Pediatrics

Pediatric services at Manuel Medical Clinic is provided by Powlin Manuel MD, MBA, MS, a board-certified pediatrician in practice since 1977, and Jamie Woodring, Pediatric Nurse Practitioner in practice for eight years and Alicia Faulk, a family practice nurse practitioner.

Immunization, ADHD, behavior disorders in children, autism, and pediatric asthma are the most common pediatric issues addressed at Manuel Medical Clinic.

Dr. Manuel has a master's degree in Psychology.

 

Call (337) 984-010 to make an appointment.

The following link provides the most update information all many important aspects of your child’s medical needs.

Pediatric Services

Powlin Manuel is a board-certified pediatrician in practice for 40 years. Dr. Manuel is a Fellow of American Academy of Pediatrics and has a Masters Degree in Psychology. Pediatric services include many aspects of pediatric care including preventative care and pediatric immunizations. Along with Jamie Woodring, Pediatric Nurse Practitioner and Alicia Faulk, FP Nurse Practitioner, the clinic provide pediatric services Monday through Friday 8 AM to 5 PM.

Immigration

Coming Soon: information for patients who seek immigration

Acne

Acne "scars, not faces only"

acne-with-scars-300x179

Acne is a very common disorder with serious deleterious effects on quality of life, yet neglected by pediatricians, teenagers, and parents.

Why is acne still so prevalent?
One factor that contributes to the high prevalence is that many teenagers think acne is a normal physiological condition. However, the awareness among the teens has increased due to the advertisements for acne products. Acne is a very common condition which can effectively be treated. I believe that pediatricians should take a more active role in educating parents and teenagers about the importance of treating acne aggressively. The scars from acne are permanent and affect “not only the face.”

What are the myths about ACNE?
It is normal for teenagers to have scarred face from ACNE? This is only a myth.
Fact is that SCARS are totally avoidable by treating ACNE properly.

Acne is caused by the following:
  • bacteria named Propionibactreium acnes
  • excessive growth of skin cells and blockage of drainage from gland’s producing sebum
  • androgen
  • inflammation
Five Myths about Acne

There are many myths about acne, which contribute to the undesirable outcome in the management of acne. A common notion prevalent, especially among boys is that it is not necessary to take care of acne, and it is a matter of concern only for girls. The following is the most shared statements, I have heard from many of my patients:

1. It is normal to have acne
2. Chocolate makes acne worsened
3. Food allergy makes acne worsened
4. Treatment of acne does not work and is not needed
5. Acne does not cause any problem.

Five Good Practices for Face Maintenance for Acne

1. Wash your face twice a day
2. Seek early medical advice for developing acne
3. Use the prescribed creams regularly
4. Take oral medications prescribed for you on a regular basis
5. Do not expect any improvement for three months, be patient.

Now that we know the facts and myths about acne, we encourage all our teenagers to think about the avoidable permanent scars and do everything to keep the face looking good forever! We advise you to keep face clean by washing every night before you go to bed, use the cleansing and peeling agents such as benzyl peroxide wash daily (available over-the-counter), apply the creams prescribed by your doctor regularly, and take the prescribed medications promptly. Above all, it is important to remember that it takes many months after you start treatment to see any benefit.

ADD/ADHD

ADHD has been a matter of grave concern for parents, especially when we reach the end of the school year. There is definitely an increase in office visits for problems related to ADHD during May in our practice. Here are some quick facts for review.

Dr. Powlin V. Manuel is double-board certified, with a Master’s degree in Psychology and has been in practice for more than 38 years. We have evaluated, treated and followed the course of progress of these patients for about 35 years.

ADHD Facts:

4.4 million in the US were diagnosed with ADHD in 2003 (NSCH Survey)
Current incidence is about 8% (8% of children attending school are treated for ADHD).
Reasons for the recent rise in diagnosis of ADHD by physicians include elevated acceptability of the diagnosis parents, increased pressure from teachers, and higher awareness by parents due to the marketing by the drug companies.

60-85% of these children will have symptoms of ADHD as teenagers; symptoms of hyperactivity decrease as the children grow older, while the disability due to inattention continues to haunt performance.
About 50% of children with ADHD will suffer from the disorder as adults with significant negative impact in life and job-performance.

ADHD is a genetic disorder with 60 to 70% rate of inheritance.
There are tests such as functional magnetic resonance imaging, which show changes in the brain of children with ADHD. It has been shown that the part of the brain involved in attention and judgment (prefrontal cortex) in thinner in children with ADHD.

One key factor to keep in mind is that these children also suffer from coexisting other conditions; anxiety, mood, and conduct disorders are higher in ADHD.

With effective treatment, the persons with ADHD can channel their natural high energy and attention into real assets for success in life.

Manuel Medical Clinic uses the following terms:

ADHD/ I:

ADHD/I is used when only inattention disorder is diagnosed without much hyperactivity. Lack of selective attention leads to the following:

  • Not paying attention to details
  • Careless mistakes
  • Does not listen
  • Loses things
  • Distracted
  • Forgetful

Lack of sustained attention leads to the following:

  • Poor organization
  • Failure to follow through and finish

Inattention is caused by inappropriate quantities of certain chemical in the brain. Inattention disorder alone is more common in girls and goes undetected and untreated. Inattention without hyperactivity is also common in adults.

ADHD/H

ADHD/H is used when hyperactivity is the predominant problem. Hyperactivity is caused by inappropriate quantities of neurochemical in the brain and leads to the following:

  • Fidgets
  • Leaves seat
  • Rushes/climbs
  • Difficulty in playing quietly
  • Driven

Hyperactive symptoms are more common in boys. These symptoms have a tendency to abate in adolescence and adulthood.

ADHD/C

ADHD/C is used when both hyperactivity and inattention disorder exists.
ADHD is an inherited/genetic disorder. For those who still do not believe in the existence of the disorder, I recommend reading molecular biology publications which describe gene changes such as DAT1 and 3′-UTR VNTR (Joober et al.,(2005); Cornsih et al., (2005). The genetic (inherited) component leads to reduced availability of certain chemicals in the brain such as dopamine. Recent research using a neuro-imaging technique, fMRI shows the diminished size of the frontal lobe of the brain, and thinning and shrinkage of gray matter of the brain in children with ADHD compared to their peers. Watch this video for more information.
As it is a disorder, a proper management is required.

