sandman. By the
time the alarm sounds again, your child
is only minutes away from catching the
school bus. He gets dressed, brushes his
teeth, and bolts out the door. Missing
from the routine: breakfast.
For many teens, this morning

routine has become a familiar, but
troubling, one. Breakfast is thought
to be the most important meal of the
day, says William Cochran, M.D.,
FAAP, a past member of the American
Academy of Pediatrics Committee
on Nutrition and vice chairman of
the Department of Pediatrics of the
Geisinger Clinic in Danville, Pa. As
the first meal, it gets the body going
for the rest of the day.
And yet, approximately 8 to 12 percent of all school-aged kids

skip breakfast, he says. By the time, kids enter adolescence, as
many as 20 to 30 percent of them have completely given up the
morning meal.
Why Teens Say No to Breakfast

Children of all ages have many excuses for skipping breakfast.
Many older teens are busy until late into the night with
homework, extracurricular activities, and part-time jobs. They go
to bed late, then get up and rush off to school, too frantic to eat.
The worst offenders are girls and older teens, though boys and
younger adolescents are certainly not immune.
Compounding the challenge is biology. As teens get older,
theyre often more inclined to fall asleep later at night its even
natural for teens to be unable to fall asleep until 11 p.m.,
according to the National Sleep Foundation and awaken later
in the morning, a biological schedule that often doesnt match the
one set by schools. When that happens, most kids would rather
snooze an extra 15 minutes then get up for a bowl of cereal.
Many of them are not getting enough sleep, says Marcie
Beth Schneider, M.D., FAAP, a member of the AAPs Committee
on Nutrition and an adolescent medicine physician in
Greenwich, Conn. They often wake up too tired or too
nauseous to eat. Experts believe that some kids, especially girls,
may be also bypassing the morning meal in an effort to control
weight gain.
Breaking the Fast Is Healthy

In reality however, skipping breakfast is more likely to cause
weight gain than it is to prevent it. A 2008 study in the journal
Pediatrics found that adolescents who ate breakfast daily had a
lower body mass index than teens who never ate breakfast or only
on occasion.
Ironically, the breakfast eaters even ate more calories, fiber,
and cholesterol in their overall diets compared to the kids who
skipped breakfast. But the kids who ate breakfast also had
diets with less saturated fat. We know that the biggest
predictor of overeating is undereating, Dr. Schneider says.
Many of these kids skip breakfast and lunch, but then go
home and dont stop eating.
Eating breakfast also has ramifications on school performance.
Study after study shows that kids who eat breakfast function
better, Dr. Schneider says. They do better in school, and have
better concentration and more energy.
Children who eat breakfast are generally in better health
overall, a fact that may be attributed to the types of food often
associated with the morning meal. Breakfast provides a golden
opportunity to fortify your teen with nutrients that can easily fall
by the wayside the rest of the day. Breakfast is a great time to
consume fiber in the form of cereals and whole wheat breads, Dr.
Cochran says. Fiber can help with weight control and has also
been linked to lower cholesterol levels.
Breakfast is also an opportunity to feed your child bonebuilding calcium and vitamin D. Kids enter their peak bonebuilding years in adolescence and continue building bone into
their early 20s. Although vitamin D is best known for its role in
promoting the absorption of calcium, new studies show vitamin
D may also boost immunity and help prevent infections,
autoimmune diseases, cancer and diabetes. As a result, the AAP
recently doubled its recommended vitamin D intake from 200
IUs a day to 400 IUs.
Exposure to the sun triggers the skin to produce vitamin D, but
experts generally caution against relying on the sun for vitamin D
too much sun raises the risk for skin cancer. Instead, experts
recommending getting vitamin D from foods, including eggs and
fortified foods such as breakfast cereals, milk, and yogurt all
perfect for the morning meal. Vitamin D is also found in salmon,
tuna, and other types of seafood. Kids who do not get enough
vitamin D from food should consider taking a supplement.
Take Action
With weight gain and obesity becoming a major public health
concern, experts agree that the push to get teens to the breakfast
table is an important one. According to the U.S. Centers for Disease
Control and Prevention, 17 percent of the nations adolescents aged
12 to 19 are overweight or obese, which sets the stage for serious
future health problems such as diabetes and heart disease.
So how do you get your teen to chow down in the A.M.? Start
by setting an earlier bedtime, which helps ensure that your child
will get up in time to eat something. Then make breakfast a
priority in your home. Ideally, the whole family can sit down
together for breakfast, a practice that should start well before the
teen years. Families that eat together tend to eat healthier, Dr.
Cochran says. It also gives parents the chance to act as role
models in terms of nutrition and eating behaviors.
Quick Tips: A Healthy

