Ready, Set, Grow

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Ready, Set, RAISING HEALTHY KIDS www.readysetgrowmag.com

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Contents

Grow

Ready, Set, Raising Healthy Kids

®

CURRENT THROUGH DECEMBER 2019

Welcome 6 Foreword 8 Editor’s Letter Fitness 10 Mix It Up!

Optimize your child’s success in sports By Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP

Nutrition 16 Family-Friendly Diets

Choose the right healthy-eating plan for everyone in your household By Laura Roettger, MSN, CPNP

20 Kids in the Kitchen!

Involve your children in healthy-meal prep By Audra N. Rankin, DNP, APRN, CPNP

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Asthma/Allergies 26 Take Control!

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Avoiding or reducing triggers — along with taking the necessary medication — can help alleviate your child’s symptoms & discomfort By Tami Kochan, RN, MSN, CPNP, AE-C

Immunization 38 Get the Facts

Protect your family & community from vaccine-preventable diseases By Lacy Eden, MS, FNP-C, and Meg McDowell, RN-S

Health 46 “Oops. I Wet the Bed”

Finding out why & how you can help your child By MiChelle McGarry, MSN, RN, CPNP, CUNP, FAANP

Message to our readers: The contents of Ready, Set, Grow are for informational purposes only and should never replace the advice and care of a licensed health care professional. Neither NAPNAP nor CW Publishing Group guarantees the accuracy, completeness or timeliness of any information contained in this publication, and neither shall be liable for any loss, damage or injury directly or indirectly caused by or resulting from such information or its use. NAPNAP’s participation in this publication shall not in any manner be interpreted to constitute an endorsement by NAPNAP of any products or services that may be advertised or referenced herein.


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Grow

Ready, Set,

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Raising Healthy Kids

®

Pediatric Health Care Advisory Panel Jessica L. Peck DNP, APRN, CPNP-PC, CNE, CNL, FAANP Ann Petersen-Smith PhD, APRN, CPNP-PC, CPNP-AC Jo Ann B. Serota DNP, CPNP, FAANP, IBCLC Sheryl Zang EdD, FNP, CNS-BC NAPNAP Staff

Mental Health 50 Depression,

Defined Understanding & helping your child By Stephanie C. Evans, PhD, APRN, CPNP-PC

Child Safety 58 Stand Up &

Speak Up! Empower your kids to address dangerous behavior By Gail Hornor, DNP, CPNP

Dental Health 64 All Smiles

Preventative care is vital to a child’s well-being By Jo Ann B. Serota, DNP, CPNP, FAANP, IBCLC

Skincare 68 Name That Rash

Managing common conditions in children By Stacia M. Hays, DNP, CPNP-PC, CCTC, CNE

Education 74 Manage Your Time Help your kids develop

Executive Director Cate Brennan, MBA, CAE

essential organizational and work-planning skills By Sheryl Zang, EdD, FNP, CNS-BC

Healthcare 78 It’s Confidential

What you need to know about giving teens space By Jade Burns, PhD, RN, CPNP-PC

Behavior 82 Open Your Child’s Mind Celebrating our diverse world By Ann Lambert, MSN, CPNP-BC

Home Front 86 One-of-a-Kind Kids Each member of your family makes it special & unique By Charlotte Rensberger, MSN, APRN, PNP-PC

92 Seeking a Sitter? How to find the best fit for your family By Nicole Boucher, PhD, RN, CPNP-PC

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Director of Marketing & Strategic Projects Michele Stickel Communications & Digital Marketing Supervisor Justin Worsley www.napnap.org CW Publishing Group Editor-in-Chief VP Publishing Operations Elaine Marotta Creative Associate Tamara Citroen Executive VP Sales Neil Agble Sales Manager Scott Andersen Senior Account Executives Elizabeth Glover, Eric Oberman Account Executive Mario Ogreni Head of Digital Sales Cliff Ward Human Resources Stuart Friedman Social Media Chris Garino Financial Controller Johanna Jaleel CEO Dean Citroen Published by CW Publishing Group 8-10 W. 36th St., Fifth Floor New York, NY 10018 646.274.7272 www.cwpg.com/cwc-usa Printed in the U.S.A. Copyright ©2019 CW Publishing Group. Copyright ©2019 NAPNAP. All rights reserved. CW Publishing Group is the trading name for CW Communications Inc. www.readysetgrowmag.com


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Foreword

Dear Parents and Caregivers, T

he National Association of Pediatric Nurse Practitioners (NAPNAP), an organization of pediatric nurse practitioners (PNPs) and other pediatric-focused advanced practice registered nurses committed to teaching parents and children why being healthy matters, writes Ready, Set, Grow (Raising Healthy Kids) just for you. For 45 years, our members have been providing families like yours with high-quality healthcare. They have a wealth of knowledge to share with you inside these pages. As you read through this edition, you’ll find answers to the questions most parents and caregivers have about kids’ health. Use this publication to learn about nutrition and fitness, growth and development, safety and many other health issues crucial to families. I encourage you to visit our website’s special section for families, napnap.org/families, for online resources on a wide variety of child health and family wellness topics, including our pediatric health conditions library, which has a free mobile app for you to download, too. Let us know your thoughts about this issue. Email me at president@napnap.org. Happy and healthy reading,

Dawn L. Garzon Maaks, PhD, CPNP-PC, PMHS, FAANP President, National Association of Pediatric Nurse Practitioners

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Get the information you need to keep your children healthy. Cancer prevention

ADHD

Disaster preparedness

Immunization safety

Flu vaccine

OTC medicine

Learning disabilities

Bullying prevention Learn more: napnap.org/families


Editor’s Letter

Family Well-Being W

hether you’re the parents of young children or adolescents, we trust you’ll find Ready, Set, Grow ® (Raising Healthy Kids) and readysetgrowmag.com valuable resources for helping to instill healthy habits in your kids, so they can make good lifestyle choices. Participating in sports benefits kids in many ways, including boosting confidence and assisting with skill development — while promoting teamwork, friendships and physical fitness. Encouraging your sports enthusiast to take part in a variety of sports in lieu of focusing (perhaps, excessively) on one activity may prevent burnout and overuse injuries (“Mix It Up!”). As you encourage a healthy lifestyle, you may wonder how to ensure that everyone in your household is opting for better foods. Learn about a variety of healthy-eating plans enjoyed by parents and kids alike (“Family-Friendly Diets”). And why not get your little chefs excited about healthful nutrition by including them in meal prep — from planning and shopping to age-appropriate “cooking” (“Kids in the Kitchen!”)? In addition to keeping your family fueled and active, safety is paramount. Your kids should know that they can come to you with any concerns, but they also need to feel empowered to defend themselves and others against harmful behavior that occurs in person or online (“Stand Up & Speak Up!”). Find out the latest news on how to protect your community as well as your loved ones when it comes to vaccinepreventable diseases (“Get the Facts”). Also essential to family well-being is mental health. Mood disorders such as depression impact your child’s reasoning, emotions and daily interactions, sometimes severely (“Depression, Defined”). Learn about symptoms of depression (distinguished from “normal” anxiety), along with how to seek assistance, treatment and support. There’s much more in this edition, so be sure to enjoy the entire magazine. And visit readysetgrowmag.com anytime, from your preferred device. You’ll find lots of stories on raising healthy children, along with a digital version of each Ready, Set, Grow issue. Looking forward to your feedback: em@cwpg.com. Elaine Marotta Editor-in-Chief VP Publishing Operations

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They’re a little bit of a lot of things, but they’re all pure love.

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Fitness

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Mix It UP!

OPTIMIZE YOUR CHILD’S SUCCESS IN SPORTS

T

he National Alliance for Youth Sports believes participation in sports can positively affect social, mental and physical development. Good sports experiences can help boost self-esteem, promote teamwork, develop leadership skills, provide natural stress relief, reduce the risk of obesity and promote lifelong healthy lifestyle habits — not to mention just being fun for both the participants and the spectators. Other benefits of sports include character development, creating new friendships, learning how to deal with both success and failure, as well as celebrating diversity by bringing together people from all kinds of different cultures to work toward a common goal.

What to Consider

No sport is 100-percent safe, and a preparticipation sports physical or wellchild checkup by a qualified pediatric healthcare provider is a critical element of protection in helping to ensure that your child is physically and developmentally ready to engage in a sport. Certain medical conditions such as kidney disease, seizure disorders, asthma or congenital heart disease — among many others — may preclude some

Ready, Set, Grow

sports participations or require special precautions or accommodations to ensure safe participation. About 6 out of 10 children between 5 and 14 years of age engage in sports activities outside of school, with 70 percent of those participants being boys and 56 percent being girls. Many of these kids tend to focus on developing and specializing one sport in organized competition rather than overall skill development and play. Of the approximately 60 million children ages 6 to 18 years who participate annually in organized sports, about 27 percent participate in only one sport. About 70 percent of children drop out of organized sports by age 13 years. Excessive focus on one sport can lead to overuse injuries, loss of interest in play or burnout. Early specialization can also lead to social isolation, abnormal psychosocial development and unhealthy behaviors. In fact, the main sport played by Division I NCAA athletes is usually different from their first organized sport, and most of these athletes played multiple sports in high school. In addition, the American Academy of Pediatrics (AAP) reported of the 322 athletes who were given an invitation to

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By Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP


Fitness

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to the AAP, children who diversify their sports experiences are more likely to be more physically active throughout their lives as well as be more successful in achieving their athletic goals.

Steps to Take

Remember, the focus of childhood athletics should be on having fun, learning lifelong physical activity skills and the positive psychosocial effects of participation. What you can do to help optimize your child's success in sports participation follows. Encourage participation in multiple sports. This helps provide variety, prevents burnout, and allows children to discover passion for a particular sport, a critical part of any future plan for success. If sport specialization is desired by both your child and you, it should be done with collaborative consultation with a qualified pediatric medical provider to enable a plan to minimize risk and optimize health.

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the National Football League Combine in 2015, 87 percent played multiple sports in high school, with only 13 percent singularly focusing on football. The truth is that only 3 to 11 percent of high school athletes proceed to compete at the collegiate level, while a mere 0.03 to 0.5 percent will ever reach the professional level. The AAP has talked about the seriousness of failure to appreciate the significant short-term and long-term consequences of overuse injuries, which can persist into adulthood and crush any dreams of college or even professional play long before a career can even begin. Overuse injuries account for approximately 50 percent of all athletic injuries. Research suggests that early specialization in a single sport can negatively affect long-term success in team sports. Athletes who participate in multiple sports have greater advantage with skill transfer and pattern recognition than those who specialize. According


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Fitness

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athletes and providers for specific sports, including baseball, cheerleading, field hockey, figure skating, golf, gymnastics, football, martial arts, swimming and many others. Injury-specific tip sheets include concussion prevention and treatment, overuse injuries, sports nutrition and strength training. Sports participation can be a positive experience with lifelong health benefits. With healthy boundaries and a cheering support group, sports experiences can be a memorable and enjoyable part of childhood. Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, is an experienced PNP who frequently provides medical services for pediatric sporting events and camps while cheering on her own four children in various athletic events.

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If your child is enrolled in an elite sports program, you should carefully monitor the training and coaching environment, be aware of best coaching practices and voice any concerns. Delay participating in a single sport competitively and exclusively year-round until at least ages 15 to 16 to minimize the risks of overuse injury, as recommended by the AAP. This reduces the risk of overuse injuries, stress and burnout while increasing the chances of long-term success later. Focus on skill development as opposed to structured competitive tournaments. Early mastery of fundamental skills is predictive of greater long-term success in sports. Set limits on training times. The risk of injury and detrimental psychosocial outcomes is greater if training exceeds 16 hours per week or if the ratio of organized/scheduled training versus free time exceeds 2:1. Make rest an important part of your training regimen. One to two days each week should be free of any training or organized competition. In addition, young athletes should take three months off each year from their preferred sport in one-month blocks, while exploring other sports or physical activities. For more resources, check out the STOP (Sports Trauma and Overuse Prevention) Sports Injuries initiative, made up of representatives including the American Orthopaedic Society for Sports Medicine, the AAP, the National Athletic Trainers' Association, the American Medical Society for Sports Medicine, among many other partners (www. stopsportsinjuiries.org). You can find more information for coaches, parents, trainers,



Nutrition

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Family-Friendly

DIETS

CHOOSE THE RIGHT HEALTHY-EATING PLAN FOR EVERYONE IN YOUR HOUSEHOLD By Laura Roettger, MSN, CPNP

ou are what you eat. While only in your child’s imagination could this be possible, there is some truth behind this phrase. The Centers for Disease Control and Prevention (CDC) reports that healthy eating can help reduce the risk of high blood pressure, heart disease, diabetes, cancer, osteoporosis, iron deficiency and dental cavities. You may be wondering how to ensure that you and your family are eating well. Read on for guidance on making good nutrition choices for all.