Diagnostic Criteria at Manuel Medical Clinic
The term, ADHD/I is used when only inattention disorder is diagnosed without much hyperactivity when
six of the nine criteria in the inattention part of the questionnaire are met.

The term, ADHD/H is diagnosed when hyperactivity is the predominant problem with at least six of the nine
components are met. According to the latest criteria if the child is 17 years old five of the nine criteria will be acceptable to qualify for the diagnosis.

The term, ADHD/C is diagnosed when both hyperactivity and inattention disorder exists with at least six of the
components in each category are present. Since there is no laboratory test to confirm the diagnosis, rating scale still considered the most important to make a diagnosis.

It is very important to follow strict criteria for diagnosis. Recent studies show that 50 to 60 percent of children on ADHD medications do not meet the criteria for a diagnosis of ADHD.

What is wrong with BRAIN in ADHD
The levels chemical involved in brain functions are not in ideal quantity.

These are:

  • Dopamine
  • Norepinephrine
  • Histamine
  • Acetylcholine
  • The role of medications is to make the levels just right; not too much or too little.

Medications:
Methylphenidate: Methylphenidate group is one of the earliest medications used to treat ADHD. The common trade names include Ritalin, Concerta, Focalin, Metadate CD, and the new liquid preparation Quillivant XR. These medications have been proven to improve attention, memory, and to reduce hyperactivity disorders. The current recommendation includes starting the treatment with stimulants even in preschool years. A recent report showed that older children on methylphenidate experienced a significant decrease in the incidence of emergency room visits due to trauma compared to those on no medication. These are classified as psycho-stimulant medications and are proven to be the most effective. The addition of omega-3 and omega-6 fatty acids as supplements to stimulant medications may be helpful to improve functions. If the child is suffering from a predominantly inattentive type of ADD, the stimulants may not be as effective compared to those with hyper active form of ADHD.

Any of the following can happen if the levels of these neurochemical are not optimal:

  • Inability to think in changing environment
  • Inability to start a task spontaneously
  • Inability to filter irrelevant external factors (interference) when you are on one task
  • Inability to set goals
  • Inability to organize thoughts in a sequence
  • Inability to keep focused on a task
  • Inability to adjust behaviors to attain your goal
  • Inability to retain memory

Procedures for making a diagnosis
1. Complete the evaluation form from all teachers and parents.
2. Make an appointment for physical examination and evaluation.
3. A hearing, vision, and developmental evaluation.
4. Evaluation for anxiety using the questionnaire as an instrument if needed.
5. Evaluation of childhood depression using CDI instrument if needed.
6. Assessment for a motivational disorder.
7. Assessment for defiance disorder.
8. Assessment of soft neurological signs.
9. Application of Screening Tests for Dyslexia

ADHD and Learning Disability

Children with ADHD are more likely to have learning disability compared to normal children. According to some studies, nearly 50% of children with ADHD will also suffer from learning disability. The various types of learning disabilities are disabilities in:

  • Listening
  • Speaking
  • Basic reading skills
  • Reading comprehension
  • Written expression
  • Mathematical calculation and
  • Mathematical Reasoning

You may suspect learning disabilities if you notice some of the following:

  • Difficulty in pronouncing words
  • Difficulty in following a sequence of directions
  • Difficulty in expressing in an organized sequence
  • Confusion in order of letters and numbers
  • Difficulty in understanding what is read
  • Difficulty in spelling
  • Difficulty in taking notes
  • Helpful instructions for parents of children with ADHD

Behavior management is the cornerstone of management of ADHD. Behavior management involves the parent’s participation and understanding of their child’s needs and should include understanding the difficulties the child faces because of ADHD. A child needs the appreciation for the progress he or she makes in successfully handling the interaction with other children at home and in school. Often the parents are so frustrated that they keep focusing on the negatives and label their child as “bad,” but fail to recognize the small improvements they make. Parents need to identify the improvements they make in their behavior in order to promote strengths.

Visit http://www.livesinthebalance.org for additional help in parenting.

Anxiety in Children

Anxiety in Children

Anxiety disorders are very common in children; they present themselves in different forms. Social phobia and social anxiety often manifest as school refusal as well as refusal to participate in group activities. The common symptoms include “flushing, blushing, and sweating” when they get the attack of anxiety; thus, they avoid getting exposed to the situation that leads to these symptoms. Panic attacks, which is another common manifestation of anxiety are not associated with these symptoms. Social phobia and social anxiety disorder start manifesting very early in life, during the early school years.

Autism in Children

Autism

Autism, an issue of grave concern: Powlin Manuel MD, MS (Psychology).

Message of hope for parents of children with autism!

Most parents are extremely discouraged when the diagnosis of autism is presented. This is especially true for parents of a young child. The optimistic side of the story is that fact that children with autism getbetter in their performance over period of time as they get older!

Eye contact in autism develops later!

Language issues in autism – such as echolalia seen as repeating other’sstatements vanish!

Proper language usage by children with autism is achieved as they grow!

Reading skills of children with autism will develop as they grow older!

Repetitive compulsive behavior in autism reduces in frequency!

Abnormal food aversions in autistic children slowly disappear!

Sensory hyper-sensitivity (intolerance to loud noises) often a characteristic of autistic children  diminish!

Behavior issues in autistic children such as abnormal level of tantrums get better!

The optimism in the outcome as the children grow older is also promoted by recent research finding on the effect of combination of vitamins on improvement in mitochondrial functions noted by researchers such like Dr. Suzzanne Goh.

Autism is a disorder of mind,  more common in males, characterized by impaired socialization, unusual expressive language, repetitive behavior, strange response to sensory stimuli, withdrawn personality,and limited eye contact with others.  As a pediatrician in practice for 38 years, with a special interest in psychology, I have observed this rapid  progression in awareness of parents about this condition.  This does not mean that there is an increase in incidence. The reported increase in its presence is due to the changes in laws. Autism presents in different clinical variations and hence known by different names. These include: Autistic Disorder, Asperger’s Syndrome, ChildhoodIntegrativeDisorder, Rett’s  Disorder, and Pervasive Developmental Disorder not otherwise specified. All of these presentations can be grouped into Autism Spectrum Disorders. The main features autism include: abnormal eye contact, language disorders such as repetition of the words talked by others (echolalia), monotonous tone, pitch, volume, and tone, repetitive behavior showing up as spinning, toe walking, and lining up of toys, and unusual sensory responses presenting as intolerance to sounds of vacuum cleaners, and unusual food preferences.