Breakfast on the Fly
Theres no getting around the truth: Adolescents are
often in a hurry, and mornings are no exception. While a
sit-down breakfast made up of the four basic food groups
is the ideal, a grab-and-go breakfast item is the next best
thing. Such sources of carbohydrates (good energy for
teens) as these should be in your teens possession as he or
she dashes out the door on a school morning:
Granola bars
Breakfast bars
Dried fruit
Fresh fruit
Dry cereal
If mornings are too difficult to orchestrate a sit-down meal, try

having some easy-to-go breakfast foods available for your child.
Good options include yogurt, granola bars, dried cereal, breakfast
bars, fresh fruit, and dried fruit. Let her take it and eat it on the
way to school if possible, or encourage her to go to school and buy
breakfast, which most schools now make available. Ideally, a
breakfast should have all the food groups represented, Dr.
Schneider says. But anything nutritious they grab on their way out
the door works. Whats important is that they get some healthy
carbohydrates, which provide energy, says Dr. Schneider.
One beverage that kids should omit from their morning meal:
coffee and energy drinks. While the craving for a quick pick-meup is certainly understandable, caffeine raises blood pressure and
heart rate in teens, Dr. Schneider says. c
Vaccination (continued from page 24)
That changes in the adolescent years, for a variety of reasons.

We live in a busy world, its true, says Dr. Byington, who is on
the American Academy of Pediatrics Committee on Infectious
Disease and is a working mom herself. But no matter how
busy we get, protecting our children is something we always
make time for.
Dr. Byington has a good suggestion for remembering to take
adolescent children in for annual checkups and needed
immunizations. Everyone has a birthday every year, she says.
Use that childs birthday as a reminder to take them in for their
annual well-child check and the vaccines he or she needs at that
time. Its the best birthday present you can give your child. c
There are other vaccines that teens in certain high-risk

categories may need, and catch-up vaccines are available in
some cases for teens who didnt receive all their scheduled
immunizations as younger children. Talk with your
pediatrician about what your child needs.
Keep It On the Schedule

For many parents, remembering to take young children to the
pediatrician for immunization is not a challenge. Well-child
checkups are fairly frequent for the first few years of life, and the
doctors phone number is never far away.
Vitamin D (continued from page 26)
preparations for infants that contain 400 IU vitamin D per dose as
well. Chewable vitamins are generally regarded as safe for children
over the age of three who are able to chew hard foods and candy.
For breast- or bottle-fed babies, liquid supplements are the best
option. There are liquid preparations that give the recommended
intake of 400 IU in 1/2 or 1 mL, which are considered to be safer by
some, says Dr. Wagner. There are also liquid drop solutions
available that provide one drop that equals 400 IU per day. The care
provider can put the vitamin D drop on an index finger and then
place the finger in the babys mouth, she suggests. Alternatively, the
drop can be put on a pacifier or breast and then when the infant
sucks the pacifier or breast, the infant receives the vitamin.
As with all medications and supplements, vitamin D
supplements should be kept out of a childs reach. The risk with
drop solutions is that an infant or other children in the house
could receive too much vitamin D, Dr. Wagner says.
Finding D Naturally
In addition to vitamin supplements, enriched foods are another
way to increase the vitamin D in your childs diet. Look for foods
fortified with vitamin D such as milk, cereal, orange juice, yogurt,
and margarine.
Vitamin D is found naturally in only a few foods they
include oily fish, beef liver, cheese, egg yolks, and some
mushrooms. Oily (or fatty) fish are one of the best sources of the

Quick Tips: The ABCs of

Vitamin D
How to make sure your child is getting enough vitamin D:
Breastfed and partially breastfed infants should be
supplemented with 400 IU a day of vitamin D
beginning in the first few days of life.
All non-breastfed infants, as well as older children,
who are consuming less than 32 ounces per day of
vitamin D-fortified formula or milk, should receive a
vitamin D supplement of 400 IU a day.
Adolescents who do not get 400 IU of vitamin D per
day through foods should receive a supplement
containing that amount.
Children with increased risk of vitamin D deficiency,
such as those taking certain medications and with
chronic diseases such as cystic fibrosis, may need
higher doses of vitamin D. Consult your pediatrician.
vitamin. For example, 3.5 ounces of cooked salmon offers

approximately 360 IU (about 90 percent of your childs daily
recommended value) of vitamin D per serving. Other examples of
oily fish include tuna, mackerel, trout, herring, sardines, kipper,
anchovies, carp, and orange roughy. c
Parent-Tested,
Doctor-Approved Advice
New!
Mommy Calls
Dr. Tanya Answers Parents