Nutrition Basics

The United States Department of Health and Human Services (HHS) and the United States Department of Agriculture (USDA) recommend that children two years and older maintain healthy nutrition by: (1) limiting calories from added sugars and saturated fats, (2) reducing their sodium intake, (3) eating a variety of vegetables, fruits, grains, fat-free or lowfat dairy products and proteins and (4) consuming healthy oils. Estimated calorie needs for toddlers to early-school-age children ranges

Ready, Set, Grow

from 1,000 to 2,000 calories per day. For middle- to older-school-age children and adolescents, the range is 1,400 to 3,200 calories per day. The HHS and USDA have devised the Healthy United States Style Eating Pattern, which provides guidance for choosing certain types and portions of foods that keep individuals within their recommended daily caloric and nutritional allowances. You can find more information about how you and your family can follow this eating pattern by visiting https://health. gov/dietaryguidelines/2015/guidelines/ appendix-3/. Options for maintaining a healthy-eating pattern include: (1) Mediterranean, (2) vegetarian and (3) Dietary Approaches to Stop Hypertension (DASH).

Mediterranean

According to the CDC, a Mediterranean eating pattern consists of: (1) mostly plant-based foods (fruit, vegetables, breads, cereals, beans, nuts and seeds), (2) foods prepared fresh without added fat, sugar or salt, (3) cooking with olive oil, (4) low-to-moderate consumption

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Y


Nutrition

of dairy products (primarily cheese and yogurt), (5) fewer than four eggs consumed each week, (6) occasional red meat consumption, (7) seafood, and (8) small-to-moderate wine consumption for adults — mainly with meals. The National Institutes of Health (NIH) states that a Mediterranean eating pattern decreases the risk of developing diabetes, high cholesterol and triglycerides and heart disease. The USDA and HHS have made recommendations for maintaining the healthy Mediterranean-style eating pattern. Those following a Mediterranean eating pattern should ensure that it contains: (1) iron, (2) vitamins and (3) calcium. Find more information by visiting https://health.gov/dietaryguidelines/2015/ guidelines/appendix-4/.

Vegetarian

According to the American Heart Association (AHA), a vegetarian eating

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pattern consists of a plant-based diet of fruits, vegetables, dried beans and peas, grains, seeds and nuts. Additionally, you may choose to consume dairy products, eggs only, or refrain from eating red meat. The AHA states that vegetarian eating patterns generally have lower total fat, saturated fat and cholesterol that leads to a decreased risk for developing obesity, coronary heart disease, high blood pressure, diabetes and certain cancers. The AHA recommends that vegetarians be especially mindful to ensue their eating pattern contains the essential nutrients: (1) protein, (2) iron, (3) vitamin B-12, (4) vitamin D, (5) calcium and (6) zinc. The HHS and USDA devised the healthy vegetarian eating pattern. The HHS and USDA say that while this eating pattern can include dairy and eggs according to preference, a completely dairyfree eating pattern can be followed by

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Dietary Approaches to Stop Hypertension (DASH)

The DASH eating pattern aims to reduce blood pressure by limiting red meat, salt, sugar-sweetened beverages and sweets. This eating pattern is high in fruits, vegetables, fat-free or low-fat milk and milk products, whole-grain products, fish, poultry and nuts. Look for the Heart-Check mark next time you are grocery shopping. In an effort to assist families with choosing heart-healthy foods, the AHA has developed the Heart-Check certification

to indicate that a particular food item meets AHA criteria for saturated fat, trans fat and sodium for individuals older than two years of age. Making healthy nutrition choices for your family is critical to preventing disease. Use these guiding principles to determine the eating pattern that is a right fit for you and your family. You are what you eat when it comes to shaping the healthy growth and development of your children. Talk to your healthcare provider before trying one of the diets presented here to weigh the risks and benefits. Discuss the need for possible nutritional supplements as well. Laura Roettger, MSN, CPNP, is a faculty member in the College of Nursing at Thomas Jefferson University in Philadelphia.

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consuming plant-based dairy derivatives or fortified soy beverages. You can find more information about how to follow the healthy vegetarian eating pattern on: https://health.gov/dietaryguidelines/2015/ guidelines/appendix-5/.

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Nutrition

Kids in the KITCHEN!

INVOLVE YOUR CHILDREN IN HEALTHY-MEAL PREP By Audra N. Rankin, DNP, APRN, CPNP

G

etting kids to participate in the kitchen can be a daunting task. The debates over vegetables! The spills and the mess! The extra time! The cleanup! Although as parents we can come up with many reasons that it’s faster and easier to do it ourselves, bringing our children into the kitchen creates a wonderful opportunity for them to learn about healthy eating. You can involve your kids in a variety of ways with meal planning, shopping and cooking, regardless of their ages and developmental capability.

Meal Planning

Allowing children to help plan meals may result in some “interesting” choices. After all, a breakfast bar with a side of jelly beans may not be the most wellreceived family breakfast! To limit the chance of odd combinations, you can encourage your kids to participate in recipe planning with the use of childappropriate cookbooks or family favorites. Although children may need guidance with meal planning based on their ages, using recipes can encourage reading, provide opportunities to

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practice math and chemistry, and help them follow simple instructions. As you plan meals, encourage your kids to create a list of ingredients at home. While making the list, they can describe the foods as well as practice writing and spelling. If you have limited recipe ideas or are dealing with non-adventurous eaters, consider picking their favorites and adding healthy foods. Cookies with carrots or smoothies with kale are examples of incorporating healthy foods into children’s favorites. Use meal planning as a time to talk about where foods come from — the garden, the farm, the sea — and emphasize the importance of using fresh ingredients whenever possible. Many foods are used differently, depending on region and culture. Encourage your kids to think about how families in other parts of the world may use the same ingredients differently.

Shopping

After making your list at home, have your children look for a few items on the list at the store. Encouraging healthy food options can often be done by shopping

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Nutrition fresh ingredients into the shopping experience. Fresh fruits and vegetables can be expensive. Note that using frozen or canned fruits and vegetables is often a cheaper option and still provides vitamins and minerals to your family.

Cooking

the “perimeter” of the grocery store. Many fresh ingredients can be found along the edges of the store, while many processed and boxed foods are found in the center aisles. Use shopping as a time to discuss healthy vs. non-healthy foods. Depending on your children’s ages, you can make games a part of the shopping experience. For example, organizing a scavenger hunt to find a fruit that starts with the letter A, collecting fresh foods that are orange or finding foods that are within a dollar range can all be fun ways to include kids in the shopping experience while reinforcing basic learning concepts. As you shop, encourage your children to talk about the food’s color and texture. Shopping seasonally, encouraging shopping at farmers markets and freezing ingredients that may be on sale now for later use are all great ways to incorporate

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Although cooking with children is often viewed as a tough task, preparing foods together is one of the best ways to get kids excited about healthy eating. You should be ready for spills, mistakes and a lot of fun! Depending on children’s ages, you may want to do some of the prep work prior to inviting them into the kitchen. They can be there as a variety of cooking activities are performed. Younger children can wash and tear foods, season foods with fresh herbs or simply hold ingredients. Older kids can measure and chop foods and practice their timing skills while waiting on foods to cook. Before the cooking begins, establish safety rules such as avoiding sharp objects. Look for kid-sized cooking utensils to help with meal preparation. Throughout the process, talk about foods and encourage tasting when appropriate. Encouraging your child to help clean up after cooking by sweeping floors, washing dishes and wiping counters can also create an opportunity to follow simple instructions and build confidence.

Bon Appetit

By modeling healthy eating, you encourage your children to do the same. Share family meals together, and enjoy your kids taking pride in participating in the preparation from start to finish. The recipes that follow are kid-friendly while incorporating healthy foods. Enjoy!

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Rainbow Rice

Preparation Time: 15 minutes Cooking Time: 1 hour Makes six 1-cup servings Ingredients 1⁄2 cup brown rice, long-grain, regular, dry 3 Tbsp brown and wild rice blend, dry 6 Tbsp barley, quick pearl, dry 2 tsp low-sodium chicken base 2 Tbsp quinoa, dry 3 Tbsp bulgur wheat, dry 1 cup fresh carrots, peeled, diced 1 cup fresh red bell peppers, seeded, diced 1 tsp extra virgin olive oil 1⁄4 tsp kosher salt 3 1⁄2 cups cooked diced chicken, 1⁄2” pieces (12 oz) 1 1⁄2 cups fresh baby spinach, chopped

Ready, Set, Grow

Return to oven and bake for 15 minutes to an internal temperature of 165° F or higher for at least 15 seconds (use a food thermometer to check the internal temperature). Serve hot. Nutrients Per Serving: Calories, 232. Protein, 22g. Carbohydrate, 28g. Dietary Fiber, 5g. Total Fat, 4g. Saturated Fat, 1g. Cholesterol, 55mg. Vitamin A, 5414 IU (271.09 RAE). Vitamin C, 37mg. Iron, 3mg. Calcium, 29mg. Sodium, 159mg. 1 cup provides 2 oz equivalent meat, 1/8 cup dark green vegetable, 1/8 cup red/orange vegetable and 1oz equivalent grains. From TeamNutrition.usda.gov https://whatscooking.fns.usda.gov/sites/ default/files/featuredlinks/cookbookhomes.pdf

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Directions 1. Preheat oven to 350° F. 2. In a medium pot, combine brown rice, wild rice blend, barley and 1 tsp chicken base with 1 1⁄4 cups water. 3. Rinse quinoa in a fine mesh strainer until water runs clear, not cloudy. In a small pot, combine quinoa and bulgur wheat with 3⁄4 cup water and remaining 1 tsp chicken base. 4. Bring both uncovered pots to a rolling boil. Stir occasionally. Turn heat down and simmer over low heat until water is absorbed, about 30 minutes. Cover and cook an additional 10 minutes over low heat. Fluff with a fork. 5. In a large mixing bowl, combine carrots and red peppers. Drizzle with olive oil and sprinkle with salt. Toss lightly. Pour into a large nonstick baking pan. Roast at 350° F for 20 minutes or until tender. 6. Combine cooked grains, chicken and spinach with roasted vegetables. Mix well.

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Nutrition

Simple Green Smoothie Makes 2 servings

Ingredients 1 cup kale or spinach 1 banana, medium 1 cup low-fat milk (or coconut milk or almond milk) 1 cup plain yogurt 1 apple, medium (cored and sliced) 1 cup frozen fruit (all one fruit or a combination of mixed frozen fruit) 1 Tbsp flax seeds (optional) 1 Tbsp chia seeds (optional) Directions 1. In a blender, blend the kale or spinach and the liquid of your choice. 2. Add in the rest of the ingredients, blending after each item. 3. Serve and enjoy, cold. 4. Reserve the leftover smoothie in the refrigerator for later in the day or the next day. From: www.USDA.gov https://whatscooking.fns.usda.gov/recipes/ supplemental-nutrition-assistanceprogram-snap/simple-green-smoothie

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Audra N. Rankin, DNP, APRN, CPNP, is an instructor at Johns Hopkins University School of Nursing in Baltimore.

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Asthma/Allergies

Take CONTROL! AVOIDING OR REDUCING TRIGGERS, ALONG WITH TAKING NECESSARY MEDICATION, CAN HELP ALLEVIATE YOUR CHILD’S SYMPTOMS & DISCOMFORT By Tami Kochan, RN, MSN, CPNP, AE-C

A

sthma is a chronic disorder that affects 1 in 12 children, according to the Centers for Disease Control and Prevention (CDC). On average, 1 in 6 children with asthma visit hospital emergency departments each year, with about 1 in 20 kids needing to be hospitalized. Asthma cannot be cured, but you can manage it if you know your child’s triggers, work to avoid or decrease exposure to them and use the medication your healthcare provider recommends.

Asthma Symptoms in Children

Common symptoms of asthma in kids include: * Coughing, which can be dry or moist. * Shortness of breath. * Wheezing, a whistling noise when breathing out and sometimes when breathing in. * Difficulty breathing. * Fatigue. Your child may stop playing or may take more breaks.

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Severe symptoms are:

* Using abdominal or neck muscles to breathe.

* Lips turning blue. * Difficulty talking.