Autistic disorder

Autistic disorder causes difficulty in social interaction, purposeless repetitive behavior, and mild to moderate intellectual deficiency.

Asperger Syndrome

Children with Asperger Syndrome have higher intelligence and better language skills and communication skills. They present with impairment in social functioning behavior, and impairment in communication without a language component (language is close to normal).

Childhood Dis-integrative Disorder

Childhood Dis-integrative Disorder starts later in childhood and is associated with seizure and mental retardation.

Rett’s Disorder

Rett’s Disorder affects more girls while the other three are more common in boys. The children develop normally for the first 1-2 years. These children develop mental retardation.

Pervasive Developmental Disorder

Pervasive Developmental Disorder is milder form of autistic disorder: has impairment in social interaction, impairment in communication; does not always have any stereotypic (repetitive) behavior.

How do you suspect if you child is likely to suffer from Autism? 

Suspect Autism if you observe the following at different ages:

Early Signs of Autism 

Autism is a communication disorder which can be detected by experienced pediatricians very early in life as early as five months of age.  One of the earliest to detect is lack of interaction with people around. with mother, shown as lack of eye contact, could be a reason to suspect. Lack of interaction with mother could be an early warning sign. Children with autism fail to respond to expression of others, an indication that something could be not normal. Autism is considered a disorder of mind in the sense that children with autism cannot interpret the emotional states of people around them.

Early Signs of Autism 
With close observation the signs of autism becomes more apparent  becomes more apparent after the age of eight months:

  • If there is no exchange of sounds by nine months of age.
  • Not turning when parents say baby’s name.
  • Not turning to look when parents direct the child to do so.
  • Lack of recognition of parent’s voice.
  • Does not speak one word. Cannot point to something to mother if he likes to get.
  • By one year of age the child does not babble, point or make intentional gestures.
  • By one year of age the child has difficulty following a pointed finger to look at something.

Evaluating a child for presence of autism

An evaluation can be done by a pediatrician experienced in treating autistic children. Psychiatrists and neurologists also perform assessment of children with autism. Evaluation of children with autism is aimed at assessing the degree of impairment in areas of socialization, abnormal language expression, repetitive behavior, and unusually sensory stimuli.

Abnormality in language includes repeating words that are spoken to the child instead of providing an answer maintaining a monotonous tone, and usually staying fixed on a topic during a conversation.Understanding other’s expression is a very common problem for these children. It is often difficult to understand what others are expressing in their talk as well as gestures. They have difficulties in getting an over all picture of a situation they encounter. Learning by observation is very difficult for children with autism. One typical feature revealed one valuation of autistic children is the lack of imaginative play.

What you can expect with outcome for children with autism?

Many of the behaviors exhibited by children with autism improve with age: echolalia disappears. Language and communication skills improve with age. Intolerance to noises diminishes. Food idiosyncrasies vanish,reading skills improve, and tantrums decrease. The patients, however,continue to have deficiencies in general cognition and continue to suffer from significant difficulties, which can interfere with attaining a normal adult life. 

Treatment of autism spectrum disorder

There is no specific treatment for autism. There are many therapies and and behavior treatment modalities that may be helpful for the conditions associated with autism thereby improving the quality of life. Co-morbid (associated)  conditions are depression,  anxiety, adhd and aggressive behavior are treated with appropriate medications.

Medical treatment of autism

Risperidone in autism

Risperidone: Irritability is very common in children with autism. Since autistic children a different perspective of what is going on around them, changes in situations can at times trigger an aggressive behavior. Risperidone  is often used for children with autism to control aggressive behavior and irritability.

Stimulant medications in autism

ADHD is prevalent in children with autism. Stimulant medications such as Ritalin though helpful shows less effect in controlling hyperactivity in children with ADHD and autism compared to children with ADHD alone.

Melatonin in autism

Sleep disorders are common in children with autism. Melatonin which is an over-the-counter medication is recommended as the first choice for treatment of sleeplessness in children with autism.

Antidepressants in treatment of autism

Antidepressants are useful in some children with autism and co-morbid anxiety disorders including OCD.

Guanfacine in treatment of autism

Medications such as clonidine and Kapvay are to treat children with autism and anxiety.

Depakote in treatment of autism

Depakote is at times prescribed in children with autism and mood disorders.

The role of occupational and physical therapy is not clear as they undergo treatment for years. Most children will show improvement in their behaviors as they get older. School will provide special accommodation to facilitate learning after they undergo evaluation by the team of school system based specialists.

Recent research shows behavioral treatment provides the best hope for facilitating improvement in behavior. A new technique gaining popularity is called pivotal response training.

Medications used in Autism

 

Behavior Problems in Children

Behavior problems in children are very common; many of these children will turn out to be normal functioning adults. However, it is important to remember that about 13% of children meet the criteria for a diagnosis of ” behavioral, developmental, or mental health disorders (Spratt, E.G., 2013). Psychosocial dysfunction is the most common chronic condition of childhood according to the author. Children are different from one another in their personality and nature. However, many aspects of children’s behavior are shaped by parents reaction to them. Knowing how to react to certain types of behaviors will go a long way in shaping future behaviors. The following are the common issues parents face.

Temper tantrums:

It is common for children to go into temper tantrums between the ages of one and six years. Temper tantrums are expressions of inability to cope with the current situation. This does not mean that the child is behaving purposefully. This means that the child is not able to handle the situation at that mental set-up. It is important to learn to manage temper tantrums so that the child will not use this as a tool to escape the situation or as a tool to manipulate the parents.

