I remember the tidal wave of emotions I felt after the birth of our first child. The fear and sense of responsibility driving home from the hospital. The sense of wonder watching him gaze at his surroundings. The joy in my heart seeing him coo or smile. Except for the times he had projectile vomiting, I wanted to be around this little guy all the time, awake or asleep. And so I was first confronted with the issue of co-sleeping.

Let’s first define what co-sleeping is in regards to this article.  Co-sleeping is when a parent sleeps next to his/her infant in the same bed. (Incidentally, my least favorite form of co-sleeping is in a motel room with family — usually because there is little sleep.)

What are some of the potential benefits of co-sleeping? Moms may not need to get out of bed to breastfeed. It may deepen the relationship between mother and child. And some may sleep better in this arrangement.

But studies indicate there are pitfalls to co-sleeping as well. The most important potential danger is SIDS (Sudden Infant Death Syndrome). Co-sleeping becomes more dangerous when parents use tobacco or alcohol or when a parent is overly tired or sleeps on a couch. The United Kingdom Department of Health advises that the safest place for an infant to sleep is in a crib in the parents’ room for the first six months of life. Similarly, the American Academy of Pediatrics, in a November 2011 report, recommends that baby can sleep in the same room as parents, but not in the same bed. Sharing a room is OK, but sharing a bed is not.

Let’s re-examine some of those purported benefits. If co-sleeping works while baby is small, fast-forward a year to when that toddler needs to graduate to his or her own bed — that could be a more difficult task. There are other ways to bond, as well: taking a walk, reading a book or playing games.

And on a related note, please place your baby on his or her back to sleep, and avoid blankets and toys in the crib (please see healthychildren.org for more information). The above AAP report also notes that immunizations and breastfeeding are associated with a lower incidence of SIDS.

Many mothers go the extra mile in pregnancy, avoiding over-the-counter medications, caffeine, soft cheeses and fish. Parents fill their homes with safety latches, gates and CO2 detectors. I would challenge parents to think of co-sleeping as a similar safety issue, where good choices can potentially save lives.

David Pommer, MD, is a family physician with Selah Family Medicine. He is a graduate of Whitworth University and the University of Washington School of Medicine. He co-sleeps with his pager, and he is happily married with three children.

It is a hassle to see the doctor.

The first battle typically involves the phone system. With carefully orchestrated options designed to keep you from reaching an actual person, it can be a minor miracle to reach the scheduler. Then, does your schedule match an opening for your doctor, if she or he has one?

Next up: the waiting room.

If your child wasn’t truly sick before arriving there, licking the waiting room toys might cinch the deal. When you are finally called back to the exam room, there is some momentary excitement, until you surmise that this is actually another smaller waiting room.

And don’t get me started on the redundancies of disclaimers and insurance paperwork.

—

I know what you’ve been through to get to see me. And I want to try to redeem the experience and make it as positive as possible. That doesn’t necessarily mean I’ll prescribe an antibiotic, however. Sometimes an antibiotic may be harmful rather than helpful.

Let’s take sore throats for example.

What percentage of sore throats are caused by strep bacteria and will benefit from an antibiotic? Only about 20 percent. The remaining are caused by viruses, and an antibiotic will not help.

And what about the color of mucous — is this important? I don’t like that green nasal drainage running down your child’s face either, but it turns out that whether it’s clear or colored does not matter. The color is caused by inflammatory cells, called neutrophils, that are present in both bacterial and viral infections.

Many bacterial infections are going to be self-limited. If a child is found to have an incidental ear infection, but is feeding well and not lethargic, he or she can probably get away with observation. A sinus infection should not be treated with antibiotics unless the patient has severe pain or symptoms have progressed past one week.

—

A study that affected how I prescribe was published in The Journal of Family Practice in 2000. It evaluated using a “backup” prescription, instructing families not to fill this unless the patient’s condition deteriorated or failed to improve. I may use this when an ear infection is mild, or if a sinus infection has not progressed beyond a week.

Sometimes people will request another antibiotic because the first one didn’t cure their infection, but it may be that the patient simply has a viral infection that just needs to run its course.