All the above can be avoided with good asthma control, which is why it’s important to know what triggers your child’s asthma. Depending on where you live, each season may have slightly different triggers.

Asthma & Allergy Triggers

Indoor allergens are prevalent yearround, but may seem to trigger more allergy and asthma flare-ups in fall or winter as we retreat indoors to escape cold or wet weather. Dust mites love the fabric found in carpets, furniture, mattresses and pillows. We cannot avoid exposure, but we can decrease it with


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Asthma/Allergies

Mold and mildew are pervasive no matter how often you clean. If you can see mold or mildew on a surface, there is likely a bigger area below or behind the surface that can cause flare-ups. You can use safe cleaners such as baking soda, borax or white vinegar to scrub moldor mildew-infected areas; however, be wary of strong-smelling cleaners such as chlorine bleach. To help prevent mold and mildew growth, turn on the bathroom fan when showering, and allow it to run for 15 minutes or longer. If your bathroom doesn’t have a fan, open a window to let moisture escape. You should also wash or

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regular, thorough housekeeping. Vacuum carpet and furniture at least twice a week. It’s best to use a vacuum with a high-efficiency particulate air (HEPA) filter. Use anti-allergy mattress and pillow covers — they stop dust mites from penetrating mattresses or pillows, and any dust mites already in these items cannot get out. Wash bed sheets weekly in water that’s as hot as possible. Dust blinds weekly, and wash curtains monthly. Animal dander is another trigger that’s hard to avoid. We love our animals, but if your child lives with allergies or asthma, try to limit exposure to pets and make your child’s room a pet-free place in your home.

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Asthma/Allergies

and fabrics, even after flames are extinguished.

Surviving Great-Outdoor Allergens

While the sun is shining from spring through fall, kids are outside more often to participate in outdoor play and activities in the backyard, on the playground or at the park. Spring and summer are seasons to enjoy beautiful trees and flowers in bloom. These months are also challenging for those who suffer from allergies related to pollens. Where you live will determine the significance of pollens at different times of the year. Pollens come from trees, grasses and weeds. You cannot avoid pollens, but

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replace shower curtains that have mildew or mold stains. To avoid hidden sources of mold and potential long-term home damage, fix leaky plumbing and remove other unwanted sources of water. Scented candles, air fresheners, aromatic diffusers, perfumes and colognes can also trigger allergy or asthma attacks. Avoid using these products in your home, and try to have your child avoid other locations in which these smells are prevalent. Smoke is a major trigger for asthmatics. Children with asthma should have limited exposure to wood-burning fireplaces and people who vape or smoke. Note that smoke can linger in walls, furniture

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Asthma/Allergies

you can help eliminate the impact they have on your child’s allergies or asthma. What you and your family can do when the pollen levels are high: * Shower after being outside or prior to bedtime to remove pollens that may be in hair or on exposed limbs. * Keep the windows closed — especially when air quality reports indicate heavy pollen periods — to prevent pollens from entering your house and coating your furnishings. * At end of the day, put dirty clothes in the laundry. Don’t allow your kids to wear the same clothes without washing them. We start seeing the vibrant colors on the trees and shrubs in the fall. In addition to the mentioned outdoor triggers, ragweed can be a problem for your child’s allergies. If your child suffers more frequent or severe allergy or asthma attacks during this season, limit outdoor time. When decreasing exposure to triggers does not help your child’s allergies or asthma, talk to your provider about medications and treatments that can help with symptoms or flare-ups. Overthe-counter (OTC) medications such as antihistamines may calm sneezing, itchy nose and watery eyes, and nasal steroid spray may help with nasal congestion. If symptoms persist, your provider may recommend prescription treatments. Consult your provider for asthma assessment and treatment planning, as there are many options and your child may respond better to some based on medical history.

Food Allergies

Food allergies are year-round and may trigger asthma symptoms. With a food

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allergy, your child may experience:

* Abdominal pain. * Diarrhea, indigestion, nausea, passing

a lot of gas or vomiting. * Hives or a rash. * Anaphylaxis (your child’s throat swells, causing difficulty breathing), which can be life-threatening. This is a 911 emergency. Common foods to which your child may be allergic include: * Fruits and vegetables — seasonal or year-round varieties. * Tree nuts. Depending on the time of year, you may notice allergy or asthma symptoms when tree nuts (almonds, walnuts, pecans and filberts) are harvested. * Peanuts. * Eggs. * Milk. * Crustacean shellfish (crab, lobster, shrimp). * Wheat. * Soybean. It’s important to talk to your provider and, possibly, an allergist, to help figure out if your child’s symptoms with certain foods is an allergy, an intolerance or a sensitivity. There are many triggers for your child’s asthma, and the key is knowing them. Your provider can work with you on a plan to help decrease or avoid triggers as well as recommend the right medication so that your child can be happy and healthy! Tami Kochan, RN, MSN, CPNP, AE-C, has been practicing in a primary care setting with a passion and focus on asthma and allergies for 12 years. She has had asthma and allergies for 15 years and has a full understanding personally and professionally of what patients and their families deal with on a daily basis.

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Why choose CIPRODEX® Otic? IT’S A CLEAR CHOICE EAR AFTER EAR • CIPRODEX® Otic is the #1 prescribed branded antibiotic eardrop of ENTs and pediatricians1 • Since 2003, over 30 million prescriptions of CIPRODEX® Otic have been filled1,2

CIPRODEX® OTIC HAS BEEN PROVEN EFFECTIVE2 CIPRODEX® OTIC HAS A WELLESTABLISHED SAFETY PROFILE2 Not an actual patient.

What is CIPRODEX Otic? CIPRODEX® Otic is a prescription ear drop used to treat certain types of infections caused by certain germs called bacteria: • middle ear infection (known as acute otitis media) in children at least 6 months of age who have a tube in their eardrum known as a tympanostomy tube • outer ear canal infection (known as acute otitis externa) in adults and in children at least 6 months of age. It is not known if CIPRODEX® Otic is safe and effective in children under 6 months of age. ®

IMPORTANT SAFETY INFORMATION Who should not use CIPRODEX® Otic? Do not use CIPRODEX® Otic if you: • are allergic to ciprofloxacin (the active ingredient in CIPRODEX® Otic), other quinolone antibiotics, or any of the ingredients in CIPRODEX® Otic. See the Patient Information leaflet in the full prescribing information for a complete list of ingredients. • have an outer ear canal infection caused by certain viruses including the herpes simplex virus • have an ear infection caused by a fungus


CIPRODEX® OTIC

A clear choice for EAR-RESISTIBLE patients CIPRODEX® Otic is the first and only FDA-approved antibiotic/anti-inflammatory for both outer ear canal infection and middle ear infection with tympanostomy tubes2,4 IMPORTANT SAFETY INFORMATION (continued) What are the possible side effects of CIPRODEX® Otic? CIPRODEX® Otic may cause serious side effects, including: • allergic reactions. Stop using CIPRODEX® Otic and call your doctor if you have any of the following signs or symptoms of an allergic reaction: Not an actual patient. - hives - swelling of your face, lips, mouth, or tongue - rash - itching - trouble breathing - dizziness, fast heartbeat, or pounding in your chest The most common side effects of CIPRODEX® Otic include ear discomfort, ear pain, and ear itching. These are not all the possible side effects of CIPRODEX® Otic. Call your doctor for medical advice about side effects. You are encouraged to report negative side effects of prescription drugs to FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088. Keep CIPRODEX® Otic and all medicines out of the reach of children. For additional information on CIPRODEX® Otic, please see the Brief Summary of Prescribing Information on the following pages and visit www.ciprodex.com for the full Prescribing Information. CIPRODEX® is a registered trademark of Bayer, used with permission. Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936-1080

© 2018 Novartis

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CDX-1356567


BRIEF SUMMARY OF PRESCRIBING INFORMATION For additional information refer to the full prescribing information. 1 INDICATIONS AND USAGE CIPRODEX® is indicated for the treatment of infections caused by susceptible isolates of the designated microorganisms in the specific conditions listed below: • Acute Otitis Media in pediatric patients (age 6 months and older) with tympanostomy tubes due to Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Pseudomonas aeruginosa. • Acute Otitis Externa in pediatric (age 6 months and older), adult and elderly patients due to Staphylococcus aureus and Pseudomonas aeruginosa. 4 CONTRAINDICATIONS • CIPRODEX is contraindicated in patients with a history of hypersensitivity to ciprofloxacin, to other quinolones, or to any of the components in this medication. • Use of this product is contraindicated in viral infections of the external canal including herpes simplex infections and fungal otic infections. 5 WARNINGS AND PRECAUTIONS 5.1 Hypersensitivity Reactions CIPRODEX should be discontinued at the first appearance of a skin rash or any other sign of hypersensitivity. Serious and occasionally fatal hypersensitivity (anaphylactic) reactions, some following the first dose, have been reported in patients receiving systemic quinolones. Some reactions were accompanied by cardiovascular collapse, loss of consciousness, angioedema (including laryngeal, pharyngeal or facial edema), airway obstruction, dyspnea, urticaria and itching. 5.2 Potential for Microbial Overgrowth with Prolonged Use Prolonged use of CIPRODEX may result in overgrowth of non-susceptible, bacteria and fungi. If the infection is not improved after one week of treatment, cultures should be obtained to guide further treatment. If such infections occur, discontinue use and institute alternative therapy. 5.3 Continued or Recurrent Otorrhea If otorrhea persists after a full course of therapy, or if two or more episodes of otorrhea occur within six months, further evaluation is recommended to exclude an underlying condition such as cholesteatoma, foreign body, or a tumor.

6 ADVERSE REACTIONS The following serious adverse reactions are described elsewhere in the labeling: • Hypersensitivity Reactions [see Warnings and Precautions (5.1)] • Potential for Microbial Overgrowth with Prolonged Use [see Warnings and Precautions (5.2)] 6.1 Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to the rates in the clinical trials of another drug and may not reflect the rates observed in practice. In Phases II and III clinical trials, a total of 937 patients were treated with CIPRODEX. This included 400 patients with acute otitis media with tympanostomy tubes and 537 patients with acute otitis externa. The reported adverse reactions are listed below: Acute Otitis Media in Pediatric Patients with Tympanostomy Tubes The following adverse reactions occurred in 0.5% or more of the patients with non-intact tympanic membranes. Adverse Reactions

Incidence (N=400)

Ear discomfort

3.0%

Ear pain

2.3%

Ear precipitate (residue)

0.5%

Irritability

0.5%

Taste Perversion

0.5%

The following adverse reactions were each reported in a single patient: tympanostomy tube blockage; ear pruritus; tinnitus; oral moniliasis; crying; dizziness; and erythema. Acute Otitis Externa The following adverse reactions occurred in 0.4% or more of the patients with intact tympanic membranes. Adverse Reactions

Incidence (N=537)

Ear pruritus

1.5%

Ear debris

0.6%

Superimposed ear infection

0.6%

Ear congestion

0.4%

Ear pain

0.4%

Erythema

0.4%

The following adverse reactions were each reported in a single patient: ear discomfort; decreased hearing; and ear disorder (tingling).