The following measures can be helpful:
1. Reduce the stress as much as possible
2. Stay calm
3. Talk about the issue the child is concerned about
4. Remove the child from exposure to any danger because of the tantrum
5. Hold the child for a short time to give some time to calm down
6. Distract the child
7. Provide comfort without giving-in for tantrum

Whining:

Children use whining as a tool to get what they want. This can be a sign not getting the attention they seek for. It is very common in today’s society for parents to be too busy to provide the attention children need at this age. The children at this age seek attention continuously. The child could be sleepy, hungry or bored.

The following practices could be helpful:
1. Put in your own words what the child is talking about.
2. Explain to the child that you will listen when he or she stops whining.
3. Continue to do what you are doing until the child stops whining.
4. Speak words of appreciation when the child stops whining.
5. Try to address the special situation that could have led to whining.

Breath-holding:

Breath-holding is a common behavior disorder in children and occurs when they are upset about something. Children cry, stop breathing, and turn blue or white. This could be associated with seizure occasionally. Breath-holding does not result in any harm to the child. They outgrow this by 8 years of
age.

Because this is associated with a tantrum and does not result in any harm, the parents should not express concern when the child wakes up. Expressing too much concern can lead to secondary gain and the behavior may persist longer. You may talk to your pediatrician as medication may be helpful

Head-banging:

Head-banging is a very common behavior disorder which the children outgrow by three years of age.
Head-banging does not result in any danger. The children will not suffer any damage from it. However, protect from sharp edges.

If head-banging is associated with other developmental disorders, the children will need special attention for the associated conditions.
You may have the child examined by your physician associated conditions such as pain in ears or head.

The following practices may help:
1. Reduce stress
2. Distract
3. Reward positive behavior
4. Stay calm and not get too excited

Thumb-sucking:

Thumb-sucking is a common behavior in children. Children attain a pacification from sucking thumb.
Encouraging to use pacifiers longer may reduce the chance of thumb sucking.

The following measures may help:
1. Reduce stress
2. Distract
3. Reward for not sucking thumb
4. May use ThumbGuard
5. May consult a dentist for appliances in mouth in older children

Aggressive Behavior:

Aggressive behavior towards younger siblings may be a way to get attention. This may be part of sibling rivalry.
Involving the older child in the care of the young child, and dedicating personal time for the older child may reduce the chance of sibling rivalry. Distract the child and try to avoid focusing on the aggressor. Stay calm and do not get excited about the older child’s action towards the younger child. Pay attention to the victim’s feeling ignoring temporarily the aggressor’s action. Parent’s need to make sure that the aggressor does not get any secondary gain from the action.

Aggressive behavior towards other children in school or playground could be related to effects of medications, especially stimulant medications used to treat ADHD.

Toilet Training:

How fast a child attains toilet control differs from one child to another. Parents should not put too much emphasis on issue of toilet training. The following measures make help to make it easier:

  • Encourage the child to sit on a toilet placed in a specific room
  • Let the child take its time
  • May be allowed to have a toy while waiting
  • Keep the child in the room until she or he uses the toilet
  • Take the child away if it fails in about 30 minutes
  • May give some token awards for following instructions

When a new sibling arrives it is normal for many children to regress in their ability to use toilet.

New born care instructions

Parenting tips provided in this page cover most areas that are important for parents of a new born baby. Dr. Manuel and Jamie Woodring, our pediatric nurse-practitioner, and our staff members at Manuel MedicaClinic congratulate you and join you to celebrate the arrival of the new member to your family.

The staff of Manuel
Medical Clinic is eager to assist you to make your experience a pleasurable one. This website provides you with information on many issues related to parenting guidance for you. Please come back and visit this page whenever you have a question concerning your baby.

Parenting Instructions on Breast Feeding

Breastfeeding is the most ideal feeding for your baby; it is natural; it is healthy.
Breastfeeding is a normal process in our life and should come naturally as an instinctual process. Breast feeding should be conducted in such a way that it does not affect your lifestyle. The following is considered some good practices to follow:

  • Find a comfortable place; be relaxed.
  • Wipe the breasts with warm water before feeding.
  • Do not feed more than 15 minutes from each breast; always alternate and feed on both breasts.
  • Do not let the breast become swollen and painful because of the retention of excess milk; express the milk which could be saved for feeding your baby.
Your diet during the period of breast feeding:

You could continue with your regular diet. However, if any item of your food items is associated with excessive crying, you may avoid them. Recently there has been some concern raised about eating fish during pregnancy and lactation because of concern of high mercury level in fish. The Environmental Protection Agency has suggested that the breast feeding mothers avoid eating shark, sword fish, golden bass, king mackerel and albacore tuna. The net effect of eating fish is beneficial. Some studies have suggested favorable effects of maternal fish consumption on infant’s behavior attention scores, visual recognition memory, and language comprehension.

Is your baby getting enough milk?

This is a question many parents ask. The incidence of jaundice is higher in breast-fed babies, one the reason being not enough intake of fluids. Breast milk flow in the first week may not be sufficient. It takes a few days for the milk to flow sufficiently. Usually, it is not a problem. I advise giving some distilled water after feeding 15 minutes from each breast. If the baby still continues to drink, the baby probably did not have enough milk.

There is no harm to supplement with additional formula feeding along with breast feeding?
In case you have not started the let down of milk yet, additional formula feeding will help. Working mothers can feed before going to work, give formula during working hours, and feed from breast after returning from work. Some institutions accommodate the use of a breast pump during the working hours.

Bottle Feeding

Cow milk based formula such as Similac and Enfamil are the usual choices. Do not be tempted to change and try different types of formula. This is a common mistake many parents make. Please call the office before you make any change. Prepare the formula strictly according to instructions using distilled or bottled water. Hold the baby with the head higher than the rest of the body. Never feed the baby while it is on its back on the bed. Tapping on the back of the baby while holding against your chest may facilitate burp and reduce the chances of excessive crying from colic.

How frequently you feed the new-born baby?

Feeding time varies; each child may require feeding at different intervals. Feed every 3 – four hours during the day, and 3 – five hours during the night. Some babies will need more frequent feeding. Do not try to empty the bottle by forcing to feed the baby. Always use a clean bottle. Try to make the quantity just enough for one feeding or about three ounces. Feed the baby as much as the baby consumes until it is satisfied. Try not to refrigerate the leftover contents. Keep increasing the quantity you take based on the previous experience of how much the baby needs. It is a good practice to burp the baby half way through feeding and at the end of feeding in order to remove the swallowed air.