Why are physicians passionate about this topic? Possibly because contrary to the goal of the Hippocratic oath, they have done harm at times with antibiotics. Little Johnny may have had the sniffles before, but now with the help of antibiotics, he’s really got diarrhea and a diaper rash to boot. Antibiotic resistance (think MRSA) has proliferated with overprescribing. If you have a strong stomach, Google “Stevens-Johnson Syndrome” and you can see some of the dangerous rashes (and accompanying trial attorneys) that can rarely result from an antibiotic.

Now don’t get me wrong. I love the great taste of pink amoxicillin suspension as much as the next guy. But these medicines are a double-edged sword that need to be used at the right time in the right situation. So please don’t demand them.

And maybe I’ll see you in the waiting room with my own children, hoping to graduate to the next, smaller waiting room. We’ll try not to lick the toys.

 –David Pommer, M.D. is a family physician at Selah Family Medicine. He is a graduate of Whitworth University and the University of Washington School of Medicine. He is married with three children.

Dr. David Pommer works at Selah Family Medicine

By Dr. David Pommer for Playdate magazine

OK, I confess. I have not been a perfect role model about “screen time” with my patients and my family. But I think this is important to discuss as summer comes to a close and many of us retreat indoors.

What is screen time? The American Academy of Family Physicians defines this term as “watching television or DVDs, playing video or computer games and surfing the Internet.” A few years ago with patients, I would primarily ask about TV and video games, but now I need to inquire about cellphone screen time as well. As I will detail below, more screen time correlates with worse health.

Let’s take a quick self-assessment to see if this may be an issue with your family.

1) Do you use television as a baby sitter so you can get other things done at home?

2) Have you misplaced your library card months ago? … Or do you first check out the video section at your local library?

3) Do your children feel that happiness comes at Redbox?

4) Have you heard your child repeat a phrase in conversation that they likely heard from TV (for example, when I heard my son state “it’s fun for the whole family” when he wanted my wife and I to buy something, I knew he had been sitting too long in front of the boob tube).

If you answered “yes” to any of the above, keep reading.

According to a 2010 Kaiser Family Foundation study, the average child spends 7 1/2 hours per day in front of a screen. Another study broke this amount into about four or more hours of TV, videos and/or DVDs, more than one hour of computer time, and almost one hour of video games. Two out of three children ages 8-18 have a TV in their bedroom. And those kids who have a TV in their room watch almost 1½ hours more television per day than those who do not.

The consequences of this excessive screen time are more sobering.

The more time kids spend in front of a screen, the higher their risk of obesity. Obesity rates are lowest in children who have less than one hour of screen time per day, while they are highest in kids with greater than four hours per day. Screen time may also negatively affect body image and school performance and may correlate with increased violent behavior.

What is our remedy?

The American Academy of Pediatrics recommends limiting screen time to no more than one to two hours of “quality programming” per day. If there is a TV in a child’s room, I would recommend removing it. Use parental controls on your computer so a child has a set limit before he or she is logged off. Establish a “token economy” where kids need to earn their 1-2 hours by chores or reading earlier in the day. Though your children will not thank you now, hopefully their brains and waistlines will thank you in years to come.

David Pommer, M.D., is a family physician at Selah Family Medicine. He is a graduate of Whitworth University and the University of Washington School of Medicine. He is married with three children.

Physical therapist Laura Reed, left, is working with 6-month-old Kaeden Beck to stretch and strengthen his neck muscles because he suffers from flat-head syndrome. At right is grandmother Rhonda Beck. Photo by Gordon King.

By Laura Reed

Physical therapists at Children’s Village see up to six new babies every month who are sent by their doctor because they have flat heads. It is estimated that one out of every 50 babies will experience this condition, called plagiocephaly.

Although there are many reasons why a baby’s head may become flat, many cases are preventable. In all cases, it’s important to seek treatment because plagiocephaly can negatively affect your baby’s developing vision, hearing and movement.

Why is my baby’s head flat?
There are many reasons why a baby’s head becomes flat. Twins or triplets are more at risk due to the limited space they have to change position in utero. Premature birth, low muscle tone or birth complications may place a baby at higher risk. Sometimes babies have medical or skeletal issues that have caused this.