6.2 Postmarketing Experience The following adverse reactions have been identified during post approval use of CIPRODEX®. Because these reactions are reported voluntarily from a population of unknown size it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. These reactions include: auricular swelling, headache, hypersensitivity, otorrhea, skin exfoliation, rash erythematous, and vomiting. 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy Teratogenic Effects. Pregnancy Category C: No adequate and well controlled studies with CIPRODEX have been performed in pregnant women. Caution should be exercised when CIPRODEX is used by a pregnant woman. Animal reproduction studies have not been conducted with CIPRODEX. Reproduction studies with ciprofloxacin have been performed in rats and mice using oral doses of up to 100 mg/kg and IV doses up to 30 mg/kg and have revealed no evidence of harm to the fetus. In rabbits, ciprofloxacin (30 and 100 mg/kg orally) produced gastrointestinal disturbances resulting in maternal weight loss and an increased incidence of abortion, but no teratogenicity was observed at either dose. After intravenous administration of doses up to 20 mg/kg, no maternal toxicity was produced in the rabbit, and no embryotoxicity or teratogenicity was observed. Corticosteroids are generally teratogenic in laboratory animals when administered systemically at relatively low dosage levels. The more potent corticosteroids have been shown to be teratogenic after dermal application in laboratory animals. 8.3 Nursing Mothers Ciprofloxacin and corticosteroids, as a class, appear in milk following oral administration. Dexamethasone in

breast milk could suppress growth, interfere with endogenous corticosteroid production, or cause other untoward effects. It is not known whether topical otic administration of ciprofloxacin or dexamethasone could result in sufficient systemic absorption to produce detectable quantities in human milk. Because of the potential for unwanted effects in nursing infants, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. 8.4 Pediatric Use The safety and efficacy of CIPRODEX have been established in pediatric patients 6 months and older (937 patients) in adequate and well-controlled clinical trials. No clinically relevant changes in hearing function were observed in 69 pediatric patients (age 4 to 12 years) treated with CIPRODEX and tested for audiometric parameters. 10 OVERDOSAGE Due to the characteristics of this preparation, no toxic effects are to be expected with an otic overdose of this product. Distributed by: Alcon Laboratories, Inc. Fort Worth, TX 76134 USA U.S. Pat.: www.alconpatents.com CIPRODEX® is a registered trademark of Bayer Intellectual Property GmbH, licensed to Alcon by Bayer Intellectual Property GmbH. ©2003, 2004, 2008, 2009, 2015 Novartis Revised: December 2015 W9012314-1115


Immunization

Get the FACTS PROTECT YOUR FAMILY & COMMUNITY FROM VACCINE-PREVENTABLE DISEASES By Lacey Eden, MS, FNP-C, and Meg McDowell, RN-S

I

n the last few years, the media have covered more and more stories about outbreaks of vaccine-preventable diseases in the U.S. and around the world. To best protect your children, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practice (ACIP) issues an annual immunization schedule with updates on which vaccinations are needed at what ages. ACIP, a group of leading public health and medical experts, reviews immunization research throughout the year to develop recommendations for the U.S. immunization schedule. Read on to learn what’s new in 2019.

Influenza

Although to some it may seem like a stomach illness marked by vomiting and fatigue, the flu is actually a respiratory illness. The CDC has provided the following information on the influenza virus to help you know what to look for and how to respond. 1. Influenza is a contagious respiratory illness caused by viruses that infect the nose, throat and, sometimes, the lungs. 2. It causes mild-to-severe illness and has, in some cases, led to death. 3. Symptoms include fever, cough, sore throat, runny or stuffy nose, fatigue,

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chills, body aches and headaches.

4. The best way to prevent the flu is by getting an annual flu vaccine. When is flu season? And what’s the best time to get the flu shot each year? According to the CDC, flu season occurs in the fall and winter with peaks between December and February. However, your child is not safe from the virus until much later, as the influenza virus has been known to be active as late as May. The best way to help prevent the flu and its debilitating symptoms is to get the flu vaccine each year. In many places, the vaccine is available as early as September. It’s best to get vaccinated by late October to get the most protection before the virus starts to spread in your community. However, the vaccine is still beneficial if you are immunized later in the flu season (January or thereafter).


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BECAUSE YOU KNOW THE FLU CAN BE SERIOUS

SAY YOU WANT THE SPRAY FLUMIST QUADRIVALENT is the only nasal-spray flu vaccine It’s recommended by the CDC and approved by the FDA to help prevent the flu this season

ACCORDING TO THE CDC

IT’S NOT TOO LATE TO VACCINATE!

IMPORTANT SAFETY INFORMATION What is FLUMIST QUADRIVALENT? FLUMIST QUADRIVALENT is a vaccine that is sprayed into the nose to help protect against influenza. It can be used in children, adolescents, and adults ages 2 through 49. FLUMIST QUADRIVALENT is similar to MedImmune’s trivalent influenza vaccine, except FLUMIST QUADRIVALENT provides protection against an additional influenza strain. FLUMIST QUADRIVALENT may not prevent influenza in everyone who gets vaccinated. Who should not get FLUMIST QUADRIVALENT? You should not get FLUMIST QUADRIVALENT if you have a severe allergy to eggs or to any inactive ingredient in the vaccine; have ever had a life-threatening reaction to influenza vaccinations; or are 2 through 17 years old and take aspirin or medicines containing aspirin – children or adolescents should not be given aspirin for 4 weeks after getting FLUMIST QUADRIVALENT unless your healthcare provider tells you otherwise. Children under 2 years old have an increased risk of wheezing (difficulty with breathing) after getting FLUMIST QUADRIVALENT You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.FDA.gov/medwatch or call 1-800-FDA-1088. CDC=Centers for Disease Control and Prevention. FLUMIST is a registered trademark of the AstraZeneca group of companies. Tamiflu and Relenza are registered trademarks of their respective owners. ©2018 AstraZeneca. Gaithersburg, MD 20878 All rights reserved. US-25314 12/18 1-877-FLUMIST (358-6478) www.flumistquadrivalent.com

Flu can spread as far as 6 feet away when people with the flu cough, sneeze, or talk, or when someone touches a surface contaminated with flu and then touches their own mouth, nose or eyes Annual, seasonal vaccination is the best way to reduce the risk of getting and spreading the flu

Who may not be able to get FLUMIST QUADRIVALENT? Tell your healthcare provider if you or your child are currently wheezing; have a history of wheezing if under 5 years old; have had Guillain-Barré syndrome; have a weakened immune system or live with someone who has a severely weakened immune system; have problems with your heart, kidneys, or lungs; have diabetes; are pregnant or nursing; or are taking Tamiflu®, Relenza®, amantadine, or rimantadine. What are the most common side effects of FLUMIST QUADRIVALENT? The most common side effects are runny or stuffy nose, sore throat, and fever over 100°F. Please see Brief Summary of full Prescribing Information on the following page.


IMPORTANT PRODUCT INFORMATION Information for Patients and Their Caregivers FluMist® Quadrivalent (pronounced FLEW-mĭst Kwä-drə-VĀ-lənt) (Influenza Vaccine Live, Intranasal) Please read this Patient Information carefully before you or your child is vaccinated with FluMist Quadrivalent. This is a summary of information about FluMist Quadrivalent. It does not take the place of talking with your healthcare provider about influenza vaccination. If you have questions or would like more information, please talk with your healthcare provider. What is FluMist Quadrivalent? FluMist Quadrivalent is a vaccine that is sprayed into the nose to help protect against influenza. It can be used in children, adolescents, and adults ages 2 through 49. FluMist Quadrivalent is similar to MedImmune’s trivalent Influenza Vaccine Live, Intranasal (FluMist), except FluMist Quadrivalent provides protection against an additional influenza strain. FluMist Quadrivalent may not prevent influenza in everyone who gets vaccinated. Who should not get FluMist Quadrivalent? You should not get FluMist Quadrivalent if you: • have a severe allergy to eggs or to any inactive ingredient in the vaccine (see “What are the ingredients in FluMist Quadrivalent?”) • have ever had a life-threatening reaction to influenza vaccinations • are 2 through 17 years old and take aspirin or medicines containing aspirin. Children or adolescents should not be given aspirin for 4 weeks after getting FluMist or FluMist Quadrivalent unless your healthcare provider tells you otherwise. Please talk to your healthcare provider if you are not sure if the items listed above apply to you or your child. Children under 2 years old have an increased risk of wheezing (difficulty with breathing) after getting FluMist Quadrivalent. Who may not be able to get FluMist Quadrivalent? Tell your healthcare provider if you or your child: • are currently wheezing • have a history of wheezing if under 5 years old • have had Guillain-Barré syndrome • have a weakened immune system or live with someone who has a severely weakened immune system • have problems with your heart, kidneys, or lungs • have diabetes • are pregnant or nursing • are taking Tamiflu®, Relenza®, amantadine, or rimantadine

If you or your child cannot take FluMist Quadrivalent, you may still be able to get an influenza shot. Talk to your healthcare provider about this. How is FluMist Quadrivalent given? • FluMist Quadrivalent is a liquid that is sprayed into the nose. • You can breathe normally while getting FluMist Quadrivalent. There is no need to inhale or “sniff” it. • People 9 years of age and older need one dose of FluMist Quadrivalent each year. • Children 2 through 8 years old may need 2 doses of FluMist Quadrivalent, depending on their history of previous influenza vaccination. Your healthcare provider will decide if your child needs to come back for a second dose. What are the possible side effects of FluMist Quadrivalent? The most common side effects are: • runny or stuffy nose • fever over 100°F • sore throat Other possible side effects include: • decreased appetite • headache • irritability • muscle ache • tiredness • chills • cough Call your healthcare provider or go to the emergency department right away if you or your child experience: • hives or a bad rash • swelling of the face, • trouble breathing tongue, or throat These are not all the possible side effects of FluMist Quadrivalent. You can ask your healthcare provider for a complete list of side effects that is available to healthcare professionals. Call your healthcare provider for medical advice about side effects. You may report side effects to VAERS at 1-800-822-7967 or http://vaers.hhs.gov. What are the ingredients in FluMist Quadrivalent? Active Ingredient: FluMist Quadrivalent contains 4 influenza virus strains that are weakened (A(H1N1), A(H3N2), B Yamagata lineage, and B Victoria lineage). Inactive Ingredients: monosodium glutamate, gelatin, arginine, sucrose, dibasic potassium phosphate, monobasic potassium phosphate, and gentamicin. FluMist Quadrivalent does not contain preservatives. If you would like more information, talk to your healthcare provider or visit www.flumistquadrivalent.com or call 1-877-633-4411. FluMist® is a registered trademark of MedImmune, LLC. Other brands listed are registered trademarks of their respective owners and are not trademarks of MedImmune, LLC. Manufactured by: MedImmune, LLC, Gaithersburg, MD 20878 Issue date: August 2018 US-25390 12/18 RAL-FLUQV7


Immunization

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Hep A

Almost everyone loves experiencing new sights and sounds when traveling to foreign places, but with foreign travel

Ready, Set, Grow

also come germs, viruses and bacteria that are foreign to your little ones. The ACIP updated the international travel recommendations for the Hep A vaccination. Travelers ages 6-11 months and unvaccinated travelers 12 months or older should receive the Hep A vaccine. Also, the update includes Hep A vaccine recommendations for homeless kids. Hep A is a disease of the liver. According to the CDC, it is transmitted person-to-person through the fecal-oral route. When contracted, many children six years of age or younger do not present with any symptoms or display an unrecognized infection, so it’s critical that your kids are protected before you jump on a plane to an exotic locale.

Hep B

Hep B is also a disease of the liver. It is transmitted when the blood or other bodily fluid of an infected person comes in contact with a non-infected person. It can cause serious health problems over time, including liver cancer and liver failure. The recommended routine Hep B vaccine series includes three doses and begins at birth. The ACIP updated recommendations for children 18 years or older who are unvaccinated or incompletely vaccinated. These children can now receive the combination Hep A-Hep B vaccine. In addition, those 18 years or older who have risk factors for Hep B, such as working in the healthcare field, can now receive a two-dose series for the Heb B vaccine in place of the three-vaccine series.

Tdap

ISTOCK.COM

The 2018-2019 influenza recommendation was updated to indicate that a live attenuated influenza vaccine (LAIV) can be used, and the American Academy of Pediatrics (AAP) has indicated it does not have a preference of shot or nasal vaccine for children during the 2019-2020 influenza season. The LAIV is administered with a single spray in the nose. It is a weakened form of the live influenza virus that is breathed in with a single sniff. There are unique circumstances under which the LAIV should not be used — for example, with children under age 2, children 2-4 with asthma and people with a history of a severe allergic reaction to any component of the vaccine. Your pediatric healthcare provider will help you determine if the LAIV is a safe option for your child. During the 2017-2018 flu season, hospitalization rates were the highest ever recorded, and 185 children died from the flu. Read more at cdc.gov/flu/about/ season/flu-season-2017-2018.htm. Be sure to help protect your children by getting them vaccinated. For more information on the flu, visit napnap.org/do-you-know-flu. In addition to the annual influenza vaccine, the ACIP has updated other immunization recommendations in the 2019 schedule. These recommendations are designated for children and adolescents ages 18 years or younger and include the hepatitis A (Hep A), hepatitis B (Hep B), tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) and the inactivated poliovirus (IPV) vaccine.

The Tdap vaccine helps protect against three potentially devastating diseases.

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Immunization Tetanus (lockjaw) causes painful muscle tightening. Diphtheria causes a thick coating to form in the back of the throat, making it difficult or impossible to breathe. Pertussis (whooping cough) causes severe coughing spells that can lead to difficulty breathing, vomiting and disturbed sleep. The vaccinations for these three diseases are combined into one single shot called the DTaP (diphtheria and tetanus toxoids and acellular pertussis) for children younger than 7 years old, or the Tdap (tetanus and diphtheria and acellular pertussis) for children 7 years of age or older. Traditionally, Tdap is administered at 11-12 years old. The 2019 immunization update indicates that those who received the DTaP, inadvertently or through a catch-up schedule at 7-10 years of age, should still receive a dose of Tdap at 11-12 years of age.