Parents have many concerns with regard to behavior of the new-born babies. The following are common:

Sleeping
New-born babies sleep for most of the day. Sleeping for most of the day, crying, breathing irregularly especially while sleeping, sneezing, spitting up, and be startled often while sleeping, are very commonly observed normal behaviors for a new-born baby. If you have any concern call the office or communicate to us using the email address provided to you.

Jaundice of the new-born babies:
Many babies develop a yellowish tinge to their skin; this is very common, especially in breast-fed babies. Before the baby is discharged, the hospital will estimate the level of jaundice and advise you accordingly. Most babies are given return appointment after about five days of discharge from the hospital to be seen by the pediatrician. The pediatrician will advise you if there is a reason for any concern.

Spitting up by new-born babies:
Spitting up formula after feeding or in between feeding is normal. Many babies are born with a weak valve between esophagus and stomach, which facilitates regurgitation of food. This happens excessively, if the baby is fed too much milk. This could be a defense mechanism to prevent getting obese. This could continue sometimes until the baby sits up by about six months of age. Persistent vomiting may need
special attention. If you are concerned, please call and talk to our associates at the office.

Crying by new-born babies:
All babies cry; some babies cry a lot more than others. Excessive crying is one common reason for frustration for many parents. There are many reasons why babies cry. Crying is after all, the only way the babies can communicate. Pick the baby up and comfort the baby in the first four months of age. Make sure that the baby is not hungry, especially if you are breast feeding. The baby might not have had sufficient milk. If additional bottle feeding makes the baby comfortable in the first few days after coming home, it could mean not
enough let-down of milk from breasts. However, it is not a good practice to feed the baby, every time the baby cries. This may set a pattern of babies developing undesirable feeding habits. Excessive crying could be one way the new-born baby control their parents.

Bathing
You can bathe the baby every day. If the skin is dry use baby oil. You can wash face with water and soap. You may use gentle shampoo every three days.

Cradle Cap

Cradle cap is normal. You may use comb with every bath to remove cradle cap.

Cleaning Eyes
Use a soft cloth to wipe the eyes from inner corner out.

Cleaning Ears
Clean the ears gently with soft cloth; do not use Q-tips

Cord Care
Lift up the cord, and wipe with alcohol with every diaper change. Keep the cord clean and dry.

Diaper Area Care
Use appropriate diaper size. Do not put the diaper tight enough to cast marks on the legs. Leave a little loose space below the cord for ventilation. Use water and soap to clean. Dry the area with cotton clothes. Apply A&D ointment to the area after cleaning to protect the skin.

Genital area care
Wipe the genital area from front to the back gently. Use only water to clean. Use soap and water to clean penis and scrotal area with every diaper change.

Care of circumcision
The bell at the tip of penis takes 10 to 14 days to fall. Clean the tip with water. Do not pull the plastic bell if it hangs. Apply clean gauze at the tip.

Caution

Fever:
If the baby has fever at this age it is very important to contact your pediatrician immediately

Trouble nursing:
Contact the office if the baby has trouble nursing.

Answers to frequently asked questions concerning a newborn baby:

How do I hold my baby?
Hold the baby supporting its head with the palm of your hand; hold close so the baby can see your face.

What type of clothing do I use for a newborn baby?
You can use the baby clothing for new born babies. Wrap the baby up well including the arms and legs. Do not forget to protect the face from cold weather if you are taking the baby out.

How do I comfort the baby when it cries too much?
Crying is normal for babies. Crying is the way baby is trying to communicate to parents and caretakers. Babies are known to be fussy just before falling asleep, some babies cry up to 15 minutes before they fall asleep. Pick the baby up; hold against your chest; tap on the back; make sure the baby is not hungry; make sure he or she is clothed comfortably; make sure that the diaper is not wet; do not get too anxious about baby’s crying; and call the office and talk to our associates if you are concerned. Rarely, conditions like stomach reflux and regurgitation can be associated with excessive crying. Do not start the habit of rocking too hard to make the baby sleep; do not start walking up and down with the baby during the middle of the night trying to comfort the baby, as it will add to your own anxiety.

Do I have to use colic medicines?
There are no “colic medicines” that I know of, that works for colic. The effective dose for any of those medications prescribed is too close to toxic dose for many of them. I stay away from colic medications; they often are associated with constipation. Should I make the baby sleep on its back or on its stomach?
Opinions have changed on this issue. The current consensus is to make the baby sleep on its back. It is advisable not to put the baby to sleep on its stomach.

How long should the baby sleep?
Babies usually sleep up to 18 hours of the day. They do not sleep continuously; they sleep one to three hours during the day time, and three to six hours at a stretch during the night. It can vary, they do not know the difference between the day and night. Keep only dim light when the baby wakes up at night. If your baby sleeps more during the day and less at night, stimulate the baby more during the day to stay awake more during day time.

My baby does not breathe “right” when he sleeps. What do I do?
Slow and irregular breathing during deep sleep is normal. The eyes will be closed and there will be very little body movement. Do not stay awake watching the baby’s breathing. Body movements, movement of eye lids, and slow and irregular breathing are also normal for the baby.

Can I feed formula with breast feeding?
You can definitely feed both breast and formula. It is important that you make breast feeding a normal part of your daily life. If you are a working mother, the baby can be fed formula while you are at work, and breast feed when you are at home.

When do I start vitamins?
We prescribe vitamins at two months of age.

Should the baby be in a separate bed room?
Opinion differs on this issue; it depends often on the culture of the opinion makers. If you want to keep the baby in your bed room for the first year, it is OK, it may be preferable in my opinion. It may help the bonding. If you prefer to keep in a separate bed room, it is fine also. If kept in a separate room, please remember to keep the remote monitoring system always on. Do not put the baby on your bed and go to sleep.

What do I do for the rash on the baby’s body?
Fine pink rashes on the body, pimple like rashes on the face, and dry patches on the face are very common for the babies, and should not be of concern. These do not require any treatment.

My baby is “vomiting”; what should I do?
Spitting up is normal for a baby. Usually, it is accompanied by a gush of air. If formula comes up and flows down the neck it is usually spitting. If it is recurrent and shoots across from mouth it could be due to reflux or due to some other problems that need to be addressed. Call the office if you're concerned.