Unfortunately, some of the things that give us convenience are also to blame for many cases of plagiocephaly. Babies now spend much of their time in infant carriers, baby swings and bouncy seats. You can imagine how a baby rests the back or side of his head when sitting in one of these devices. Prolonged pressure quickly causes a baby’s head shape to change; skull bones not yet fused together actually shift, causing his head to become flat.

What are the symptoms of this condition?
By the time a baby begins physical therapy at 6 to 12 weeks of age, the flatness often is very noticeable and the baby also has uneven eyes, ears, nose cheeks, forehead and jaw.

Muscles in the baby’s neck may also become tight, making it hard for her to turn her head one way, a condition called torticollis. The combination of these conditions makes it difficult for your baby to look to both directions, reach with both arms, and roll to both directions. It makes it difficult for your baby to raise his or her head when on his or her tummy.

If untreated, a baby could experience a “head tilt” posture that does not go away. Alignment of the eyes, ears and jaw may be affected as well as the shape of the skull. Vision and hearing also may be impacted, as well as motor coordination and balance.

How can I keep my baby from getting a flat head?
Prevention is the easiest treatment. It’s really pretty simple!

First, to decrease the risk of SIDS, always, always have your baby sleep on his back. And, always have your baby secure in his car seat when riding in a vehicle. However, when the baby is not sleeping or riding in a vehicle, here’s what you can do:

• Give your baby lots of time on her tummy when you can closely supervise her. Place your baby on her tummy, helping her to prop on her elbows several times a day, for short periods of time.
• Use a front pack or baby sling for baby-wearing, versus a bouncy seat, swing or infant carrier. Limit time spent in car seats to only those times when your baby is riding in a vehicle.
• Change the way your baby’s head is positioned when sleeping. For one nap, turn his head toward the left. For the next nap, position his head in the middle. For the next nap, to the right.
• Encourage your baby to look to the right and the left by giving her lots of things to watch with her eyes.

What should I do if my baby’s head seems flat?
You should talk to your doctor immediately if you notice that your baby’s head is flat, or if she prefers to turn her head one way more than the other.

Your baby will be evaluated for any tightness of neck muscles, limitations of movement and abnormalities of the skull.  The therapist will provide you with stretching and positioning exercises to perform several times each day.

Depending on the severity of your baby’s torticollis and plagiocephaly, weekly therapy may be recommended. In addition, some babies will need to wear a helmet to re-shape their head.

Laura Reed is a pediatric physical therapist at Children’s Village in Yakima.

ASK THE DOCTORS If you have a health question, we’ll find the answer. Write to the doctors at talkback@playdateyakima.com.

Dr. Robel says: Probiotics, or friendly bacteria that reside in our gut, may increase fertility and reduce early miscarriage as well as help prevent eczema and allergies in infants, according to several recent studies.

Probiotics are found in yogurt and other fermented foods. They serve to protect us from infection and help prevent a wide range of health problems including constipation, diarrhea, colitis, irritable bowel syndrome, allergies and various skin problems.

New research is finding that probiotics may also be beneficial to women trying to conceive. In a study done in Belgium, supplementing with a probiotic while women underwent in vitro fertilization increased the rate of conception compared to women not taking the supplement. Likewise, several studies have found that women given a probiotic at the onset of pregnancy have lower rates of spontaneous miscarriage in the first trimester.

Besides the benefits to mom, there are benefits to your infant. Taking a probiotic supplement for the last three to four weeks of pregnancy may reduce rates of eczema and allergies by as much as 50 percent, according to a study published in The Journal of Allergy and Clinical Immunology.

Probiotics can be obtained by eating yogurt labeled as containing “live and active cultures.” Also, there are various supplements that can be taken.

Always speak with your health care provider before taking any supplements, including a probiotic, to decide if it is right for you. Also, not all supplements are created equal so it’s important to get a recommendation to ensure you are getting what your body needs.

— Heidi Robel, ND, is a naturopathic physician and acupuncturist in private practice in Yakima.
She’s expecting her first little one in August.

Will thumb-sucking harm my child’s teeth?

ASK THE DOCTORS If you have a health question, we’ll find the answer. Write to the doctors at talkback@playdateyakima.com.

Dr. Tercero says: Non-nutritive sucking habits (finger or pacifier sucking) are normal in infants and toddlers. These habits help address a child’s need to feel secure.