IPV

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a great way to be a proactive advocate for your child’s healthcare. Be sure to view the CDC’s full immunization recommendations and schedule by visiting napnap.org/vaccinations-childrenand-teens or cdc.gov/vaccines/schedules/ easy-to-read/child-easyread.html. Lacey Eden, MS, FNP-C, an Assistant Teaching Professor, teaches in the graduate program in the College of Nursing at Brigham Young University. She is a primary care provider in a busy clinic in Lehi, UT. Meg McDowell, RN-S, is a research assistant and busy undergraduate nursing student at Brigham Young University.

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Many vaccines are combined to reduce the number of shots your child must receive. Inactivated Polio Vaccine or IPV is often combined with other vaccines your child needs. The fourth dose of IPV should be given on or after your child’s fourth birthday. The 2019 updated recommendation for children who receive the recommended four doses of IPV through combination vaccines prior to turning 4 years old, is to receive one more dose after his or her fourth birthday and six months after the last IPV dose. Rising rates of some immunizationpreventable diseases has increased the urgency and importance of ensuring your child is properly vaccinated. Understanding the ACIP recommendations for immunizations is



Health

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“OOPS. I Wet the Bed” FINDING OUT WHY & HOW TO HELP By MiChelle McGarry, MSN, RN, CPNP, CUNP, FAANP

ccording to the American Academy of Pediatrics (AAP), an estimated five million children in the U.S. wet the bed. Bedwetting is more common with younger kids, but as many as ten percent of sevenyear-olds and five percent of ten-year-olds may wet the bed. It’s more common for boys to do so than girls. Regardless of age, rest assured that your bedwetting child is not choosing to do this and is not just being lazy. There are reasons for bedwetting. It’s important not to blame or punish your child for bedwetting incidents. It’s better to learn — along with your child — possible causes of the bedwetting and ways to overcome it.

What Can Cause Bedwetting

The AAP suggests that causes of bedwetting include: * Deep sleep that delays waking for a full bladder. * Inability to hold and empty urine throughout the day. * Constipation, which puts pressure on the bladder. * Small, unable-to-hold urine for a full night. * Family history or underlying medical issue.

Ready, Set, Grow

Recently, pediatric urology specialists have suggested that another possible cause of bedwetting is “pee-holding.” This is when kids hold their urine and tire their bladder. Then at night, when sleeping, the pelvic floor — the muscles used in holding — relax and the urine is released. Often kids urinate more than once at night because they have not urinated the typical six-to-eight times necessary during awake hours. The same effect could come from “poop-holding” because a large amount of stool in the rectum takes up space in the pelvic area, which squishes the bladder, causing it to contract and not hold urine throughout the night. These two issues almost always occur simultaneously. And they both can cause what can commonly be referred to as a “small bladder.” It is important to know that the bladder can be functionally small due to daytime holding of urine and stool. These actions can tire the bladder so that it can’t hold urine at night, even though it is a completely normal-sized bladder.

Bathroom Breaks Matter

A great question to ask your school-age children — whether they have any urine

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A


Health

48

Drink Up

Water intake is also very important to elimination health. A good guideline is for your child to drink half of his body weight in ounces of water, i.e., a 50-pound child would drink 25 ounces of water a day, preferably throughout the day between breakfast and dinner. If bedwetting is negatively affecting your child — mentally or physically — speak with your pediatric healthcare provider to discuss the best course of action for your child’s situation. Reassurance that your child will grow out of it is not enough, and effective treatments are available. MiChelle McGarry, MSN, RN, CPNP, CUNP, FAANP, is a pediatric and urology nurse practitioner who has practiced pediatric urology since 1999 and successfully treated thousands of patients with bowel and bladder dysfunction, including bedwetting. She is the director at the Pediatric Effective Elimination Program (PEEP) Clinic & Consulting PC in Denver.

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or stool issues or not — is what the rules are for going to the bathroom at school, posing it as an open-ended question. The answers that they give can be very revealing about their stool and urine patterns at school. It’s also important to note that the more you hold stool and urine, the “better you get at the holding,” meaning that this can lead to actually feeling as though you don’t need to go. To overcome these holding issues, make sure your children have adequate opportunities to use the restroom throughout the day and evening, especially during school or after-school activities. Become a bathroom-break advocate, if necessary. Teach your kids the importance of going to the bathroom when they feel the urge. Along these same lines, don’t ask your children if they need to go to the bathroom, as the answer will almost always be “no!” Instead, build bathroom breaks into the day so that they learn to go six-toeight times regularly.


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Mental Health

Depression, DEFINED UNDERSTANDING & HELPING YOUR CHILD By Stephanie C. Evans, PhD, APRN, CPNP-PC

M

ental illness is a very real condition in the brain. Among the many possible causes are genetics, emotional trauma, physical trauma, exposure to substances during pregnancy and poor nutrition. Often the exact cause of a mental illness is unknown. One in five children has a diagnosed mental illness. Most kids with a mental illness will have changes in the brain before any signs or symptoms appear. According to the National Institute of Mental Health (NIMH), most of those who will be diagnosed with a mental illness have the first symptom appear before the age of 14, but do not seek treatment for the illness for an average of ten years from the first noticed symptom.

Anxiety Disorders in Kids

Anxiety — a normal reaction to stress — occurs in almost everyone. Anxiety disorders are different and happen when feelings of nervousness or anxiousness affect daily activities and relationships negatively. A child with an anxiety disorder will have excessive worry and may develop emotional and/or physical signs and symptoms. The disorder might be one of several different types: generalized anxiety, social anxiety, phobias, separation anxiety or panic disorder. The NIMH estimates that approximately 32 percent of children have some type of anxiety and 8 percent of children have a severe anxiety disorder that impairs their daily lives. The exact cause of anxiety disorders remains unknown. However, the most likely explanation is a combination of factors, including stress, the environment and the developmental stage of the child. Anxiety disorders may run in families. Each child is unique, and signs and symptoms

50



Mental Health

52


Depression in Kids

Feelings of sadness are normal for children occasionally, and are a part of life for everyone. However, depression is more than a feeling of sadness on occasion. It is a common mental disorder for people, occurring in up to 20 percent of teens and up to 5 percent of children younger than 12. Depression is a mood disorder that impacts the way a child may think, feel, act and interact daily with others. Depression may range from mild, to moderate, to severe in expression that occurs daily. It is difficult to identify the root cause of depression in those diagnosed. There may be a genetic predisposition

to depression. It may also occur due to traumatic life events, major life changes, stress or illness. It’s important is to identify changes in behavior and to observe signs and symptoms that may include but are not limited to: * Feeling sad or hopeless daily. * Irritability and not wanting to participate in activities. * Changes in mood, to low energy, tired, sluggish or restless. * Social isolation, not wanting to interact with peers or others. * Difficulty paying attention. * Changes in sleep patterns; a significant increase or decrease in sleep. * Changes in eating patterns: eating significantly more or less than normal. * Feelings of worthlessness, uselessness, guilt or of not belonging. * Self-injury and/or self-destructive behavior. Major depression in children can lead to thoughts of self-harm or suicide. If you are concerned your child has depression, seek assistance from your provider.

Diagnosis

Step one is to make an appointment with your child’s provider for an assessment. Primary care providers have training for assessment of mental health and mental illness in children. During well-child visits, your provider will ask questions and assess possible mental health concerns at each age as part of early identification. If you make an appointment specifically for evaluation of possible anxiety or depression, your provider will conduct a complete physical exam to rule out possible physical causes for the behavioral changes. In addition, he or she may have you and/or your child as well

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of anxiety disorders will vary based on the age and developmental stage of the child. Signs or symptoms you may notice caused by an anxiety disorder include but are not limited to: * Excessive worry and/or fear. * Restlessness and irritability. * Agitation or fidgeting. * Changes in mood to include strong feelings of anger. * Social isolation, not wanting to interact with peers or others. * Withdrawing from normal activities. * Insomnia and/or sleep difficulties and fatigue. * Poor concentration. * Headaches. * Stomachaches, nausea, diarrhea and gastrointestinal issues. If your child has signs and symptoms that impact daily activities, is refusing to participate in things he or she once enjoyed or has a significant change in behavior, you should seek assistance from your healthcare provider.


Mental Health as teachers and other family members complete questionnaires prior to making a diagnosis of a mental illness.

Treatment

Destigmatizing Mental Illness One of the biggest concerns with a diagnosis of mental illness is the stigma often associated with the diagnosis. The stigma of being diagnosed with a mental illness has been known to keep people from seeking the help that they need. The best way to help your child is to be open and honest and talk to him or her

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Your provider will work with you to develop an individualized treatment plan. He or she may recommend one of many types of therapy — such as cognitive behavior therapy, play therapy or psychotherapy — based on the diagnosis and age of your child. You may be referred to a specialist in therapy for children. In addition, some mental illnesses respond well with medication management, either

short or longer term, depending on the diagnosis. Not all mental illness will need medication, and there is the possibility medication will only be needed for a short period of time during which your child attends therapy.

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Mental Health your community, including the school nurse or counselor, and use resources to help educate yourself and others. Stephanie C. Evans, PhD, APRN, CPNP-PC, is an Assistant Professor of Nursing at Texas Christian University. A primary care PNP with more than 20 years of experience working with families and children, her research is focused on improving mental health in primary care for children.

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about what is going on. It’s important to identify mental illness early, seek treatment for your child, work with your provider and take care of yourself so you can take care of your child. Seek support groups for parents of children with the same mental illness. Acknowledge and discuss the illness with family members, and educate other people on mental illness to change the stigma associated with diagnosis. Don’t be afraid to ask for help. Reach out to others in

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Child Safety

Stand Up & SPEAK UP! EMPOWER YOUR KIDS TO ADDRESS DANGEROUS BEHAVIOR By Gail Hornor, DNP, CPNP

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s parents and caregivers, we try to do everything we can to protect our children. Despite our best efforts, we live in a world where bad things can happen to kids. According to the U.S. Department of Health and Human Services, nearly 700,000 American children suffer child abuse each year, of which more than 50,000 are victims of sexual abuse. The Office of Juvenile Justice and Delinquency Prevention states that more than 200,000 children are victims of sex trafficking annually. Too many kids experience bullying — both faceto-face and on the internet. You can make a difference by empowering your kids to prevent and report abusive behavior. You are their best protection against abuse and bullying. Kids who have positive, secure relationships with their parents are emotionally stronger and more resilient. The consistent use of positive

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parenting practices from infancy to adolescence enhances the parentchild relationship — making kids more confident, assertive and empowered. These practices include maintaining open communication, having developmentally appropriate behavioral expectations, using nonphysical and non-emotionally abusive methods of discipline and ensuring a safe environment. The Centers for Disease Control and Prevention offers positive parenting tips and videos. https://www.cdc.gov/ncbddd/ childdevelopment/positiveparenting/ index.html.

Empowerment Basics

According to research studies, bullying can impact about 10 to 15 percent of kindergarten students and up to 50 percent of high school students. Always keep the lines


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Child Safety of communication with your kids open. Talk to your children every day about school, friends and academic performance. Pay attention to their internet and social media use. Let them know that it’s not OK if anyone online or in person makes fun of, bothers or hurts them (physically or emotionally). Work with your kids to develop a strategy to address bullying. Encourage them to ignore the bully and to just walk away. Discuss that the bully just really wants to upset them. Encourage your children to practice confidence and how they will respond to bullying. Stress the importance of talking about bullying to you, a teacher, a counselor or a friend. Helping your children deal with cyberbullying follows the same

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principles. Ignore the cyberbully as well; never retaliate. If cyberbullying is repeated, ask the bully/bullies to stop. Again, talking about cyberbullying is important; encourage your children to talk to you or another trusted adult about cyberbullying. Don’t delete bullying messages; save the evidence. Never pass on messages from cyberbullies electronically. It’s important to block the cyberbullies’ access to your kids and report the activity to the content provider. If safety is ever a concern for either traditional or cyberbullying, notify the police. Examples of bullying or cyberbullying that rise to the level of a crime include the following: threats or violence, child pornography, sending sexually explicit messages or photos, taking


a photo or video of someone in a place where he or she would expect privacy, stalking or hate crimes. If bullying occurs on school property, notify school authorities. Most states have anti-bullying laws — find out what your state requires of your child’s school to address bullying.

