The PAA Doctor’s Blog is Back!

PAA is kicking off 2022 with a revamp of our monthly blog post! We hope this will keep PAA families informed on what’s happening at the practice and in our wild world of child health.

COVID-wise January 2022

The holidays and the emergence of the Omicron variant has brought COVID back with a vengeance.  Like the rest of the country, our community is seeing a tremendous surge in cases, including in children.  Thankfully, severe illness in children remains very rare. In reporting states, children represent a very small percent of hospitalized patients, and virtually zero cases of COVID in children resulted in death. However, continued vigilance and research is paramount.

In order to safely increase our testing capacity, PAA is re-instituting parking lot testing. Children will first be evaluated via telemedicine appointments to assess risk.  From these appointments, parking lot testing, done from your car, will be scheduled from 7-8 pm at our Healthplex office.

PAA continues to vaccinate all children five years and older and booster children 12 years and older. So far, we have vaccinated over 1,100 children in our community! The vaccine has proven extremely well-tolerated and safe in children.  Please call our office to schedule an appointment for one of our COVID vaccine clinics.

On December 27, the CDC made significant changes in their recommendations, shortening periods of required isolation and quarantine in some situations.  While PAA is following these guidelines, some school systems including Fairfax County ( and some childcare centers are recommending longer periods due to limits in distancing and masking capabilities during meal times.

We will work with families to help navigate this rapidly evolving process. Together we can keep our children safe, healthy and in school.

Family Challenges in the Age of the Coronavirus

A three-year-old boy is jumping on the couch while his parents are trying to work from home. He falls and breaks his arm.

A nine-year-old girl with learning disabilities is being taught at home. Her mother struggles to teach her without a special education plan.

A nineteen-year-old boy with severe anxiety had finally adapted to college and developed a close group of friends.  Back at home with his parents, he experiences mounting anxiety with sleep loss and panic attacks.

Across the country families are coping with the effects of the coronavirus pandemic. While children are thankfully at lower risk of health impacts of this illness, they are experiencing a host of other physical and psychological effects as a result of the emergency.

As the pandemic unfolds, families and children are struggling to cope with great challenges. Here are some rays of hope within the cloud of coronavirus:

  1. Schedule activities with your child

Young children thrive in routine and predictability. As families struggle without childcare or school, a written daily schedule that includes one-on-one time for you and your child can help ease the stress.  For example, schedule 30 minutes to write a poem about what you see out the window, 60 minutes for a simple science experiment or 90 minutes to walk outdoors, collect interesting objects and make a collage. The expectation of this special time will help your child relax while you work and can result in memorable experiences.

2. Promote creative alternatives

Teenagers are missing significant opportunities and events.  Many of these are irreplaceable. But current limitations can promote creative thinking and flexibility.  What opportunities can be found that can replace the lost opportunity? Encourage your adolescent to find creative ways to express themselves within current constraints. It will not be the same, it likely will not be as good, but it can still be rewarding.  It may even be worth repeating.

3. Cook with your child

Parents are cooking most meals at home.  Use this as an opportunity to cook with your child.  Cooking involves measurements, math and creativity. Include meal preparation in your home education and you can make the family meals while teaching math and cooking skills. Virginia pediatrician Dr. Nimali Fernando created the excellent Dr. Yum Project to help families cook healthy, child friendly meals

4. Explore the nature outside your door

Our busy lives usually give us little time to get to know what is living and growing around us. What plants are growing in your neighborhood?  What birds are around? For activity ideas, check out The National Wildlife Federation’s Green Hour Program or the Cornell Lab of Ornithology’s great kids education resources

5. Reach out to relatives

Isolation can be particularly hard for elderly people who may live alone. Engage your child in reaching out to grandparents.  Schedule a time for your child’s grandparent to read a story by video, have a tea party or even help with schoolwork. This time can also help support a working parent. 

The sudden, dramatic changes we face will have lasting impacts on all of us.  Amidst the losses and pain we experience, glimmers of light can help us to see it through. 


Five Things That Worry Pediatricians More Than Parents

Most parents know the importance of protecting children with car seats, gates on stairs and locks on cabinets. Some hazards, however, don’t get the attention they deserve. Here are five less appreciated child safety risks that strike fear in the hearts of pediatricians.