Top 101 Questions About
Babies and Toddlers
By Tanya Remer Altmann, MD, FAAP
The new must-have resource

for parents of children up to
age 3! Small enough to fit
in a diaper bag, but big on
straightforward, medicallysound advice delivered in the
warm, funny style that has
made author Tanya Remer
Altmann, MD, FAAP, a favorite on NBCs Today show.
Softcover, 178 pages, X-CB0052 $12.95
A Parents Guide
to Childhood
Obesity
A Road Map to Health
By the American Academy of

Pediatrics, Sandra G. Hassink, MD,
FAAP, Editor in Chief
Worried about waistlines? Get

scientifically based advice on
nutrition, fitness, environment,
behavior, and more. Contains
worksheets, questionnaires,
and other interactive tools to
help your child achieve and maintain a healthy weight.
New Mothers Guide

to Breastfeeding
Pediatrics, Joan Younger Meek, MD,
MS, RD, FAAP, IBCLC, Editor in Chief,
with Sherill Tippins
Filled with indispensable

advice on successful
breastfeeding, New Mothers
Guide to Breastfeeding
provides everything new
mothers need to know, from
preparing for the first feeding
to adjusting to home, family, and work life as a nursing mother.
This book offers suggestions on preparing prior to babys arrival,
breastfeeding benefits, establishing routines, and even how
fathers can get involved.
Spanish: Softcover, 258 pages, X-CB0029 $18.95
Food Fights
Heading Home
With Your
Newborn
Winning the Nutritional

Challenges of Parenthood
Armed With Insight, Humor,
and a Bottle of Ketchup
From Birth to Reality
By Laura A. Jana, MD, FAAP, and

By Laura A. Jana, MD, FAAP, and

Restore peas and harmony

to the family table with
Food Fights! Written by 2
award-winning authors and
pediatrician-moms, this new
book combines the science
of nutrition with the practical insight of parents who have lived
through mealtime melees themselves. Sprinkled with humor
throughout, Food Fights offers sumptuous strategies for getting
little ones to eat right!
This award-winning book covers

everything you need to know
during the first year of your
babys life: feeding, sleeping,
diaper changing, dressing,
traveling, health, illness, and
so much more. Dont leave the
hospital without it!
The Wonder Years

Pediatrics, Tanya Remer Altmann,
MD, FAAP, Editor in Chief
Your Babys First

Year
The first 5 years of a

childs life are filled with
major developmental and
behavioral milestones. This
book shows parents how to
make the most of them with
dependable, authoritative, and
up-to-date information on child
development.

Pediatrics, Steven P. Shelov, MD,
MS, FAAP, Editor in Chief
Your Babys First Year helps

make decisions and discoveries
easier for caregivers. This
up-to-date resource even
includes a month-to-month
guide to growth, behavior, and
development.
Softcover, 698 pages, X-CB0038
$6.99
Spanish: Softcover, 698 pages,
X-CB0024 $15
Guide to Toilet
Training
By the American Academy of Pediatrics,
Mark L. Wolraich, MD, FAAP, Editor in
Chief, with Sherill Tippins
Guide to Toilet Training cuts

through the confusion on how
and when to give parents
practical information, proven
techniques, and expert advice.
$14.95
Spanish: Softcover, 208 pages,
X-CB0030 $18.95
Hardcover, 219 pages, X-CB0047 $15
ADHD
A Complete and
Authoritative Guide
Pediatrics, Michael I. Reiff, MD,
FAAP, Editor in Chief, with
Sherill Tippins
What are treatment options?

How do you work with schools?
What does your childs future
hold? Understand and manage
this often confounding
disease with information on
medication, behavior therapy,
adolescent ADHD, and more.
To order, call 888/227-1770 or visit www.aap.org/bookstore.
From the American Academy of Pediatrics

A Parents Guide
to Building
Resilience in
Children and Teens
Giving Your Child Roots
and Wings
By Kenneth R. Ginsburg, MD, MS Ed,

FAAP, with Martha M. Jablow
Back talk, apathy, chemical

useare they really bad
behaviors or unhealthy ways
of coping? One of the nations
foremost experts in adolescent
medicine shows parents how to help kids cope with pressure and
bounce back from stress.
Waking Up Dry
By Howard J. Bennett, MD, FAAP
Carefully crafted for children