The Importance of Supporting One Another

ProtectingAgainstSexualAbuse Protecting children from sexual abuse begins in infancy. Teach your kids the correct names for all parts of their bodies, including private parts. Make sure your children know that no one should touch, tickle or look at their private body parts. Educate your kids to tell you or another trusted adult if their private parts are violated. Provide a list of adults they could tell, should the need arise. You are your children’s best protection against sexual abuse. The majority of victims are not sexually abused by strangers; rather, they are most at risk from someone they know, trust and love. Individuals who have sexually abused a child are at high risk to abuse again; never leave your child with someone who

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has a history of sexually abusing children. Pay attention if any adult wants to spend a lot of alone time with your children. Most importantly, if your children disclose sexual abuse, listen to them. Always report any disclosure of sexual abuse to child protective services.

Establishing Rules for Online Behavior

In today’s world, teens and kids must understand internet safety. It’s important to teach kids safe, responsible online behavior because it’s not unusual for older children and teens to meet a sexual abuse perpetrator online. The internet is also a major vehicle for recruitment and advertising in sex trafficking. Encourage your children to talk to you about their internet use. Establish rules for internet use. Make sure kids understand it’s not OK to post or trade personal pictures with anyone they don’t know. Make it very clear to your kids to never post or trade

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Stress to your children the importance of supporting other children who are bullied. Never laugh at the bullied kids or participate in the bullying. Encourage kids to let the bully victim know that the bullying they witnessed was not OK. They should always be open and honest with school authorities or the police if ever questioned about bullying that they have witnessed or experienced. For additional information, visit https://www.stopbullying. gov/what-is-bullying/roles-kids-play/ index.html.


Child Safety

Building Resilience & Empathy Building resilience in children is a crucial aspect of empowering them. Resilient kids are better able to protect themselves from bullying or abuse, and better equipped to deal with it successfully if it does happen. To build child resilience, be supportive so kids can process exposure to stress (such as bullying or abuse) in a way that results in their positive growth. Relationships with siblings, grandparents, other relatives and friends are also a source of resilience for kids. Help them identify their strengths and likes —

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whether in academics, sports, arts or their personalities. Encourage them with honest praise and by pointing out their skills. Stress the importance of being part of a team and learning to work together. Instill an understanding of how their behavior affects others and that empathy for others is important. Praise your kids for having the courage to tell you or another adult if something bad happens to them or to another child. Your efforts have worked! Your children have demonstrated the ability to stand up and speak up regarding improper, abusive behavior. Gail Hornor, DNP, CPNP, is a PNP at the Center for Family Safety and Healing at Nationwide Children's Hospital, a hospital-based child advocacy center. She has worked in the field of child maltreatment for more than 25 years.

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nude or other sexually explicit photos with anyone. Children should never share personal information such as their address, phone number or school with someone they don’t know. Tell your kids not to agree to get together in person with anyone they meet online.



Dental Health

All SMILES PREVENTATIVE CARE IS VITAL TO A CHILD’S WELL-BEING

By Jo Ann B. Serota, DNP, CPNP, FAANP, IBCLC

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ental caries, usually known as tooth decay, is the most common chronic disease in children in the U.S., ranking above asthma and hay fever. The American Academy of Pediatrics (AAP) reports that 59 percent of children 12 to 19 years of age have at least one documented cavity. Dental caries is caused by acidproducing bacteria that destroy the tooth’s enamel, its protective barrier. With tooth decay, there is a greater risk of tooth loss, dental abscess and pain. Caries in children causes not only discomfort, but difficulties with chewing, which may lead to poor weight gain and inhibit growth and development. Another concern is that untreated caries may cause a systemic infection, abscess of the gums, cellulitis and the risk of infecting the permanent teeth. According to the AAP, dental caries contributes to the 51 million hours of school absenteeism and parental loss of work hours annually. Children often miss school because of mouth pain. This pain may be reflected in poor school performance, anxiety, fatigue, irritability or withdrawal from normal activities. Tooth loss from dental caries may affect a child’s jaw development and impact the development of the permanent teeth.

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Establishing Healthy Habits

You can help prevent caries in your kids by exposing their teeth to fluoride, practicing good oral hygiene and limiting carbohydrates (especially sugary, gummy foods, sodas and nighttime bottles with milk and juices). Delaying the introduction of external bacteria into your child’s mouth (e.g., not kissing your child on the mouth, not cleaning a pacifier by using your mouth to wipe it clean, and not using utensils handled by others) will also promote good oral hygiene. It’s important to take a proactive role in caring for your children’s dental hygiene. Dental hygiene should begin in infancy with gum care and tooth brushing as the teeth erupt. The first dental visit, per the AAP, should be in the first year of life. Then biannual dental visits should become part of your children’s routine preventative health maintenance. As kids grow, they should be responsible for daily tooth care. Be sure that your children have the


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Dental Health

appropriate soft-bristled toothbrushes, and replace toothbrushes as they wear. Also, fluoride toothpaste, dental floss and appropriate fluoride mouth rinse (for children six years of age and older) should be located where kids routinely do their daily oral hygiene. Establish and encourage a daily routine of brushing teeth in the morning and before bedtime. You may need to remind your children and even have an incentive in place to maintain daily oral healthcare.

Taking Healthy Measures

Preventative measures against cavities have been promoted in dental and medical communities. One of the most effective measures is the addition of fluoride to community water supplies. According to the Centers for Disease Control and Prevention, about 75 percent of the U.S. population is served

by community water systems that contain enough fluoride to protect teeth. Grassroots efforts are needed to encourage all communities to have fluoride added to their water supplies. You should know the current level of fluoride in your community water supply, and can find out by calling your local water company or having your water tested. Fluorosis, a cosmetic condition in which teeth are stained by overexposure to fluoride, does not endanger teeth. In fact, it may be more protective. Fluoride supplementation is most effective in kids younger than eight years of age, when the mineralization of the teeth is still occurring. If your water supply does not have fluoride and other sources of fluoride are low, contact your provider about fluoride supplementation for your children. The use of fluoridated toothpaste in infancy is now recommended instead of fluoride supplements if there is a concern about the amount and sources of fluoride in children’s diets. The amount of fluoride in a one-inch strip of fluoridated toothpaste contains 1 or 1.5 milligrams of fluoride. Children under three years of age and after the first tooth erupts should have a smear (or the size of a grain of rice) of fluoride toothpaste placed on their toothbrushes. Kids ages three to six years of age should have a pea-size amount of fluoridated toothpaste on their brushes. It is acceptable for children to not rinse (most children will swallow the rinse water) after brushing but to spit out the excess toothpaste. This will give kids the necessary fluoride coating on their teeth from the saliva and a reduction in the amount of fluoride swallowed. The application of fluoride varnish (a concentrated topical fluoride)

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varnish is covered by Medicaid as well as by many private dental insurance plans. Your pediatric practice can verify billing requirements for treatment. Preventative dental care is an important part of a child’s well-being. Establishing a dental routine and appropriate dental assessment for your kids leads to cavityfree smiles and happy children. Jo Ann B. Serota, DNP, CPNP, FAANP, IBCLC, is co-owner of Ambler Pediatrics, Ambler, PA. She is president of the NAPNAP Foundation, past president of NAPNAP, corresponding editor of primary case studies for the Journal of Pediatric Health Care and a Ready, Set, Grow advisory panel member.

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is another preventative measure to consider to prevent dental caries. Application of fluoride varnish is a noninvasive procedure done in the child’s pediatric practice or clinic. After an oral examination by your provider, fluoride varnish is brushed on the surfaces of the teeth to prevent new cavities from forming. It is well tolerated by most kids. After application, eating soft foods and avoiding brushing should follow. Children should resume their normal twice-daily brushing the next day. Fluoride varnish should be applied at least every six months to both primary and permanent teeth. If there is a high risk for cavities or limited access to a dentist, varnish should be applied every three months. Fluoride


Skincare

Name That RASH COMMON CONDITIONS IN CHILDREN By Stacia M. Hays, DNP, CPNP-PC, CCTC, CNE

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ometime or another your child will develop a rash or itchy skin. Such skin issues are common during childhood, and treatment can usually begin at home. If the over-the-counter (OTC) remedies available to you do not improve the condition, your healthcare provider may have to treat it.

Acne

If your teenager has acne, he or she is not alone. Almost 95 percent of teens develop acne at some time during the ages of 12 and 19 years. Lesions most commonly appear on the face, neck, upper back, chest and shoulders. The tendency to develop acne and its severity are believed to be genetic. A teen with severe acne likely has a parent with severe acne. Acne often worsens (flares) during times of stress (such as final exams) or during menses, and typically each flare occurs in the same part of the body.

Preventing & Responding to Breakouts

Steps to take to decrease the risk of developing acne and to help your teen’s skin during a breakout follow. 1. Avoid overwashing. This can irritate and change the skin’s balance, which can lead to further breakouts. 2. Avoid using oil-based products on the skin. Use only makeup, lotions and sunscreens designated noncomedogenic on the face. These are specially formulated not to block pores. 3. Avoid picking or squeezing. Bacteria live under fingernails. Picking and squeezing add more bacteria onto the skin and drive infectious material deeper into the pores. This creates more infection and worsening breakouts.

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Picking and squeezing can also cause permanent scarring.

Treating Acne

For at-home treatment of mild acne, there are many OTC options available at your local grocery store or pharmacy. Wash the areas twice daily with a cleanser containing salicylic acid. This aids in removing dead skin cells and keeping the pores open. The American Academy of Dermatology also recommends applying a lotion containing benzoyl peroxide once or twice daily. For moderate to severe acne, prescription medications are required, so you would need to see a healthcare provider. Your provider may prescribe a combination of topical and oral antibiotics or a stronger topical or oral retinoid. He or she may also prescribe an oral contraceptive designed specifically to decrease acne. It’s important to always wear sunscreen, especially when treating acne. Many medications make your skin easily susceptible to sunburn. Achieving clearer skin requires patience and persistence in following the daily prescribed regimen. With the right treatment plan, your teen’s acne will improve.

Methicillin-Resistant Staphylococcus Aureus (MRSA) Staphylococcus aureus are normal bacteria found on humans, animals and other surfaces. They appear on skin and in the mucous membranes of the nose. Antibiotics can usually treat an infection caused by these bacteria, but MRSA are resistant to typical medications. They are spread through contact with contaminated items such as towels, workout equipment

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Skincare and sneezing and coughing. MRSA cause a skin infection when there is a break in the skin’s surface through a scratch or cut. This rapidly develops into a painful abscess or boil — with redness, swelling and warmth around the infected area. It is often mistaken for a spider bite. Infections caused by MRSA typically don’t respond to OTC antibiotic ointments and will need to be managed by your provider.

Treating MRSA

Treatment begins with draining the boil and keeping it loosely covered. Your provider may prescribe oral antibiotics such as trimethoprim-sulfamethoxazole or clindamycin. If infections continue to develop, your provider may prescribe daily ointment to be applied into each nostril. To prevent spreading infection, it is important to keep the area covered if it is draining. The entire family should wash their hands frequently. This is especially important after using the bathroom, before eating and after changing the bandage. Typically, these infections do not require hospitalization and resolve after draining. Completing the course of antibiotics as instructed can prevent the infection from spreading.

Psoriasis

Psoriasis is a chronic inflammatory skin disorder that affects two percent of children. There is often a family history of psoriasis or other autoimmune diseases. The affected areas are well defined, and may be itchy. The classic sign is a rash with silvery scales, with pink or red patches underneath. With children it is more commonly seen on the face, but can appear on the scalp, neck, elbows, knees, soles of feet and nails. When it appears on

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nails, small pitting or separation of the nail from the nailbed will be seen. Certain situations are known to cause the rash to worsen. Stress, cold weather and strep throat are the most common in children.

Treating Psoriasis

There are no OTC medications that can treat psoriasis. Treatment requires management by your provider or a dermatology specialist. Small areas often respond to topical treatments, including prescription-strength steroid creams and vitamin D derivatives. Phototherapy with UVB waves can also be an effective treatment. Larger areas may require additional medications that affect the immune system, so your child will usually be referred to a specialist such as a dermatologist or rheumatologist for management. Immune-modifying medications, including oral methotrexate in combination with injectable medications such as etanercept or ustekinumab, may be prescribed. Improvement is typically seen after three months of treatment. Complete clearance of the rash does not always occur, but significant improvement can occur with consistent treatment as prescribed. It is important to apply the medications as prescribed,

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Skincare

Eczema

If your child’s skin is frequently dry, red and itchy in spite of applying daily moisturizers, he or she may have eczema. Eczema is a chronic skin condition that improves, then recurs. Many times, moisturizers alone will not improve your child’s skin.

