Preventing “Flat Head” in Infants

Megan Muscia, D.O.

Megan Muscia, D.O.

Every day I spend a good portion of my day examining babies head shapes and sizes. In recent years, as pediatricians, we have seen an increase in flattened heads. The biggest reason there is an increase in head flattening is due to the recommendation for babies to sleep on their backs. Most of the time the issue is relatively minor, but plagiocephaly (flat heads) can cause some cosmetic issues and be signs of developmental delays, so it is something I pay close attention to.

This head flattening from laying on the back is called positional plagiocephaly. Early in life the skull is very malleable and susceptible to pressures applied to it. Because of this, we see plagiocephaly during the first few months of life when babies spend a lot of time on their backs and that pressure causes a flattening of the infant’s head. There can be a symmetric flattening across the entire skull. Sometimes we may also see it just on one side of the skull, especially when an infant has a preference to look one direction more than another which can be due to a muscle imbalance in the neck called Torticollis. If you think you are noticing a flattening or abnormal shape of your child’s head, it is important to discuss it with your pediatrician. They can decide if they think it is related to positioning of your child’s head, or if it could be related to another process causing abnormal shapes or growth of your child’s head.

How can you prevent this flattening from happening or getting worse? The most important thing you can do is alternate your child’s head position. If you start doing these things early on you will likely be able to prevent the positional flattening that can occur over time.

  • Tummy time – lots of it; early on chest to chest time counts, as your baby gets older tummy time is very important. It gives the skull a break from the pressures put on the back of the head while lying flat.
  • Alternate the arms you hold your baby in during feedings. Breastfeeding naturally does this because the baby feeds from both breasts and you have to alternate arms to feed the baby. When bottle feeding a baby, it is easy to use your dominant arm to hold the baby every feeding. Be sure to alternate arms when feeding.
  • Alternate the end of the crib/bassinet you place your baby’s head. Each time you lay your baby down to sleep (on their back) alternate which end of the bed you put your baby’s head.
  • Hold your baby more – limit time spent in car seats, swings, strollers where your baby’s head is laying on a flat surface. If you are going to be out running errands for several hours, be sure to take your baby out of the car seat to give the head a break from lying flat all day.

While these techniques may not prevent all types of plagiocephaly, it will help diminish the severity. Sometimes infants do need treatments such as physical therapy and occasionally helmets can be used to treat plagiocephaly as well. If you have any concerns about the shape of your baby’s head, please discuss it with your pediatrician at your baby’s next checkup.

The Beat on Bronchiolitis

Nicole Keller, D.O.

Nicole Keller, D.O.

Hello again! I just returned from maternity leave in the thick of cold and flu season. But in addition to the common cold and that nasty influenza bug, there is another illness that is roaring through the pediatric population at the moment – bronchiolitis! This is a big scary word and in my blog I’d like to help you understand what it means to us and to your kids.

Bronchiolitis is a fancy term for inflammation of the smallest parts of the lung tree (the teeny tiny little airways in the lungs). In addition to inflammation, the hallmark of this illness is large amounts of secretions – basically, your child becomes a boogery mess! It is a constant running of the nose, congestion, and mucus build up in the upper airway. This leads to stuffy noses, wet coughs, and sometimes difficulty breathing and eating.  You can also have fevers on and off with this illness. Some kids will have wheezing in their lungs but this is usually from mucus plugging – not airway muscle spasm (like in asthma).

Bronchiolitis tends to have the most effect on young children – you can contract the viruses that cause bronchiolitis at any age but the clinical presentation of bronchiolitis typically is seen in kids less than one year old.  Part of the reason we worry about bronchiolitis is because of this tendency for it to have the most power in our littlest patients. You see, they have the smallest of the smallest airways, so, when you clog up those airways with mucus, they have the hardest time clearing those airways to breathe. If you can’t breathe well, you can’t get oxygen where it needs to be and that’s bad. Additionally, if you can’t breathe, many times it makes it hard to eat. If you have a baby who can’t breathe well and has a hard time staying hydrated it can be a really tough road to get through this illness.