  1. Ramen

Ramen is hot.  Very hot. It sits in open bowls on countertops.  Inquisitive little hands find these bowls and tip them over, resulting in spills of boiling water.  Instant soup is one of the leading causes of burns in young children. Parents should be very aware of where they place bowls of hot soup, as well as tea, bottle warmers, crockpots, or anything that contains hot water. Prevent scald injuries by placing these items on the back of the kitchen counter, out of the reach of prying little fingers

 2. Sofas

Parents of newborns are often exhausted.  It is all too easy for a new parent to doze off while holding their baby on the sofa, sometimes in the middle of a sleepless night.  Parents desperate to do laundry are tempted to place a sleeping baby on the sofa “just for a minute”. Beware of the sofa! It is a bad place for babies!  In the blink of an eye a baby can turn and fall off the edge, or get their face covered by cushions. Always place babies in a safe place, such as a bassinet or crib. Never place an infant on a sofa unattended. It only takes a minute to flip off the edge.

3. The Flu

Pediatricians are always reassuring parents about viruses and colds.  Not Influenza. The Flu is not a cold. It is high fever, vomiting, severe cough and misery for days.  Every pediatrician has been scared by a very sick child with the Flu. Young children, like grandparents, are at higher risk of complications, such as pneumonia, that can be life threatening. Parents of infants less than six months, please get the Flu shot!  There is no other way to protect babies who are too young to be vaccinated. Older children should get the shot themselves. It is always better to prevent the Flu than to try and treat it. The shot protects against severe disease even when it doesn’t prevent infection completely. The Flu shot has been around for decades and is extremely safe.   Just do it!

4. Walkers

First time parents hope their child walks early.  Second time parents know better! Babies on the go are babies looking for trouble. Walkers take babies places they shouldn’t be, like stairs or kitchens or even fireplaces.  Let your baby exercise in a jumper rather than a walker. It is much safer!

5. Grapes

Grapes, with their round shape and smooth covering, are just the right size to get stuck in little windpipes. Always cut grapes for children less than three years old to prevent choking.

Appreciation of these hazards will make your child safer and your pediatrician happier.   A winning combination!


Five Things I Like About Lice

Lice have few friends in this world.  While I would not count myself among them, I do appreciate that lice have several endearing characteristics.  Here are five things that I, as a pediatrician, like about lice.

  1. Lice can’t fly

Lice can only crawl. They cannot fly or jump. This means they can only travel from one person to another by crawling directly from head to head. This is a very good characteristic.  You cannot get lice from another person unless you put your head close to theirs.  That is why preschool children are most likely to get lice.  While older people usually respect others’ personal space, preschoolers are often on top of each other, rolling and tumbling. It is also why caregivers of young children often get lice.

  1. Lice don’t carry any diseases

Fleas carry plague, ticks carry Lyme disease, and mosquitoes carry malaria and all sorts of bad things.  Lice carry no diseases.  This is very good.  While lice are highly distasteful and itchy, they will not make you sick.

  1. Lice can only live on a human head

I love this quality of lice.  Bedbugs can live for months on a surface without feeding on a person.  Lice, on the other hand, die after 1-2 days of falling off a human head.  They do not lurk on bed sheets, hats or hairbrushes.  It is usually recommended to wash sheets and hats that were in contact with an affected person within the past few days. But the risk of spread from objects is very small.  This means that there is no reason to use chemicals in the home to stop the spread of lice. That’s good!

  1. Lice are relatively easy to kill

Anyone who has tried to eradicate bedbugs knows that it is very, very hard.    Bedbugs hide in miniscule crevices in beds, luggage, you name it.  Lice pose no such challenge. They live in only one place and are often susceptible to over the counter medication.  When this does not work, there are several prescription medications that will kill them.  While repeat treatments may be needed, and nit combing is labor intensive, it is nothing compared to the heating of a room to 120 degrees for two hours required to kill bedbugs.

  1. Pets don’t get lice

Cats and dogs do not get lice. Only people get lice.  An affected child can hug their pet and rub heads all they want, the pet won’t get lice.

Next time that your child gets lice, remember all these good qualities.  Take a deep breath and treat your child’s head.  It could be a whole lot worse!