Treating Eczema

At-home treatments for mild eczema begin with applying thick emollients, such as petroleum jelly, two to three times per day. It is important to apply emollients after bathing and while your child’s skin is damp. Use dye- and fragrance-free soaps to decrease irritation. OTC steroid creams can be applied sparingly, one to two times a day until the redness improves. If your child’s eczema does not respond to OTC treatments, contact your provider. For more severe eczema or eczema that does not respond to OTC remedies, more intensive treatments with prescription-strength steroids and emollients will be prescribed. Wet

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wraps at night may also be suggested. Wet wraps hydrate and calm the skin, helping topical medications work better. Apply wraps after bathing, application of emollients and medications. To apply, moisten clean cotton cloths with warm water and squeeze until slightly damp. Wrap the affected areas, then wrap again with a clean dry cloth. Finally, cover with nightclothes. Leave wraps on for several hours, making sure they stay moist. Regardless of your child’s skin issue, talking with your provider is the first step. After a thorough physical exam and discussion, a treatment plan will be developed. If the condition requires care from a specialist, a referral to a dermatologist or other specialty provider will be arranged. Chronic skin conditions require daily care. You can help your child to make skincare a daily habit. Stacia M. Hays, DNP, CPNP-PC, CCTC, CNE, is the Specialty Track Coordinator for the Pediatric Primary Care Nurse Practitioner Program at the University of Florida. She practices at a NP-run rural health clinic and is the current AANP Florida (North) State Representative.

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and to follow up with the specialist as instructed for continued treatment and monitoring.


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Education

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Manage Your TIME! HOW TO HELP YOUR KIDS DEVELOP ORGANIZATIONAL & WORK-PLANNING SKILLS By Sheryl Zang, EdD, FNP, CNS-BC

Time & Prioritize Tasks

According to an article in Psychology Today, it’s essential for kids to develop a sense of how long it takes to complete tasks and how to prioritize them. They will discover through repetition how long it takes to do homework, learn a new scale on the piano or finish an art project. Once they have a grasp of the time required, help them budget necessary time in their schedules with all their other obligations. Before your children know how much time is needed for homework (or other tasks), help them determine the typical

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base time by recording how long certain tasks take. After a few days of monitoring the necessary time, your kids can start to allot time on the schedule for similar types of homework and tasks.

Plan for Assignments,Activities & Other Responsibilities To be most efficient, kids need a designated study area where they can do homework without being distracted. Teach your children to plan ahead for supplies they will need. To help your children understand priorities and progress, have them make a homework chart or use a calendar planner to list assignments and due dates. After completing each assignment, they can put a checkmark next to it. This teaches kids how to keep track of deadlines and school responsibilities, plus it gives them a feeling of accomplishment. Beyond homework planning, teach your children to track all of their school and social activities on a weekly calendar for the whole family to see and incorporate into daily life. Let your children take responsibility for adding new tasks and

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hildren and teens are busier than ever. Their days and evenings are filled with school, homework that’s due the next day or projects for a future date. They may have extracurricular activities such as theater, band, sports or music lessons. They may also have responsibilities at home — watching a younger sibling, walking the family dog or completing chores. With so much on their schedules, it’s important to help your kids understand time management and organization.


Education

events and marking off completed ones. This is your opportunity to help your kids realize they may be overscheduled and teach them how to prioritize so they do not become overwhelmed. With only so many hours in the day, it is not possible to keep adding activities without taking away something to make time available. Part of time management and planning is teaching your children to evaluate their activities to see which they want to continue and if they would like to try something different. If your kids decide to stop participating in an activity, help them understand responsible timing for such a decision — at the end of a sport’s season, after a scheduled performance or at the end of a school year. If your family struggles with having enough time before and after school, teach your children the time benefit of setting the table for breakfast the night before or picking clothes and making sure their backpack, lunch box and sports gear are prepared for the next day. Sometimes time management is about

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convenience, so teach your children to appreciate simple breakfasts and prepare afternoon snacks in advance that they can easily access when they get home. Another important part of time management is organization, so keep your spaces neat and tidy and praise your children for doing the same with their rooms, school gear and sports equipment.

Set a Good Example

You can also model good time management and organization with real-life examples they can understand. It can be as simple as involving them in planning a week’s meals, creating a shopping list, going to the grocery store to make the purchase and finally putting the food in the correct places in your kitchen so you can quickly find them when you start each night’s dinner.

Maintain a Healthy Balance

It is vital that kids of all ages follow a good sleep routine. The American Academy of Sleep Medicine (AASM) recommends

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as bedrooms. Collaborate with your older children and teens to determine a good balance of screen time in relation to the rest of their obligations. There are going to be situations where a schedule is thrown off. A sport activity may go into overtime or a parent in the carpool may be late picking up and dropping off children at home. If the schedule changes one day, evaluate what can be saved for another day. Weekends are a good time to catch up and it may be a good idea to plan a weekend calendar also — one that is different from the weekday calendar. Time management is a great way to make positive changes throughout your busy year! Sheryl Zang, EdD, FNP, CNS-BC, is an Associate Professor at Downstate Medical Center, College of Nursing. A nurse for 41 years, she is presently running groups for children and teens with diabetes.

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that children 6 to 12 years of age sleep 9 to 12 hours per 24 hours on a regular basis to promote optimal health and that teenagers 13 to 18 years of age sleep 8 to 10 hours per 24 hours on a regular basis to promote optimal health. Consider these factors when determining appropriate bedtimes for your children. Knowing that they have a consistent bedtime will also help your children plan their after-school and evening activities appropriately. Don’t forget to plan time for fun, too! Most kids today want screen time — whether television, gaming or social media. The American Academy of Pediatrics has the following recommendations: For children ages six and older, place consistent limits on the time spent using media; make sure media does not replace adequate sleep, physical activity and other behaviors essential to health; and designate media-free times together, such as dinner or driving, as well as media-free locations at home, such


Healthcare

It’s

CONFIDENTIAL WHAT YOU NEED TO KNOW ABOUT GIVING YOUR TEENS SPACE By Jade Burns, PhD, RN, CPNP-PC

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onfidential health services are essential to promoting good health and wellness for adolescents. Why is this important? Organizations such as Healthy People 2020, Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP) and others describe adolescence as mainly a transitional stage

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in life in which children are enduring physical and emotional changes as well as significant social influences — all of which play an essential role in shaping them as individuals and young adults. Such changes include puberty, exploring independence, developing new friendships, finding out who they

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Ready, Set, Grow

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Healthcare are as individuals and understanding responsibility versus risk. And, as they mature, privacy becomes more important to your children. Let’s face it: Discussing sexuality, drugs and alcohol, peer pressure and relationships may not be easy. However, it's essential for you to know that teens might want the discussion of these topics — along with their healthcare — kept confidential.

TheSignificanceofPrivateTime Why give your teens space? Whether regarding sexual activity, sexually transmitted diseases, sexual orientation, transgender issues or relationships, teens need the space to express themselves. Preserving one-on-one time is part of the office visit and allows for open communication about sensitive topics. It gives your teens an opportunity to practice autonomy and decisionmaking regarding their healthcare. It provides a judgment-free zone that allows them to share habits, feelings and

thoughts about themselves. When appropriate and when your teens are comfortable, one-on-one time with the healthcare provider offers a space where they can answer questions regarding sexuality, gender identity, peer-related difficulties, home difficulties, identity difficulties and other topics that are life-changing to them. Young people face tremendous adversity within their peer groups. Stigma is real, and issues such as sexuality and gender are often misunderstood. Revealing certain aspects of who they are could mean rejection from their peers and even their families. Establishing trust within these environments to discuss these topics provides incentive and opportunities for additional visits and follow-up care.

Privacy 101

Teens can receive services and confidential advice from a variety of sources, including their primary care provider and school-based and public health clinics. Many services are offered during school hours. Teen rights vary from state to state, and most ensure confidential care for sexual health education, birth control, STD testing and treatment, along with mental health counseling for depression and substance abuse. You should be aware that having a confidential conversation is a normal part of the clinic routine and may start as early as 12 years old. It’s best to anticipate being asked to step out of the room. Parental involvement and notification is not always mandatory unless teens are at risk for hurting themselves or others. Teens must also feel that their visit is positive and complete. Not all teens

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disclose information to their providers. Confidentiality doesn’t mean that you as the parent are entirely eliminated from the picture. During these visits, providers encourage teens to talk and share with their parents. It is also useful to include and review past medical and family history. At the end of the visit, the provider can discuss non-confidential issues with you, or the provider can be present as a support system when the teens are comfortable discussing sensitive information with their parents.

Positive Parenting & Support

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* Guttmacher Institute (Minor consent). * American Academy of Pediatrics

Gateway (Dealing with parental rejection). * Kidshealth.org (What to expect at an office visit). * CDC (LGTBQ health + Positive parenting). Healthy People 2020 states at this stage and age in life now more than ever healthy development, safety and the wellbeing of young people are necessary as they transition into adulthood. Understanding the importance of risk, sexuality, wellness and confidentiality is critical in developing the autonomy of young people and establishing a lifetime of healthy behaviors. Jade Burns, PhD, RN, CPNP-PC, is a research fellow at the University of Michigan School of Nursing, Center for Sexuality and Health Disparities. She is a practicing primary care PNP who specializes in adolescent healthcare, family planning, health promotion and HIV/STI prevention.

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Have honest and open conversations with your teens. It’s important to them that you understand they have the right to seek out care and they’re going through complex issues that they may not be comfortable discussing with you immediately, regardless of how supportive you are. If you are with your children at their annual well visit or sports physical, it’s an ideal time for your children to have a one-on-one with the provider. Teens need another space where they can be open and honest. One-on-one time provides another opportunity for an expert to provide solid advice. Providers often serve as mediators to get the same messages across about safety. It’s okay for you to talk about sexuality and other topics with your teens. It's also important for you to understand vocabulary around gender and sexuality (e.g., gender identity, cisgender, gender expression, sexual orientation) and ask questions such as, “What can I do to support you?” Several resources can help you navigate the importance of confidentiality: * Office of Adolescent Health (Know that you are not alone).

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Open Your CHILD’S Mind CELEBRATING OUR DIVERSE WORLD By Ann Lambert, MSN, CPNP-BC

iving in America offers our children the opportunity to meet, interact with and befriend a variety of people with different appearances and capabilities. To encourage their relationships to grow and thrive, we should teach our kids to respect and celebrate these differences. We may eat certain foods, wear different clothes, speak differently and observe unique spiritual customs, but we are all people wishing to lead happy, healthy, productive lives together.

What Children Observe

As early as age two, children notice differences in gender and race. By age two-and-a-half, children learn to label boys and girls. They are also learning colors, and they begin applying these words to skin color as well. Children at about three-years-old notice physical disabilities. Most parents have experienced an awkward moment when a son or daughter, regardless of age, has stared at someone who is different. You may have seen a preschooler

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pointing out someone’s color, size, clothing or other features. Although such situations are uncomfortable, curiosity and observation are natural, and it’s up to you to help guide your kids in how to process what they notice and respond positively.

Helping Children Understand Differences

* Start with things, not people. A simple idea is to introduce the concept of difference to very small children through objects. A fun activity for parents and children can take place right in the grocery store. Maureen Costello, Director of the Teaching Tolerance program (tolerance.org), encourages parents to go through the store aisles and find items that are specifically from other cultures. This type of hands-on activity helps to demonstrate that variety is normal. * Use age-appropriate language so kids can understand what you are explaining. Instead of including extensive details about cultural history or medical causes, just give enough 83

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Behavior information that your child can handle at the time. Your comments can be simple: “This person needs a special chair to move around.” “He wears a yarmulke to respect his religion.” As you introduce the topic, respect and understanding are likely to follow. * Bring other cultures into you children’s lives. Children’s books are great resources for helping kids develop their own identities and understand that others can be different from them. There are many great books available at your local library to introduce this topic to your children, including: Dear Zoo, Elmer, It’s Okay To Be Different and Whoever You Are (all on diversity); Don’t Call Me Special (on disabilities) and The Skin You Live In (on acceptance). Some online retailers and educational stores have age-appropriate board or card games to help teach children about various cultures and diversity.