What causes this nasty bronchiolitis you might ask? One of the most common viruses associated with bronchiolitis is called RSV (respiratory syncytial virus). Other viruses (like coronavirus, metapneumovirus, parainfluenza, etc) cause bronchiolitis but RSV is the one we tend to worry about the most – although none of them are fun. The virus stays in the system for a few weeks but is the most contagious in the first days to weeks of the illness. The entire illness may actually take four to six weeks to resolve completely. That’s an eternity when you are dealing with a sick little one at home!

So what can you do for bronchiolitis – how do you get your kids through this common, yet miserable, disease? In short, supportive care. You see, bronchiolitis is caused by viruses, and viruses don’t respond to antibiotics. Viruses get better on their own with time. But, until that “time” has come when your child is finally recovering from this illness, there are some “supportive” things you can offer your child.

Supportive care options for bronchiolitis:

  • Push fluids, small amounts often to maintain hydration.
  • Acetaminophen (Tylenol) or ibuprofen (motrin) to help with discomfort or fevers. No motrin in kids less than six months.
  • Suction the nose with nasal saline – you can use drops or a mist to apply into the nasal passages and then suction out the mucus with a bulb syringe or other suction device (such as a “NoseFrida”).

Other treatment options can sometimes include breathing treatments and even less commonly steroids, but, the AAP doesn’t recommend these on a regular basis since they really don’t help much and may just result in side effects.

Your child should be seen if they are having symptoms like this. We’ll want to check their oxygen level, hydration, and breathing status to make sure they are handling the illness appropriately. Sometimes, kids that aren’t doing well with this illness need to be hospitalized for intense supportive care that may include oxygen administration, IV fluids for hydration, and frequent deep suctioning. Bronchiolitis can result in complications rarely so we are very cautious with these children.

If your child is having trouble drinking, having trouble breathing (such as sucking in between or under the ribs), having fevers for longer than five days in a row, or other worsening symptoms, they should be seen in your pediatrician’s office or in the ER if they are in distress. If you’re not sure, call us! We can help decide with you over the phone to make sure your child gets the care they need.

In the end, bronchiolitis is a common, miserable viral illness that affects nearly everyone at some point in their life. It is mostly harmless, but, can take a lot of effort and a long time to resolve and sometimes gets worse before it gets better. Remember to have your child seen if you are worried about this illness. Please call your pediatrician’s office if you have questions or concerns about this…oh, and wash your hands to help stop the spread of illnesses like this too. Thanks for reading!

Second child…we get it!

Megan Muscia, D.O.

Megan Muscia, D.O.

I had my second child about five months ago and have now returned to my life as a working mom. Once again, being the parent of a newborn is a humbling experience. It reminds me that every baby is different. It reminds me what I thought I had figured out about parenting one child has been turned upside down in trying to parent two kids. So to all the new parents out there, I get it and I agree, it’s really, really hard. You would think as a pediatrician I would have all the answers and my kids would never have tantrums and parenting would be easy. Well, I promise you, I have a lot of pediatrician parent friends and all of us agree, we are not perfect parents and we still have a lot to learn! Sure, I know what to look for to make sure my baby is developing well, and I know when they should start solid foods or remain rear-facing in a car seat, but that doesn’t mean I don’t understand that it’s hard to follow what may seem like impossible recommendations sometimes.

With my second baby I realized how much more tired I was especially for my middle of the night feedings.  How much I would have loved to snuggle up with my baby and not put her in her bassinet to sleep. I get it, you are sleep deprived and sometimes may feel like you are barely hanging on. Despite how much I understand your desire to want to co-sleep with your baby because you both sleep better; I just can’t tell you it’s ok. The thought of potential suffocation from co-sleeping terrifies me. I know you would never forgive yourself if something happened to your baby, and I could never forgive myself if I told you it was ok.