When is a Cough more than a Cold?

Most children get several viral upper respiratory infections, or colds, in the winter season. Young children in childcare can appear to have one continuous cold for months, as one virus overlaps with another with no recovery in between.

Sometimes, however, colds can develop into more significant conditions. When should a child be brought to the doctor?  Here are some tips to help parents make that decision.


Fever is a nonspecific sign that your child is fighting an infection, whether it is a common virus or more serious condition.  Thanks to vaccines, fevers today are rarely due to serious infections.

High body temperature is not dangerous, and is part of how our bodies fight off infections. Even fevers as high as 104-105 do not hurt the body or cause brain damage, and are not a reason alone to go the hospital.  However, when children have high fevers, they look and feel terrible. It can be frightening.

Doctors recommend treating fevers of 101 or above so the child feels better.  It is ok, though not necessary, to treat lower fevers if treatment is helpful.

Pediatricians want to see children who have had a fever for more than three days.  Any fever with pain, whether in the throat, ear, head or elsewhere, should be evaluated by a doctor.


It can be hard for children, particularly babies, to breath through congested noses. This is a mechanical problem, which improves somewhat with nasal saline drops, suctioning, and humidifiers.

Sometimes, however, colds can progress down into the lungs.

After a few days, a cough may get worse instead of better.  Children and babies may show signs of labored breathing, such as breathing fast, using their stomach muscles or sucking in around the ribs or clavicle with each breath.  

Whenever there is a concern for difficulty breathing, it is important to contact your pediatrician, even in the middle of the night.


When children feel sick they often refuse to eat. Babies with congested noses struggle to feed, and older children may need a lot of encouragement.  While it is ok to skip solids for a couple of days, it is important that sick children drink fluids.

Fluids with electrolytes and calories are better than water. Milk and formula are fine, while clear fluids, such as electrolyte solutions, may be easier for children to keep down.  Older children often are happy to eat popsicles and juices that may not be part of their regular diet.

Minimal fluid intake can lead to dehydration, usually after a few days. Signs include decreasing urine output, dry lips or gums and absence of tears. Children with signs of dehydration need to be been by a doctor.

General Appearance

Children with viral infections look and feel lousy.  They are less active, fussy and don’t eat or sleep well. However, once the fever is reduced, they generally feel well enough to engage in reduced age-appropriate behaviors, such as sitting up, communicating and drinking. Children with very atypical behavior, such as marked weakness or irritability, particularly when without fever, need to be promptly evaluated by a physician.

Prolonged congestion

Sometimes the congestion just won’t go away.  If significant nasal congestion continues more than ten-fourteen days, children should be seen to make sure they have not developed a sinus infection.

Having a sick child at home is never easy. Thankfully, most childhood illnesses today resolve with time. Monitor your child, and contact your pediatrician for any of the concerns above so we can provide the care they need.


Kids and Animals- Natural Companions

A ten-year old girl comes home from school upset after a fight with her friend. She goes to her room, closes the door and lies on the bed to pet her cat.

 A seven-year old boy struggling with reading refuses to participate in class. One day, a volunteer with R.E.A.D. (Reading Education Assistance Dogs) comes with a golden retriever.  The three of them sit on pillows as the boy slowly sounds out words in a book.  The dog watches and listens.

 A thirteen-year old girl gets her first job caring for a neighbor’s dog.  She carefully writes down instructions, wakes early to feed and walk him, sits with him while doing homework and brushes his fur.  He wags his tail to show appreciation for her job well done.

Kids naturally love the animals in their lives.  “Dog” and “cat” are common first words, and children form strong attachments to their pets. While the positive influence of animals is apparent to most parents, there is a growing body of research demonstrating specific benefits for children’s emotional as well as physical health from their interactions with companion animals.

Interacting with animals reduces stress and anxiety in children. It lowers levels of blood cortisol (a stress hormone) as well as blood pressure. The presence of an animal can help children to cope better with stressful situations. This can be valuable in educational settings to promote learning.  It can be particularly helpful for children experiencing disruption in their lives, such as moves, deaths in the family or parental separation.  Animals can offer consistent and reliable bonds that support children through the stresses of life.