Although normal and harmless for young children, non-nutritive sucking can result in long-term problems if persistent. Prolonged finger or pacifier sucking can lead to a permanent open bite and other dental and jaw deformities.

In order to prevent these problems, the habit must stop by age 5. However, the difficulty of ceasing this habit increases with age, so it’s best to stop the habit before age 3. If the habit persists beyond the age of 3, it’s recommended to see a dentist for professional evaluation.

— Ashley Tercero, DDS, is a children’s dentist at Yakima Pediatric Dentistry.
Her 7-month-old daughter, Kya, doesn’t have any teeth.

What is postpartum depression?

ASK THE DOCTORS If you have a health question, we’ll find the answer. Write to the doctors at talkback@playdateyakima.com.

You’ve just had a baby. You’re not sleeping, your hormones are completely confused, your body hurts and there is this constant crying noise in your ear. Who wouldn’t be a little depressed?

The “baby blues” are common, and usually develop within the first few days after birth. You might experience mood swings, anxiety, sadness and insomnia. This is a transient phenomenon and usually resolves without treatment within two weeks.

Postpartum depression is also common, developing in up to 10 percent of mothers, but often goes unrecognized. The symptoms can be nonspecific, including fatigue, sadness and crying, insomnia, feeling guilty or inadequate, being overwhelmed, poor concentration, decreased libido, anxiety and not wanting to do usually enjoyable activities. In rare and extreme cases, a woman can develop psychosis (a loss of contact with reality).

Treatment usually involves a combination of counseling, medication, exercise and spiritual or emotional support. Some women are more prone to developing PPD, so if you have a previous history of depression or other mental health issues, you may want to talk to your doctor before the baby arrives. Usually, a mother doesn’t have a follow up appointment with her doctor until six weeks after delivery. It’s important to seek help sooner if there are any concerns for PPD.

— Ryan Moultray, DO, is an osteopath at Selah Family Medicine. Will and Owen call him Dad.

Do children need to take vitamins?

ASK THE DOCTORS If you have a health question, we’ll find the answer. Write to the doctors at talkback@playdateyakima.com.

DR. MOULTRAY SAYS: A multibillion dollar industry, vitamins. Why? Because we like to think that even though we don’t eat a well-balanced diet, we can take a little pill and it will bring our health into perfect equilibrium. And the benefits of vitamins are extremely difficult to quantify, therefore difficult to disprove. In fact, certain vitamins, such as K, A, D, and E, can accumulate in the body and cause toxicities if consumed in excess.

So, the short answer to the question: No. Most children who eat a diverse diet, with the right combination of fruit, vegetables, fortified cereals, grains and meat, are not at risk for any nutritional deficits, and therefore really don’t need to take a vitamin.
But, do my 4- and 2-year-old children eat perfectly balanced diets, or would they prefer to eat crackers and fruit snacks all day long? In my opinion, a basic multivitamin (we like Flintstones) about every other day is sufficient.

There are definitely some caveats to this simple perspective. Particularly, there are a few nutritional deficiencies to be aware of with babies and young children. Iron deficiency can lead to anemia and developmental delays. Most formulas are supplemented with iron. Some breastfed babies (which is the recommended diet for most babies) can be at risk for this deficiency when they reach 4-6 months of age. Making sure they consume cereals fortified with iron will help alleviate this risk, and screening blood work can also be performed.

Fluoride, which helps combat tooth decay, is another nutrient they may need. Most homes that receive city water will have access to water that is supported with an appropriate amount of fluoride, provided that the child drinks it. Some wells and bottled water have fluoride in them, but this is more difficult to quantify. Your doctor can help you determine if supplementation is needed.

A problem we don’t think about very often in the sunny Yakima Valley is vitamin D deficiency. This is because exposure to sunlight helps your body produce vitamin D. Infant formula and most store-bought milk is fortified with sufficient vitamin D, however breastfed infants could potentially be at risk for a deficiency.

Finally, in some selected populations of children vitamins may play a more essential role. These include breastfed babies of vegan mothers (vitamin B-12 deficiency), and children with chronic medical conditions such as liver or bowel disease.

So, to play the broken record that we hear constantly: “Make sure your child eats a well-balanced, diverse diet.” And if you can figure out how to get your 2-year-old to eat cauliflower, please let me know.