When does the baby start seeing?
Baby can see your face at birth; especially babies can respond to your eye contact at a short distance. They can follow the movement of objects for a short distance also.

PKU Tests
The hospital will take blood samples for PKU tests before you leave the hospital. PKU tests in Louisiana includes tests for Phenyl Ketonuria, Galactose, Thyroxin level, Biotinidase and Hemoglobin. If you leave the hospital earlier than 48 hours after birth the tests will be repeated during your first visit at 10 days. Remember to ask your pediatrician the results of your PKU tests.

Newborn safety instructions
I am sure that you have more questions than those discussed in this page. Please use the email and other means of communication provided
to you to contact us.

Breast Feeding

Breast feeding instructions – updated information

Breast Feeding

Updated information on breast feeding.

Breast-feeding is the most ideal feeding for your baby; it is natural; it is healthy. Breast-feeding is a normal process in our life, come naturally as an instinct. It is amazing how the process works! Hormones released from the brain of the mother changes to facilitate the instinct to feed the baby. There should be no doubt that breast feeding will occur normally and naturally. The problem is too much information. Mothers read too much; getting so many conflicting pieces of information. Too many conflicting views often lead to maternal anxiety. Even the instruction pamphlets provided at the hospital make it sound like it is an impossible task. Many of these instructions are written by “experts’ with an agenda for exclusive breast with so many strict instructions which make the new mothers feel insecure, inducing a fear of failure. Breast feeding should be conducted in such a way that it does not affect your reasonable lifestyle. The fear of having to follow strict practices, I find is the reason for discontinuation of breast feeding too early even by well-meaning mothers.

Good Practices for Breast Feeding

The following is considered some good practices to follow; but not the only ones, there are many approaches.

  • Find a comfortable place; be relaxed.
  • Wipe the breasts with warm water before feeding.
  • Do not feed more than 15 minutes from each breast; always alternate and feed from both breasts.
  • Do not let the breast become swollen and painful because of the retention of excess milk will cause pain. Expressed milk using breast pump or done manually, could be saved for feeding your baby later.
  • Be flexible; there are different ways to achieve the same goal; not being flexible and strictly adhering to a ritual in pumping breast induces anxiety in many mothers. There are many ways to things, including breast feeding; they all produce the same good result.
  • It is OK to add supplemental formula if you feel that you are not producing sufficient volume of milk. There is not scientific evidence to state that supplemental feeding is inferior to exclusive breast feeding. It is very common not to have enough volume of milk for many days after delivery as there may be a delay in the production of a releasing hormone from the brain for various reasons. If the baby does not receive enough quantity of breast milk after sucking 15 minutes from each breast, is is OK to add a formula.

Your diet during the period of breast feeding:

You could continue with your regular diet. However, if any item of your food items is associated with excessive crying, you may avoid them. Recently there has been some concern raised about eating fish during pregnancy and lactation because of concern of high mercury level in fish. The Environmental Protection Agency has suggested that the breast feeding mothers avoid eating

  • shark,
  • sword fish,
  • golden bass,
  • king mackerel and
  • albacore tuna. The net effect of eating fish is beneficial. Some studies have suggested favorable effects of maternal fish consumption on infant’s behavior attention scores, visual recognition memory, and language comprehension.

Is your baby getting enough milk?
This is a question many parents ask. It is difficult to decide if the baby is receiving enough fluids in the first 10 days after birth. If the fluid intake is less than sufficient, there is a higher chance of developing jaundice. The incidence of jaundice is higher in breast-fed babies, one the reason being not enough intakes of fluids. Breast milk flow in the first week may not be sufficient. It takes a few days for the milk to flow sufficiently. Usually it is not a problem. I advise giving some distilled water after feeding 15 minutes from each breast. If the baby still continues to drink, the baby probably did not have enough milk.
There is no harm to supplement with additional formula feeding along with breast feeding especially during the first ten days after delivery. There is a big debate over this issue as some mothers read about the importance of exclusive breast feeding. There is no research evidence to support this view.
In case you have not started the let down of milk yet, additional formula feeding will help. Working mothers can feed before going to work, give  formula during working hours, and feed from breast after returning from work. Some institutions accommodate the use of a breast pump during the working hours. Recent changes in work place rules encourage management to provide a special area for breast feeding by the employees.

Constipation in Children

Parenting Tips for Constipation in Children

Constipation is a very common problem that makes parents worry a lot. Fortunately, it is very rarely associated with any serious medical issues.

Constipation in the new born:

Most infants have bowel movements many times per day; some will pass stools after every feeding initially. The number of stools varies widely from one infant to another. Some infants may not have stools every day. If the child is not uncomfortable, not having bowel movements for two to three days at times will be fine. If the stool is hard, and the child is struggling to pass stool talk to your pediatrician. We recommend giving some water in addition to usual bottle feeding or breast feeding may be suggested. Changing to a different type of formula may help to solve the problem in some infants. Use of a glycerin suppository may be suggested as a temporary measure but not recommended for recurrent usage.

Constipation beyond the age of infancy:

Constipation in a toddler
Constipation beyond the age of infancy is not as common. Insufficient quantity of vegetables in food could be a contributing factor. Use of vitamin D supplements and codeine in any form may contribute to the problem. Increasing dietary fiber will help to reduce the chance of constipation. Your doctor may suggest the use of mineral oil, Miralax powder, or milk of magnesia, or lactulose solution for relief of constipation.

Chronic constipation in toddlers and older children:

Constipation in older children
Chronic constipation at times associated fecal soiling in toddlers, and older children could be associated with anxiety and other emotional problems, which will require an evaluation by your pediatrician.

Diabetes in Children

Diabetes in Children

Diabetes in children has become a serious issue now complicated by increased incidence of overweight and obesity. Children usually suffer from type one diabetes mellitus (TIDM) due to deficiency of the hormone insulin. This is associated with genetic reasons, which lead to the development of an antibody against the cells producing insulin. A sibling with type I diabetes has 8 – 10 % chance of having diabetes. Identical twins stand to have 50% chance of developing DM. While 100% of children less than 10 years of age suffer from type I diabetes, about 20% of children between 10 and 19 years of age suffer from type II diabetes, especially in obese and over-weight children (Kaufman, F.T. 2013).