Animals can provide non-judgmental comfort and security.  This social support can help children in their interactions with people as well. The calming effect of animals has been shown to be particularly valuable for children with developmental or psychiatric challenges. Therapy sessions that include dogs have been shown to increase attention, sharing and cooperation and reduce behavior problems in children with ADHD.  For children with autism, animals in the classroom can reduce anxiety and improve social interaction. Dogs can also facilitate recovery in hospitalized children.

Exposure to pets at a young age may provide protection for children against allergies and asthma.  For older children with allergies to certain animals, however, having these pets may not be possible.

Caring for pets has other associated benefits for children.  Walking a dog, for example, helps kids get exercise, time outdoors and promotes social engagement and conversation.  In their increasing tech-centered lives, this can help relieve feelings of loneliness or isolation. Caring for animals, a first job for many children, can also promote a sense of responsibility and self-esteem.

Of course, living with animals also carries risks.  Pets, like people, can get tired or anxious.  It is important for children to learn their pet’s cues and not to interact with them when they are showing signs of stress, to avoid scratches or even serious bites.  Similarly, protecting against shared infections is critical.  Pets need to be kept clean and up to date on their vaccines, and children should wash their hands after interactions.

Companion animals can be a wonderful addition to the lives of children, and can promote their optimal emotional and physical health.  It’s no wonder that more than 75% of U.S. homes with children include a pet in their family!


Feeding Babies Around the World

One of the joys of my job is meeting families from around the world.  I enjoy learning about child rearing traditions in different countries, such as traditional first baby foods. These first foods are often based on the starches most readily available in a given region. Other local foods may be added to the starch to make a porridge with increased nutritional value.

Here are some global feeding traditions I have learned about through conversations with parents and grandparents of children in our practice.  I have noticed that many of these traditions include an added source of iron, one of the most important nutrients for young children’s healthy development.


It is common to make a rice porridge called “congee”.  Rice is cooked in a large amount of water until it is fully disintegrated.  Meats as well as vegetables may be added, particularly as the baby gets older, to add additional nutritional value to the rice porridge.


Babies in some parts of Africa are fed a soft food known as “fufu”.   It is made from the flour of plantains, cassava or corn, depending on the region. This can be mixed with varying additional ingredients.  For example, a mother from Togo told me that parents there add a traditional dried fish to the fufu. A mother from Cameroon discussed the addition of dark green vegetable leaves, such as the leaves of the sweet potato plant. These are cooked with the fufu, providing additional iron and other nutrients.  


Families in India often give lentils to young babies.  This is particularly true in regions where families are vegetarian for religious purposes. At first, the lentils are boiled and the water may be removed, mixed with salt, sugar and clarified butter and fed to the baby. As the baby grows older, the mixture is made thicker and vegetables as well as rice are added.   A food commonly fed to babies is called “khichri”. It is made from lentils mixed with spices and salt and pressure cooked, making it very soft and easily swallowed. Legumes like lentils are an excellent source of both protein and iron.


A father from Bolivia described to me that, when his mother came to watch his baby, she brought with her ground black corn meal.  She had grown this black corn and ground it herself. She made the baby soup with vegetables and, sometimes meat, which she then thickened into a porridge using the ground corn meal.

As families feed their infants for the first time, it can be reassuring to note that there is no single “right” way to feed a baby. Across the world it is done many, many different ways!  By choosing mild starches with supplemental sources of vitamins and iron, babies learn to transition from milk to solid foods and receive the nutrients needed for healthy growth and development.

Safe Water Play for Kids

Years ago my family visited a lake in New York’s Catskill Mountains.  I was playing with my three-year-old daughter in the shallow water when I saw older children throwing rocks at a mother duck and her babies.  Horrified, I marched over to make them stop.  A few minutes later, ducks safely in the middle of the lake, I turned back to my daughter. She was lying motionless and facedown in the water!  I raced over and scooped her up.  Thank goodness she was fine, and had only been facedown for seconds.

I will never forget how still she lay with her face in the water.  There was no splashing or thrashing.  This, I learned, is typical.  While parents expect a child might alert them to distress in the water, this is often not the case.  Children drown quickly and quietly.  This is one of the many reasons for parents to be ever vigilant when it comes to water safety.