• When he’s not sipping soy milk with sons Will and Owen, Ryan Moultray works as an osteopathic doctor at Selah Family Medicine.

DR. ROBEL SAYS: I feel that most of our children should be supplementing their diets with a multivitamin/multimineral for several reasons. Most of us, especially our children, are not eating the recommended minimum servings of fruits and vegetables a day. If we are not getting our fruits and veggies, we are losing out on important vitamins and minerals our body needs.

Second, our soils are becoming deficient in trace elements due to decades of agriculture overwork. This means that many of our food crops are depleted of nutrients.

Finally, our children are exposed to far more air pollution and stress then most of us were as kids. This exposure increases our children’s need for certain vitamins, especially C, E and B.

Not all multivitamins are created equally. It is important to read the labels when purchasing your child’s multi. Always look at the supplement fact sheet on the back of the bottle and avoid anything containing artificial flavor and sweeteners or blue, red, or yellow dyes. Also, never take more then the recommended dose that is on the bottle.

Remember, adding a multivitamin/mineral is not a substitute for proper nutrition. It is important that your child eat a well-balanced diet that’s adequate in fruits and vegetables. If your child isn’t eating well, add the multivitamin but also work on improving her nutrition.

Adding a multivitamin just in time for the cold and flu season can decrease the number of days spent at home with a sick child.

• Heidi Robel is an aunt to three delightful children and a naturopathic physician and acupuncturist in private practice in Yakima.

Do you recommend any vaccines for teenagers?

ASK THE DOCTORS If you have a health question, we’ll find the answer. Write to the doctors at talkback@playdateyakima.com.

DR. MOULTRAY SAYS: It’s easy to overlook immunizations in the teenage population. They are generally healthy and do everything within their power to avoid going to the doctor’s office, where they are apt to get stuck by a needle, or made to turn their heads and cough.

Lucky for us, they do invariably come in for a sports physical, sinus infection or the occasional skateboard accident. It is within these rare encounters that we, as health-care providers, try to squeeze in a little preventative medicine. Immunizations are an important part of this, and there are several that are recommended for teenagers specifically.

First, a “tetanus booster” is usually given around the age of 11 or 12. This vaccination also has a diphtheria booster, and pertussis was recently added to the booster for teenagers and adults because the vaccine’s protection decreases after five to eight years. Pertussis causes whooping cough, which is on the rise in our country. We have seen many cases here in the Yakima Valley as of late, as well. All three bacteria can cause serious infections, which is a compelling reason to keep it up to date.

Next, the meningococcus vaccine, or MCV-4, is recommended for all children at 11-12 years of age. This protects against a bacteria that is the most common cause of meningitis, a dangerous infection of the brain. It can also cause a serious infection in the blood stream. About 2,500 to 3,500 cases occur per year in the U.S., and up to 15 percent of people die from it; another 10 to 20 percent have long term complications. Most of these infections occur in young children and teenagers, and it is spread by respiratory secretions (spit and snot).

Finally, one that’s a little controversial is the human papillomavirus, or HPV, vaccine. This protects against four of the most common strains of the HPV virus, which we now know cause 99 percent of all cervical cancer in women.

It is controversial because the main way that you contract the virus is by sexual contact, and of course, none of our daughters will ever engage in this type of activity until they are properly married. So the vaccine should be unnecessary, right? I guess it depends on how much you trust your daughter (and her boyfriend).

Three others that are recommended in higher risk groups are the pneumoccocal vaccine (pneumonia), influenza and Hepatitis A. If your teen has some chronic medical issues, you should ask your provider if these are necessary.

Vaccinations are an effective way to prevent serious infections, and they’re not just for little kids. So, teens, if you thought you were past the agony of the nurse’s needle, think again!

• Ryan Moultray is an osteopathic doctor at Selah Family Medicine. Learn more about him at selahfamilymed.com.

DR. ROBEL SAYS: Vaccinations offer many benefits including prevention of serious illnesses as well as the spread of these diseases, as Dr. Moultray mentioned. Vaccines work by injecting a weakened form of a virus or bacteria into the body. The body then forms proteins, called antibodies, that recognize and attack the disease.