* Use daily situations to teach your children. Some parents tend to avoid children’s questions or change the subject quickly. It’s better to answer honestly. Treat the situation naturally. If kids ask about a person’s clothing or how they speak, answer honestly and with factual information. The curiosity of children creates teachable moments. We tend to gravitate toward people like us. Take the opportunity to teach children about kids who are different from them, and give your children the confidence to ask questions about others. * Buy a globe or world map. Educate children about world events, and show them on the map where such events are taking place. This will allow for more questions, promote discussion and create more teachable moments for your family. * Be proactive. Talk about diversity before it comes up. When your children have new classmates with different


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in your children’s lives to avoid making derogatory comments about other cultures, or limit your children’s time with less tolerant people. If you are accepting and tolerant, your kids will be as well. Children observe the world around them and ask questions to better understand what they see and hear. We can help them understand similarities and differences in people by providing brief, objective responses to their questions. They can be better prepared to feel good about themselves and others. We are living in a very diverse world, and it’s up to us to teach kids to value all people. Ann Lambert, MSN, CPNP-BC, is an Associate Clinical Professor at Auburn University School of Nursing and works as a Primary Care PNP with Pediatric Associates in Alexander City, AL.

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ethnicities, they will notice. Discuss the subject openly before they bring it up. Talk matter-of-factly about how people are from other countries, have different skin colors and eat different foods. It’s better for you to bring up the situation before your children do at a time that may be uncomfortable for everyone. It takes purposeful commitment to step outside of ourselves and expose our families to something different. * Act as a role model for your kids. The tips listed above can promote cultural awareness, but nothing is as powerful as the role model you are for your children. Your kids will imitate your behavior and attitudes as well as the actions and attitudes of other adults who are influential in their lives — so be sure you are respectful and culturally sensitive. If necessary, ask other adults

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One-ofa-Kind KIDS EACH MEMBER MAKES YOUR FAMILY SPECIAL & UNIQUE By Charlotte Rensberger, MSN, APRN, PNP-PC


egardless of how many children you have, you want each to feel cherished and loved by you. Every child is different, and the uniqueness of each is important — and sometimes even challenging. According to the National Institutes of Health News in Health, six out of ten children in the United States develop secure attachments to their parents, and the remaining four avoid their parents when they are upset or resist their parents altogether. Studies show that this lack of connection can make children more prone to behavioral problems. Tips and techniques to help ensure that your children feel special, regardless of their personality traits, follow.

Get to Know Each Child

Perhaps the most basic step in making your children feel valued and loved is to get to know them. This process can be challenging, especially if you don’t have much in common. However, the experience can be memorable and enjoyable if you approach it correctly. Every child’s cognitive and physical development occurs at varying rates. Children possess distinct strengths and interests, and require diverse levels of support to reach their full potential. While no two children follow the same developmental pathway, most will achieve predictable milestones as they grow. Your children’s personality traits become more evident, and this is not always a pleasant time. As kids explore themselves, they can develop relationships and habits that can frustrate you. Their distinct character attributes should be explored, supported and

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celebrated — even the ones with which you may not agree. This isn’t to say that you should support unhealthy behaviors such as drinking, smoking, etc. You should always discourage such dangerous or harmful behaviors. Getting to know a shy or resistant child could take time, so be patiently persistent. Let kids share with you at their own speed, but remind them that you are excited to learn more about them when they are ready.

Be Willing to Adjust Your Parenting Style

While every child needs structure and clear expectations, not every child will be receptive to the same parenting style. You must be willing to adapt your approach to meet your children’s needs. Most of the time, your kids will want to please you. However, that doesn’t mean that they won’t test boundaries. This is a developmental certainty. Your children will break the rules at some point, and how you respond to the situation can impact their future behavior. Some children may be quite sensitive, while others may require a more structured disciplinary plan to convey behavioral expectations. If you aren’t willing to change the way you approach parenting, you and your child will both end up frustrated. Many parents worry about getting parenting “right” and compare their techniques to those of other parents. Remind yourself that all parents are having similar experiences, as they, too, are working to develop loving relationships with their children. Consider sharing your situation with other parents, because it may be mutually beneficial.

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As you work to get to know your children, take a sincere interest in their passions and interests. This may take some creative thinking: Take your high school football player to a college game at your alma mater, escort your budding pianist to the symphony or join your artist at a painting class. Your children will remember that you spent time with them, and that you took time out of your day. You may not have a lot of money to spare, but not every investment is financial. The investment of time and energy is also valuable, such as prioritizing your child’s basketball game or spending countless hours at the kitchen table assisting with the math concept he can’t seem to grasp.

Be Patient With Your Difficult Child

Not every child is a ray of sunshine. Sometimes your child’s personality can change overnight. Children with challenging personalities require extra time and patience. But remember that every child has the potential to be a well-adjusted person. Be honest with yourself about your child, even if you struggle to connect with her or understand her idiosyncrasies. Acknowledge that your personalities do not have to be the same, that sometimes differences and distance can be beneficial. There may be legitimate causes for difficult behavior: ADHD, anxiety, depression, learning disorders. Additional support or resources could be beneficial, so advocate for your child. It’s not always easy to admit that you need help, but be willing to admit when it’s needed. Your child’s teachers and pediatric providers can be great resources, so keep the lines of communication with them open.

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Celebrate Successes

While your children’s strengths may not be the same as yours, remember that they are important to your kids and are imperative in defining their character. Celebrate achievements, even when they don’t seem like a big deal to you. It’s just as valuable to acknowledge hard work, dedication and improvement. A child who is working diligently to achieve a goal should be commended with just as much enthusiasm as a child who excels naturally. This doesn’t mean that you must reward your children for every goal they score in a soccer game. Attendance at practice and support of their teammates are also important skills for them to possess. Their personalities may develop on a continuum, and celebrations or setbacks made along the way can be impactful. Don’t avoid failures: There is always something to learn when things don’t go well. Discuss what didn’t go well, and what can be done to make improvements.

Highlight Every Member’s Distinct Role in Your family

With every child born into a family, there may be concern from older children that parents won’t have enough time and love to go around. Human beings are social by nature and, to thrive, need to feel valued and connected. With each new sibling comes the potential for sibling rivalry. Make sure that every family member knows his or her place. Give each child agespecific chores, and make sure your kids understand that their active participation in your family is desired and essential. Your straight-A student could assist her younger sibling with some challenging

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Invest in Your Child


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fits-all. Every child brings a special set of characteristics to your family. By using some of the techniques and suggestions listed here, you can show your children how important they are, and how each child’s one-of-a-kind personality is a good thing! Charlotte Rensberger, MSN, APRN, PNPPC, is a PNP with 15 years’ experience in pediatric nursing. She works in a newborn nursery in Southwestern Michigan.

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homework. Maybe your budding chef can create the week’s menu and help write the grocery list, which is a good skill to develop. This shows that you can use your children’s characteristics to benefit the family. Also remember that some kids may not know their role in the family, and may need some time to figure things out. Help them explore what possible roles could be, and allow them to sit back and observe the rest of the family if necessary. Children are not made to be one-size-


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Home Front

Seeking a SITTER? HOW TO FIND THE BEST FIT FOR YOUR FAMILY

By Nicole Boucher, PhD, RN, CPNP-PC

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hether you’ve just landed your dream job and need a full-time babysitter or you simply would like to enjoy dinner out, picking the right sitter for your family can be stressful — but it doesn’t have to be if you know which qualities to seek and how to screen the candidates. According to the American Academy of Pediatrics (AAP), sitters should be: * Reliable. * Friendly. * Mature. * Good with children. * Someone whom your kids like.

The Interview

Interview each candidate to determine competence and reliability. According to the AAP, you should ask potential sitters about: their previous experience with children and other sitting jobs they’ve held; the ages of the kids they have cared for and how they handled discipline within each agegroup; and whether they have completed a babysitting class, first aid class and CPR training. Have the candidates describe play activities they enjoy with kids who are the same ages as your children.

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If there is a specific activity you find important — such as reading — make sure the potential sitter is comfortable with it.

Prepare for the New Sitter

Prior to the sitter’s arrival, make your home as safe as possible. Store medications where they are inaccessible to your children and the sitter. Guns should be stored unloaded, and separate from the ammunition in a locked container inaccessible to children. Move any personal documents or personal information to a locked, secure place. Have the sitter arrive early. According to the AAP, you should sit in a room with your children and the sitter. Allow your children to sit and play with you. Have the sitter watch the interactions and make eye contact with and smile at your children. Once you feel that your children are developing a level of comfort with the sitter — by smiling back or starting to include the sitter in the play activities — have the sitter join you and your children in the activity. All of you should play together for a little while. Then move back and allow the sitter to interact with your


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children while you watch. Children will react differently based on age. Younger children may take longer than older kids to warm up to someone new. Those younger than a year may take the longest time to warm up. Before leaving your children, teach them what to do if they feel uncomfortable with the sitter. They should call you or contact a relative if you are not reachable. If your children feel uncomfortable talking while the sitter is listening, establish a code word that conveys that there is a problem. The code word should be easy enough for you and your kids to remember, and should only be used if necessary. Additionally, talk to your children about “safe touch” and how they should not be afraid to tell you if they are uncomfortable with any touches that occur while you are out. When you must leave, always say goodbye to and reassure your children that you will be home when your activity or work is over.

Set Ground Rules

According to HealthyChildren.org, you should have emergency supplies such as a flashlight and a first aid kit available. Discuss emergency exit and fire escape plans and display them prominently. Tell the sitter where you will be and how to get a hold of you in an emergency. In addition, list the following phone numbers: * Parents. * Grandparents, if close and available. * Neighbors. * Pediatric healthcare provider’s office. * Poison control. * Police/fire, if other than 911. * Home phone and address to provide to an emergency response team.

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Be specific about your expectations. Each household is different, and your sitter needs to understand the guidelines you have established for your family. Discuss: * How much screen time (television, handheld electronics) is allowed. For example, you could say you allow your children to watch no more than a half-hour of television at one time and no more than two hours per day of total screentime, including television and the computer. * Use of the telephone by your children and the sitter. You can state that you expect the sitter not to be on her cell phone or your home phone for any reason except an emergency. * Visitors for your children or the sitter. * No smoking or drinking rules. You can say you do not allow smoking or drinking in your house. * Whether taking your children outside of your home is allowed. * Pool rules.

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* Feeding, bathing and sleeping

arrangements. You want the sitter to know your children’s routine. * Any allergies or specific needs any of your children may have. Most importantly, you and your children should be comfortable with and confident in the sitter’s ability to provide excellent childcare and handle an emergency situation.

Evaluate the FamilySitter Relationship

Once the sitter is in place, evaluate how well she is working within your family. There are several ways to tell if a sitter is not a good fit. According to babycenter. com and TopConsumerReviews.comBabysitters 2016, the following scenarios could indicate cause for concern. If you notice any of these behaviors, you should seriously consider finding a new sitter. * The sitter is secretive about the time spent with your children. * Your child/children have had too many accidents that should have been avoided easily, or your infant or toddler has bruises that do not coincide with his abilities. * Your children are afraid of or do not seem to want to be left with the sitter. * The sitter’s stories do not add up. * You notice that the sitter is not following your guidelines. * You simply have a bad feeling about the sitter.

states allow a person to observe someone via camera in his or her home without notification. State laws vary when it comes to having sound or recording another party such as a sitter. Check your state’s laws to determine how a nanny cam can be used in your home for monitoring your children or sitter and preventing theft. It’s important to remember that webcams can be hacked into and you should take security precautions to protect your webcam. Nicole Boucher, PhD, RN, CPNP-PC, has been a primary care PNP for nearly 20 years. A clinical assistant professor at the University of Michigan, she teaches in the PNP program.

Some parents opt to install a nanny cam. This allows you to observe the sitter interacting with your children from a remote location via a camera and computer or mobile phone. Laws in all 50

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Nanny Cams


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The contents of Ready, Set, Grow® (Raising Healthy Kids) are for informational purposes only and should never replace the advice and care of a licensed healthcare professional. Readers should consult their healthcare provider in all matters relating to their health or that of their children, particularly with respect to any symptoms that may require diagnosis or medical attention. Neither NAPNAP nor CW Publishing Group (which includes Citroen Wolf Communications, Inc., and other affiliates) guarantees the accuracy, completeness, fitness or timeliness of any information or product contained in this publication, and neither shall be liable for any loss, damage or injury directly or indirectly caused by or resulting from such information or product, or its use. NAPNAP’s participation in this publication shall not in any manner be interpreted to constitute an endorsement by NAPNAP of any products or services that may be advertised or referenced herein. If Ready, Set, Grow can be of any further assistance, please contact us.


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