I told my husband I hate being a pediatrician in winter because I feel like I spend a lot of time telling families there is nothing I can do to help their child’s cough or illness. So many illnesses this time of year are viruses and there aren’t any medications that will speed up the healing process or stop their coughing. I too have had a kid with ear infections and nights where my daughter has been up several times a night coughing and puking and there is nothing I can do to help. I am in the trenches with you, I get it. Trust me, if I had a secret weapon I would give it to you!

I think the reason I wanted to write this so badly is that I know it can seem lonely as a parent, like no one is going through what you are going through. I do realize how hard it can be to follow some of the recommendations I discuss at our visits. When I discuss limiting screen time, I get it that its hard. Sometimes you need 30 minutes to take a shower or get dinner on the table or get ready for work. I too struggle with this issue. I know that it seems like your kid’s legs are scrunched up in that rear facing car seat and it’s hard to get them in and out of the car as they get bigger. I too have a hard time squishing my daughter in her car seat. I recommend these things because I truly care about your child. I take it very seriously that I do everything I can to protect your child. To protect them from preventable, potentially life threatening illnesses with vaccines; to protect them from preventable injuries by telling your kids to wear a helmet when riding a bike; to protect them from sexually transmitted diseases by discussing sexuality with them as a teen.

So while I know it may seem like whoever wrote the recommendations I give to you at every visit clearly didn’t have children, I want you to know, I do, and most of them probably do too.  As pediatricians, we know parenting is hard, we know there is no such thing as a perfect parent, and it may not be possible to follow every recommendation perfectly.  We know parenting is a struggle. This is not to say it doesn’t have a lot of amazing times as well, but when you are a sleep deprived parent of a newborn, or sitting through an epic temper tantrum, or dealing with a teenager who is too cool for their parents, just know we get it, and we are with you.

AAP New Safe Sleep Recommendations

Vrinda Kumar, M.D.

Vrinda Kumar, M.D.

Approximately 3,500 infants die each year in the United States from sleep-related infant deaths, including SIDS, deaths without a certain cause, and accidental choking/strangulation.

Just last week, the American Academy of Pediatrics (AAP) released new “safe sleep” recommendations to protect against SIDS (sudden infant death syndrome). These are the first updates to the recommendations since 2011. SIDS is an otherwise unexplained death of a child. The risk and incidence of SIDS is highest at 6 months of age and under, but can be seen in older infants and young toddlers as well.  Even though many SIDS deaths are often unexplainable and have no obvious cause, we do know that unsafe sleeping habits can contribute to SIDS.

The new recommendation still includes some of the older recommendations, including “back to sleep” (putting children to sleep on their backs), no co-sleeping, no soft bedding/bumpers/blankets/or other items in the bed. Babies should sleep on a firm mattress made for infants/toddlers.)

However, the recent recommendations to decrease the risk of SIDS in children also include:

  • Share a bedroom with parents, but not the same sleeping surface, preferably until the child turns 1, but at least for the first 6 months. Room sharing decreased the risk of SIDS by as much as 50 percent.
  • Fully vaccinate child according to CDC guidelines.

The older recommendations have not changed and still apply:

  • Avoid baby’s exposure to smoke, alcohol, and illicit drugs
  • Back to sleep
  • Use a firm sleep surface
  • Breastfeeding is recommended
  • Keep soft bedding and loose bedding away from sleep area
  • Consider offering a pacifier at nap time and bedtime
  • Avoid head covering and overheating
  • Avoid positioners and wedges (and choking hazards like teething necklaces!)
  • Do not use home cardio respiratory monitoring devices as a strategy to prevent SIDS. They have not been shown to decrease risk of SIDS.
  • There is no evidence that swaddling decreased risk of SIDS.

It is important to understand that some deaths are not preventable, even if all the above guidelines are followed. However, following these decreases the chances of a SIDS death and should be followed, despite media and commercial advertisements which may potentially promote other environments which are not consistent with AAP recommendations.

Learn more about safe sleep at

Helping Kids Digital Detox

Nicole Keller, D.O.

Nicole Keller, D.O.