(aged 613), their parents,
and caregivers, Waking Up
Dry offers a comprehensive
program with instructions
on behavior management,
techniques, alarms, contracts,
and more.
$14.95
Immunizations
& Infectious
Diseases:
An Informed
Parents Guide
Pediatrics, Margaret C. Fisher, MD,
FAAP, Editor in Chief
Provides authoritative answers

on concerns ranging from
vaccines and antibiotics to
contagion and prevention.
$14.95
Sports Success Rx!
Your Childs Prescription for

the Best Experience:
How to Maximize Potential
AND Minimize Pressure
By Paul R. Stricker, MD, FAAP
Give your kids the healthiest

possible sports experience!
Includes age-appropriate
skills, overuse injuries, ways
to perform better, proper
conditioning, effect on young
psyches, positive coaching,
and more.
$15.95
Less Stress,
More Success
By Kenneth R. Ginsburg, MD,
MS Ed, FAAP, and Marilee Jones,
former Dean of Admissions, MIT
A first-of-its-kind book, Less

Stress, More Success helps
parents and teens learn how
to prepare for the college
experience.
$14.95
Caring for Your Baby and Young Child: Birth to Age 5

By the American Academy of Pediatrics, Steven P. Shelov, MD, MS, FAAP, Editor in Chief; Robert E.
Hannemann, MD, FAAP, Associate Medical Editor
The instruction manual for children! Everything on basic child care is covered in this
comprehensive, richly illustrated top sellernutrition, safety, growth milestones, behavior,
discipline, common illnesses, and so much more. Available in English and Spanish!
English: Softcover, 752 pages, X-CB0032 $20
NEW EDITION! Spanish: Softcover, 720 pages, X-CB0046 $20
Caring for Your School-Age Child: Ages 5 to 12
Caring for Your Teenager
By the American Academy of Pediatrics, Edward L. Schor, MD, FAAP, Editor in Chief
By the American Academy of Pediatrics, Donald E. Greydanus, MD, FAAP, Editor in Chief, and Philip Bashe
With more than 100 illustrations, Caring for Your School-Age Child: Ages 5 to 12 is a complete
guide to the complex developmental issues of the middle years.
Raising a happy, healthy teenager can be a challenge. Caring for Your Teenager gives families a
survival guide to dealing with developmental and behavioral issues.
Softcover, 624 pages, X-CB0003 $20
Also available in bookstores nationwide
If only the early warning

signs of scoliosis
were this obvious.
Scoliosis, or curvature of the spine,

is one of the most common types
of spinal deformity. It can occur
at birth, but is usually diagnosed
between the ages of 10-15. The
first indications may be subtle,
and can include uneven shoulders
or one hip higher than the other.
A routine physical exam can often
spot these first signs and early
detection is key to avoiding a severe
deformity. These websites offer more
information: orthoinfo.org, srs.org,
posna.org, aap.org.
SCOLIOSIS
RESEARCH
SOCIETY

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American Academy of Pediatrics

What every parent

Waiting Room Copy

David Tayloe, M.D., FAAP

Healthy Children Summer/Back to School 2009

American Academy of Pediatrics

Ask the Pediatrician

When Parents Are Deployed

Well Child Care

New Baby, Older Children

Teens and Immunization

Vitamins and Minerals

Breakfast: The Right Start to the Day

Paul R. Stricker, MD, FAAP

For advertising information, please contact:

Managing Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . Sam Gaines

Dr. David Tayloe, AAP president,

The latest parenting news, research,

Having a parent deployed as part of his or her military service is hard

President . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . William G. Moore

The American Academy of Pediatrics would like to thank

Healthy Children Summer/Back to School 2009 3

This Just In...

The latest parenting news, research,

Teen Sex: Life Imitates Sitcoms

Healthy Children Summer/Back to School 2009

The top 10 percent of teens who watch sexually charged

Risky Business: Driving Without a License

Healthy Children Summer/Back to School 2009 5

To submit questions to Healthy Children, send an e-mail to [email protected]

Ask the Pediatrician

2. Games Children Play

Simon Says: In this version, however, Simon moves quickly!

Story Tellers: Turn your children into their favorite storybook

Playing with Food: For a daring yet less energetic activity,

In addition, consider these precautions:

Q: Now that the new First Family has gotten a

puppy, my three children, ages 5, 7, and 9, want a

Treat your pet humanely so it will enjoy human

Never leave young children alone with an animal. Many

Dont allow your child to tease your dog by pulling its

Make sure your children dont disturb your dog when

Take your dog to the vet as scheduled and keep its

Obey local ordinances about licensing and leashing

Teach your children how to greet your dog. Your children

QUICK TIP: Treat a pet as part of the family.

Pen or marker caps

Small button-type batteries

Toys with small parts

Toys that can be squeezed to fit

Healthy Children Summer/Back to School 2009 7

Healthy Children Summer/Back to School 2009

Help your children deal with

eployment is heart wrenching for all military

Share and Listen

Monitor What They See

Quick Tips: Deployment Resources

Healthy Children Summer/Back to School 2009 9

Babies: Feeding and/or sleeping difficulties, increased