Drowning tragically remains a leading cause of death in children. For children ages 1-4, drowning kills more children than any cause other than birth defects.   Most infant and toddler drownings occur in bathtubs and buckets, toddlers most commonly drown in pools, and older children in rivers and lakes.

While playing in the water is one of the great joys of summer for kids, it is no time for parents to relax!  Rather, active engagement and  “touch supervision” at all times is needed to ensure safe water play.  Here are some guidelines to create the safest experience for your child when enjoying the pool, lake or beach:

All Eyes and Hands On Deck!
Always be within arms reach of your young child near any body of water. This is called “touch supervision”. Avoid distractions, such as talking on your cellphone, reading, chatting with neighbors or saving baby ducks. And never assume someone else is watching your child.

Life Jackets Always
Use a US Coast Guard approved life vest whenever your child is near a natural body of water or, if they are a weak swimmer, a pool. Toys, water wings, and other flotation devices are not life-saving.

Learn to Swim!
Start swim lessons when your child is developmentally ready, with a program appropriate for their age.  Water safety classes are not recommended for children less than one year.  For those ages 1-4 it is important that the class adheres to national YMCA guidelines. Traditionally, children over 4 are considered most ready to learn to swim. Even older children, however, need to have continued supervision at all times near the water.

Home Pool Safety
Ensure that all home pools are surrounded by a four-sided fence that is at least 4 feet high with a self-locking gate.

Never let your child play on a pool cover. They are unsafe and should be fully retracted prior to pool use.

Remove toys from the pool after use, as they can tempt a child to jump in. Inflatable pools should ideally be emptied when not in use.

Never dive into a pool’s shallow end or into an above ground pool.

Learn CPR
In the event of an emergency, providing CPR until an ambulance arrives can be life-saving.

Follow these measures and enjoy the safest summer fun with your child!

Safest Sleep for Your Baby

Safest Sleep for Your Baby

The American Academy of Pediatrics first recommended that babies  sleep on their backs in 1992.  This campaign, known as “Back to Sleep”, was a major breakthrough in protecting babies from Sudden Infant Death Syndrome, or SIDS.

SIDS describes the sudden death of an infant less than one year of age that remains unexplained after a thorough evaluation and autopsy.  This has sometimes been referred to as “crib death”.  Two to four months of age is the highest risk period for SIDS, with more than 90% of cases occurring before 6 months.

In the 1980’s, before Back to Sleep, more than 1 out of every 1,000 babies in the United States would die from SIDS.  After the Back to Sleep Campaign was launched, this number steadily decreased until the risk had been cut in half!  Since the early 2000’s, however, the rate has stayed the same.  Approximately 3500 babies still tragically die from SIDS every year in the U.S., more than from any other cause between one month and one year of age.

Thankfully, there are steps that every parent can take to protect their baby from SIDS.  More than 95 percent of cases occur when one or more risk factors are present, many of which are modifiable.

Some risk factors are maternal.  Maternal smoking and late or no prenatal care both increase the risk for SIDS.  It is important to avoid smoking before and after delivery, and to ensure good prenatal care.

There are also infant and environmental risk factors for SIDS. Special care should be taken with premature babies, who are at higher risk.  Here are steps parents should take to ensure safe sleeping:

  1. Always place a baby on the back for sleep, whether for naps or at night.
  2. Use a firm, flat mattress with a tightly fitted sheet. Do not place any other bedding/pillows/bumpers or stuffed animals in the sleep area.
  3. Place the baby in a sleep area designed for infants (bassinet/crib/portable crib) in your room close to your bed.
  4. Do not place the baby in your bed. Sharing a room, but not a bed, is recommended ideally for the first year of life.
  5. Never place the baby on a couch or armchair for sleep, as these are extremely high-risk locations for infant sleep.
  6. Breastfeed your baby and ensure up to date vaccinations.
  7. Avoid overheating your baby.
  8. Consider using a pacifier during sleep.
  9. Do not use a car seat/swing/sling for routine sleep.
  10. Use a “wearable blanket” or thin swaddling blanket to keep your baby warm.      Once your baby can roll (usually around 4 months) swaddling is no longer recommended.
  11. Avoid products that claim to reduce the risk of SIDS, such as wedges, positioners and heart or breathing monitors.
  12. Place your baby on his or her tummy while awake and you are watching (“tummy time”).