A recent article published in The New York Post addressed screen time and kids. It compared screen time to a drug for children (“digital heroin” is the phrase they used). I suppose in many ways, screens can be as addicting and enticing as a drug – scary! Whether we like it or not, in recent years, screens have become a normal part of everyday life. Between TVs, phones, tablets and computers, many of us are participating in screen time for hours a day without even realizing it. But, like most things, this “addiction” affects kids in different ways than adults. Their growing minds are particularly impressionable which makes regulating screen time a new parenting challenge.

The American Academy of Pediatrics’ stance on screen time was initially very stringent. No screen time at all was recommended for kids less than two years old and for older children, two hours a day was the maximum recommended. In the past year, this recommendation was amended. It now doesn’t focus as much on the age and amount of time but the appropriate use of screen time in children. Overall, as pediatricians, we still don’t recommend using screen time in large amounts during the day, but, we also realize that screens are officially a part of our lives and it’s unrealistic to expect our kids to not be participating in their use. Instead, we ask that caregivers use screen time wisely. Like anything, when used in the correct way, screen time can have benefits/perks. On the other hand, when kids are allowed to dictate their use of screen time without supervision, the threat of it becoming an addictive drug becomes a reality.

There are some positives to screen time in general. Educational apps can help reinforce learning points in toddlers and school aged children. Communication has become easy among family and friends across the world. Classic games and puzzles can be easily transported and used in just about every environment, as well. These are some great things! We as caregivers and role models for our kids just have to keep these benefits in mind and assure that the scale doesn’t tip towards negative use of screen time.

Negative effects of too much screen time can be seen in your child’s behavior during the home time and at school. Kids become accustomed to immediate gratification that screen time tends to give them that is not present in real life. Patience wears thin very quickly in a child who is used to large amounts of screen time. In addition, attention is affected with large amounts of screen time. Multiple apps, music, and ads running at the same time make the brain fire rapidly at multiple targets but not focus for any amount of time on one task. This may make a single focus task (like reading a book) actually seem harder because their brain isn’t used to the lack of other background “noise.” Poor attention and lack of patience lead to tantrums and angry eruptions when kids try to complete other tasks they are asked to complete. Homework time, meal time, and other quiet moments in the day may become tense and rushed as kids are eager to return to their screens.

To help you avoid turning screen time into a potential dangerous “drug” in your child, try some of the following tips to keep screen time a safe and beneficial tool for your children:

  • Time limits: although many kids require computers to complete homework, make sure your kids aren’t spending excessive amounts of time on their screens beyond homework time (it’s hard to put a number on how much time is appropriate – I’d shoot for no more than one to two hours beyond homework time). In addition, while doing homework, make sure they are focused on their assignment and not being distracted by other open apps or programs.
  • Parental controls: most devices will allow you as a caregiver to have control over what apps are purchased, how long they can be used, or if they can be opened without a parental lock. Use these options to make sure your child isn’t getting into any inappropriate material or staying “plugged-in” for too long a period of time.
  • Keep screens out of the bedroom: make sure your kids are completely un-plugged at bed/nap time. Strict rules about not using any screens around sleep time is important to ensure kids are getting appropriate rest. This is really important!
  • Participate actively in screen time with you kids: if you are going to allow your child to use a screen for playing on, play with them! Let them show you what they’ve learned on their educational apps and teach them new ways to use apps for fun and for learning. This can be a great form of modern parent-child interaction.
  • Offer no-screen alternatives: while our kids may not like it, sometimes it is just best to take the screen away. Set rules/expectations for when screen time is allowed and when it isn’t every day of the week. During no-screen times, remember all the ways YOU used to stay entertained without a screen. Playing outside, going for family walks, exercising, board games, coloring, puzzles, reading books, or playing with toys (blocks, cars, dolls, etc.) all have their benefits in child development and entertainment. Don’t forget these seemingly simple and basic ways to entertain and enrich your child’s life.

Well, I’ve now had my full of screen time. I hope you’ve gotten some benefit from this blog on the appropriate use of screens in our kids. Thanks as always for reading!