It is important to remember that many vaccines do not give permanent immunity to the person receiving the vaccine and thus boosters in later years are necessary. A vaccine does not always provide complete immunity to a disease. Some individuals receiving a vaccine may later on develop that disease, if exposed.

Also, vaccines don’t always come risk free. Side effects may include soreness, redness or swelling at the sight of injection (often temporary), and rarely, serious allergic reactions or certain neurological disorders.

Finally, the HPV vaccine protects against only four common strains of HPV. However, there are about 40 different strains, some of which may also lead to cervical cancer.

Talk to your provider about the benefits of your teen getting vaccinated, the risk of the disease and the risk of the vaccination so you can make an informed decision when choosing to vaccinate.

• Heidi Robel is a naturopathic doctor in private practice in Yakima. She has a Web site, too: drheidirobel.com.

I need to find a new family doctor. What’s the difference between an M.D., a D.O. and an N.D.?

ASK THE DOCTORS If you have a health question, we’ll find the answer. Write to the doctors at talkback@playdateyakima.com.

DR. MOULTRAY SAYS: Great question. I’ll tackle the first two: D.O. stands for Doctor of Osteopathic Medicine, an “osteopathic” or therapeutic approach to health care. M.D. is short for Medical Doctor, an “allopathic” approach that focuses on treatment of injuries or disease. There are many of each in the Yakima Valley, and they are very similar.

In most offices and hospitals, D.O.s and M.D.s work side by side (with very few cat fights, I might add). Both are fully qualified physicians, licensed to prescribe medication and perform surgery. Each can choose to practice in any medical specialty, from family practice to neurosurgery.

One of the aspects of osteopathy that attracted me was the philosophy of practicing “whole person” medicine — that is, discovering and treating the root of the disease, rather than simply treating the symptoms of illness. It’s an approach that strives to help the human body heal itself (it’s usually very good at healing if you put good things into it and move a lot).

This philosophy also considers how illness is affecting a person’s state of well being, emotionally and spiritually.

Osteopathic medical schools emphasize training students to be primary care physicians, which are in great need in our country. Approximately 65 percent of practicing osteopaths specialize in primary care, such as pediatrics, family practice, OB/Gyn and internal medicine.

Osteopathic physicians receive extra training in the musculoskeletal system — your body’s interconnected system of nerves, muscles and bones. This training provides a better understanding of the ways that an illness or injury in one part of your body can affect another.

Osteopaths also receive training in a technique called osteopathic manipulative treatment (OMT), a hands-on approach to diagnosing and treating illness and injury, which encourages the body’s healing ability.

In your search to find a doctor, I think you will find that the truly exceptional ones, regardless of whether they are M.D., D.O. or N.D., will be the ones who take the time to listen to you with empathy, and approach your health concerns with consideration of mind, body and spirit.

• Ryan Moultray is the proud papa of two boys, Will and Owen. He’s an osteopath at Selah Family Medicine.

DR. ROBEL SAYS: Finding a family physician can be a daunting task. An ideal family physician is someone with whom you will form a lasting relationship over the years, someone you trust, and someone who will listen to your needs.

N.D. stands for Doctor of Naturopathic Medicine. Naturopathic medicine is guided by treating the whole person, including the body, mind and spirit — not just symptoms of a disease— using treatments that work with the body’s natural healing mechanisms, treating the cause of the disease and not just managing symptoms as well as promoting prevention. Naturopathic physicians also hold the belief that doctors are teachers and thus spend time educating their patients.

Naturopaths have had four years of graduate education, and are educated in all of the basic sciences like D.O.s and M.D.s. However, naturopaths also study holistic and nontoxic approaches to treatment with a strong emphasis on disease prevention and wellness. N.D.s are highly trained in Western science as well as alternative medicine, thus providing a very unique perspective to family medicine.

Naturopathic physicians receive extensive training in clinical nutrition, diet and lifestyle changes, homeopathy, herbal medicine, counseling, and physical medicine including naturopathic manipulation.

Naturopathic physicians also perform minor surgery and prescribe some drugs when necessary.

There are many factors to take into account when finding a family doctor. Whether it be a D.O., M.D., or N.D., hopefully this information will help you find a physician that will resonant with you and your family’s needs.

• Heidi Robel is a naturopathic physician and acupuncturist in private practice in Yakima. She’s also auntie to three delightful children.