Many parents worry that babies are at higher risk of choking when they are on their backs.  In fact, the opposite appears to be true! Babies cough up and swallow fluids easier when on their backs.

At about 6 months of age, many babies can roll from their back to their stomach.  When babies do this on their own, parents do not need to worry about turning them onto their backs during the night.

Every parent can take steps to ensure the safest possible sleep for their baby.  Making the baby actually sleep is the subject for another article!

How we beat Rotavirus

How we Beat Rotavirus

As a pediatric resident in 2000, winter meant Rotavirus. Every winter, miserable babies with fever, severe vomiting and watery diarrhea would fill our hospital wards. Anxious parents would watch and wait as we treated their weakened babies with intravenous fluids to prevent severe dehydration.

The babies I treated were not alone.  Before the vaccine, almost one in sixty-five babies were hospitalized for Rotavirus in the United States.  That meant 50,000 hospitalized babies, 500,000 seen in physicians’ offices and 160,000 treated in emergency rooms for the illness every year.  In countries with limited medical resources, Rotavirus is deadly.  In fact, it is more fatal than any other single infection, killing about 1,400 children every day.

Rotavirus is hard to control because it is extremely contagious. The virus gets taken in by mouth and is then excreted in the stool.  It lives a long time on surfaces like toys and changing tables, so young children who are constantly touching objects and putting them in their mouths are easily infected. The illness lasts days or weeks and can spread like wildfire through childcare centers. That’s why affected babies cannot return to childcare until all diarrhea is resolved.

This places a great deal of stress on parents.  The first stress of caring for a sick baby, and the second stress of prolonged absence from work.

In August 1998, a vaccine against Rotavirus, called RotaShield, was introduced to protect against this serious viral infection.   What happened over the ensuing decade is a remarkable story.

The RotaShield Story

Every vaccine undergoes extensive testing prior to introduction to the market to ensure that it is safe.   Sometimes, however, very rare side effects can only be detected once a vaccine or drug is given to hundreds of thousands of people.

Rotashield administration began in fall 1998, and by July 1999 about 800,000 children had received the vaccine.  It was only then that a concern emerged that more children may be getting a rare blockage of the intestine, called intussusception. Because the condition is so rare, it was hard to know if there was truly an increased number of cases.

It turns out that the vaccine was associated with about 1 extra case of intussusception per 10,000 vaccinated infants. This information led to the vaccine being taken off the market less than one year after it was introduced.

Scientists went back to the lab to try and develop a safer vaccine.  It took seven years!  Finally, in 2006, a new vaccine called RotaTeq was introduced, and a second vaccine, Rotarix, came out in 2008.

These vaccines have been a remarkable success story. While mild disease can still occur, severe Rotavirus infection in children has been virtually eliminated. Between 2007-2011, the vaccines prevented more than 176,000 hospitalizations, 242,000 emergency room visits, and 1.1 million outpatient visits.  I have only seen a couple of cases since 2006, versus dozens I saw every year in the early 2000’s.

A great deal of research has been done to determine if the new vaccines cause any increase in intussusception.  It is believed that the vaccine causes a very small number of extra cases, about 1 in 100,000 infants, primarily in the first week after vaccination. In summary, the risk of severe infection, about one in sixty five, far outweighs the risk of the vaccine.

The Rotavirus vaccine is a great success story of protecting babies from one of childhood’s most dangerous infections.  I don’t miss Rotavirus!


July 2001, VOLUME 108 / ISSUE 1

Intussusception, Rotavirus Diarrhea, and Rotavirus Vaccine Use Among Children in New York State

Hwa-Gan H. Chang, Perry F. Smith, Joel Ackelsberg, Dale L. Morse, Roger I. Glass


September 2016, VOLUME 138 / ISSUE 3

Intussusception Rates Before and After the Introduction of Rotavirus Vaccine

Jacqueline E. Tate, Catherine Yen, Claudia A. Steiner, Margaret M. Cortese, Umesh D. Parashar Accessed 11/15/2017