With increasing incidence of over weight and obesity, the percentage of Type 2 diabetes is increasing in children between the ages of 11 and 19 years. About 20% of children diagnosed between the ages of 11 and 19 who are obese suffer from type 2 diabetes. While the incidence and onset of type 1 diabetes cannot be modified, the incidence of type 2 diabetes can be reduced by controlling over weight and obesity.

The goal of treatment of diabetes in children is to keep the hemoglobin A1c level (most parents should be familiar with this measurement) between the range of 6% to 7% as it helps to reduce complications related to diabetes. This is often accomplished by following the instructions on dietary management such as reducing sugar intake and maintaining the ideal blood sugar levels. Often with the new combinations used by a specialist, this could be achieved with one or two injections per day of fixed doses with additional boluses of regular insulin. The use of insulin pump and continuous glucose monitoring produce better results.

Diabetes-education

New Patient Forms

Forms are being revised and will be published soon.
New patient forms will be provided on arrival to the office.

Coming Soon

Coming Soon

Headache in Children

Migraine Headache

Migraine is a very common problem affecting about twelve percent of our population. Migraine affects a larger number of women compared to men; and adults suffer more than children. Migraine runs in families. In the following paragraphs, we discuss some important information that could help you understand what you should to do to reduce the impact of migraine headache in the quality of life.

Stages of Migraine

Three different stages are defined to explain the problems that usually occurs in a sequence. An understanding these stages can help you to take appropriate measure for relief and comfort:

Stage One

Stage Two

Migraine stage 1

Stage Three

Migraine stage 3

Causes of Migraine (Triggers of Migraine)

Foods and Migraine

What Foods to Avoid if you suffer from migraine?

If you suffer from migraine, some food items are best avoided as they can trigger a migraine attack or make the symptoms worse because of certain components in them. Those offensive chemical components include tyramine, phenylethylamine, sodium nitrate, sodium nitrite, and mono-sodium glutamate. Each item in the following list has been reported to affect the symptoms of migraine; however, we advise our patients to avoid and challenge to decide if any of the items affect you adversely.

The following foods may be considered for elimination and challenge:

  • Chocolate
  • Coffee
  • Tea
  • Hot dogs
  • Bacon
  • Onions
  • Chinese foods containing MSG
  • Aged cheese
  • Sausages: salami, pepperoni, bologna, etc.
  • Alcohol
  • Garlic
  • Avocado
  • Bananas

These food items may be tolerated if you are not at the threshold of an onset of a migraine attack, if other triggers of migraine are not present.

Immunization Schedule for Children

Recommended Schedule of Immunization

At Birth: HBV
At 2 Months: DTaP, Hib, IPV, HBV, PCV7
At 4 Months: DTaP, Hib, IPV, HBV, PCV7
At 6 Months: DTaP, Hib, IPV, HBV, PCV7, Flu
12 – 15 Months: DTaP, Hib, HBV, PCV7, HAV, MMR, Var
18 – 23 Months: HAV
4 years of age: DTaP, IPV, MMR, (Var if needed
11 – 12 Years: TdaP, MCV4, (Var, HBV, MMR if needed)

Adult Immunization

The following immunization are recommended for adults:

  • Seasonal influenza vaccination
  • Pertussis vaccination
  • Streptococcus pneumoniae vaccination
  • Shingles (Herpes Zoster) vaccination
  • Human Papillomavirus (HPV) vaccination
  • Meningitis vaccination

Safety in children

Follow this link for a review of immunization schedule from Center for Disease Control:
http://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html

Immunization and Parent’s Doubts: Powlin V. Manuel, MD, MBA, MS.

At Manuel Medical Clinic and Allergy Center, achieving maximum ideal immunization has been a goal for a long time. However, we have not been able to achieve our goals at full immunization of our patients. Parent’s reluctance has been the main factor. There are many obstacles contributing to parent’s reluctance to comply with recommendations for immunization of their children. The concern for long term complication resulting from immunization is one main reason. There are many other myths about immunization, which are found to be baseless and are just assumptions. Contributing to the lack of compliance are the myths such as measles, mumps, and rubella vaccine contributing to autism, thimerosal being related to autism, and diphtheria and tetanus toxoids and acellular pertussis vaccine being related to sudden infant death syndrome. The real fact is that none of the above assumptions are true (Temte, J.L., 2012).

Let us give our children the maximum protection by keeping up with the immunization on scheduled intervals.

Migraine

Coming Soon

Coming Soon

Obesity in Children

Worried overweight woman portrait
Five Practical Tips to Reduce Obesity in Children:

1. Reduce sugar containing drinks.
2. Reduce screen-time (TV, Games) to less than 2 hours per day.
3. Do not eat or drink while watching television
4. Make vegetables half of the quantity consumed at each meal.
5. Ask the pediatrician if your child’s weight is normal.

Managing obesity in children

The key information from a research is the finding in adults that caloric restriction leads to weight loss, improvement in mood, better sleep, quality of life, sexual drive and overall satisfaction. The same finding can apply to teenagers in my own experience.

Limit the following:

  • Sodas
  • Sugars
  • Starches
  • Chips
  • Candy
  • Bagles
  • Fruit Juices
  • White Bread
  • Watermelon
  • Pineapple
We need to pay attention from being fat very early in life

Watch the following facts:
Large new borns
Formula-fed infants

If parents or sibling are obese
Not participating in outdoor activities
Sitting in front of TV for a long time

Add the following items to food:

  • Olive oil
  • Canola oil
  • Peanut butter
  • Nuts
  • Seeds
  • Avocado
  • Fish
  • Lean Meats
  • Plant Proteins

Remember the following:

  • Breast feeding reduces obesity
  • Over feeding formula causes obesity in infants
  • Sodas and beverages in teenagers causes obesity
  • Television in bed room adds to obesity.
  • Watching TV more than two hours adds to obesity
  • Using food as a reward adds to obesity
  • Do not watch TV while eating or drinking

What To Do to Prevent Obesity:
Infants: Brest feeding is better.
Do not try to finish force feeding just to finish what is in the bottle.

Preventive measures for obesity in toddlers:
Allow the child to decide how much to eat.
Avoid use of food as a reward.

Preventive measures for obesity in preschoolers:

  • Avoid high calories drinks.
  • Do not use food as a reward.
  • Do not enforce eating.
  • Encourage and facilitate physical activity.
  • Limit TV and other screen time to less than 2 hour per day.
  • Observe family meal time.
  • Do not allow eating or drinking while watching TV.
  • Half of quantity of food provided should be vegetables.
Why Should you reduce your weight?

You should reduce your weight to reduce the following risks:

High Blood Pressure
High Cholesterol
Diabetes
Muscle and joint disorders
Poor exercise tolerance
Poor self-esteem
Poor academic performance

Obese child may mean obese adults higher mortality

  • Heart attacks
  • High blood pressure in 50%
  • Insulin resistance and diabetes
  • Higher cholesterol level
  • Fatty liver disease
  • Colon cancer
  • Arthritis
  • Emotional problems

For additional information watch the video.

Oppositional Defiance Disorder (ODD)

Oppositional Defiance Behavior: Powlin V. Manuel MD, MS, MBA.

Dealing with oppositional behavior is one of the most difficult situations the parents grapple with. It is estimated to be present in as much as 16% of all children according to some reports. It is more common in boys and start early in life. Incidence of ODD is higher in children with ADHD. At the same time, up to 60 percent of children with ODD also suffer from ADHD (Howard, B.J., 2013). We recommend all children with oppositional defiant behavior to have an evaluation for ADHD.

Parenting Instructions

Coming Soon

Coming Soon

Preventing Recurrent Infections in Children

Incidence of ear infections is in early childhood.

This is especially true in the first year of life and in toddlers. The following measures will help to reduce recurrent ear infections:

  • Breast feeding.
  • Avoid smoking.
  • Avoid feeding while lying down.
  • Routinely give Flu Vaccine
  • Routinely give Pneumococcal Vaccine.
  • Avoid day care if possible.
  • Choose day care with small group of children.
  • Treat upper respiratory infections promptly.
  • Avoid allergens and treat allergies promptly.

References:
Clements, D.A. et al. (1995). Influenza A Vaccine Decreases the Incidence of Otitis Media in 6- to 30-Month-Old Children in Day Care. Arch Pediatr Adolesc Med.149(10):1113-1117.
Duncan, D. et al., (1993). Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media. Pediatrics,91(5), 867-872.
Niemela, M., Uhari, M.,& Mottonen, M. (1995). A Pacifier Increases the Risk of Recurrent Acute Otitis Media in Children in Day Care Centers. Pediatrics, 96 (5), 884 -888.
Uharim M., Mantysaari, K,,& Niemela, M.(1996). Meta-Analytic Review of the Risk Factors for Acute Otitis Media. Clin Infect Diseases, 22 (6):1079-1083.doi: 10.1093/clinids/22.6.1079

Safety in children

Scabies

Scabies is a disease of skin (skin infestation) caused by a mite (a microscopic parasite). This is a very common infestation and can spread rapidly if not treated. The spread occurs from skin to skin contact between individuals. In children, the infestation comes from contact with other children in schools, from adults living at home, and from child-care centers. Infestation from sexual partners is very common. Among members of a house-hold, sharing clothing, towels and bedding is another source of contacting scabies.

Tips for treatment of scabies

Please follow the directions provided by your physician. The specific directions vary depending on the types of medication prescribed. The general tips for an effective treatment of scabies include the following:
1. Give a scrub bath to expose the mites residing in the rashes.
2. Use any soap of your choice.
3. Wipe and dry the body.
4. Apply the prescribed lotion or cream all over the body from neck down to the toes without leaving any skin lesions.
5. Leave the medication overnight while you sleep.
6. Bathe after eight hours.
7. Change the sheets and bed covers and clean them by washing in hot water and followed by drying in hot dryer. 8. Repeat the treatment one more night as directed usually in seven days.
9. Treat other family members if anyone has symptoms.

Itching may continue for additional two or three weeks after the mites are killed by the medication. This is due the reaction of our body to the elements of mites. Use the medications or lotions prescribed for relief of itching until the itch is relieved.

Temper Tantrums

It is a common problem! Related issues include:

Personality of the child
I believe temperaments are built in the personality of the child and child is born with them.

Communication
Immature development of language and not understanding what the parents want and not understanding what the child wants could be a factor.

How to deal with Temper Tantrums
Explain the rules that apply to the child.
Use rewards to complying; give rewards closer to the good behavior; provide immediate reinforcement for any worthy behavior.
Ignore and do not yield to aggression; ignore behaviors in spite repeated attempts to get attention.
Provide alternative activities to give time to settle down.

Time-out
Time-out for ages: 2 to 6 years of age
Duration: one minute per year
Provide a warning once
Provide an explanation
Return to time-in immediately after
Consistency in reward and punishment techniques and a lot of patience will be your friend!

Upper Respiratory Infection

A virus usually causes upper respiratory infection. A virus is a germ that attacks your body.
There is no medical treatment to cure upper respiratory infection. The patient will get better after a few days. However, other infections can follow a viral respiratory infection, in which case the symptoms of respiratory difficulty may show up. Call the office or the emergency number provided to you if you are worried that your child’s condition is getting worse.

Feeding Instructions:

Regular food is advised. Fluids are encouraged.

Medications for Upper Respiratory Infection

Antibiotics are not prescribed for treatment of upper respiratory infection. We do not prescribe a decongestant as we do not want to dry up the nasal secretions. When a virus attacks the airway, the immune system of the nose and sinuses produce local antibodies to kill the viruses through mucus. Sneezing and nasal discharges are the means by which the viruses are eliminated. Cough is a symptom due to the secretions of mucus and thus decongestants are better avoided.

What happens after the child gets upper respiratory infection?

Temporary immunity follows after any viral infection. If your child is known to have asthma, upper respiratory infection may trigger a wheezing attack. You may choose the nebulizer treatment prescribed in that situation. Keep your follow-up appointment if you are given one. When children are sent to daycare it is very common to suffer from frequent respiratory infections. If there is recurrent occurrence of respiratory congestion, allergy needs to be ruled out.