I’m not gonna lie, I LOVE talking about puberty as a pediatrician. Now, I have not had to go through it as a parent just yet, but we are pretty open and have utilized some resources to help prepare my oldest. One day after coming home from a group session led by the wonderful (and now Insta famous!) Annie Wolf and her Girls Club KC class (which includes education and support for girls’ bodies, self-love and puberty) my oldest was talking so positively about the idea of getting her period, that my 6 year old son exclaimed: “I can’t WAIT to get MY period!” … I mean, talk about positivity!

First things first, what ages are we talking about? One of the biggest points I make sure to discuss, is how NORMAL it is to notice or NOT notice changes during these ages, because everyone starts at a different time.

Normal range for girls starting puberty changes: 8-13 years old

Normal range for boys starting puberty changes: 9-14 years old

*If you are noticing changes like breast buds, pubic hair, increasing size of penis or testicles at younger ages than the range list above, please see your pediatrician. Of note, body odor is a common isolated symptom that kids can start having as young as kindergarten and we do not worry about this unless it is accompanied by other pubertal changes.

Please see ALL the helpful information here: HealthyChildren.org - Puberty Articles

GIRLS:

Breast buds: The earliest sign of true of puberty in most girls is breast buds. Common for it to start on one side and then involve both. Girls will often complain of tenderness of the breast bud when touched or bumped. This marks the onset of BIG GROWING YEARS. I often see patients gain a little more weight just before or as they are starting to notice puberty changes because their bodies are are preparing to grow 3-5 inches per year over the next 2 years!

Pubic hair: Often starts shortly after breast buds, but 15% of girls may notice pubic hairs before breast buds. Arm pits and legs can start to grow coarser hair, too.

Vaginal discharge: Clear or white, starts about 6-12 months before first period

Periods:***Most girls will start their first period about 2 years (give or take 6 months) after they start noticing breast buds. This marks the end of the biggest growth phase. Girls will still grow, just at a slower rate. Growth plates are often closing within about 2 years after starting periods.

Acne: See my post on ACNE care HERE!

BOYS:

Increased size of testicles and scrotum: This marks the start of puberty in boys. Common for testicles and scrotum to nearly double in size.

Pubic Hair: Starts at the base of the penis, and about 2 years later they will notice some hairs on their face, armpits and later their chest.

Penis growth: Can be adult-sized as early as age thirteen or as late as eighteen. Another important note, because size can be a source of concern in teen boys.

Acne: See my post on ACNE care HERE!

Voice changes: After the peak of the growth spurt, their voice box and vocal cords get bigger. Their voice can "crack" (gets higher or squeaks unexpectedly) as it deepens, but once it is done growing, the cracking will stop.

Erections: Can occur at younger ages and more common during puberty. I do think it is important to give boys who have started to show signs of puberty changes some information about erections and wet dreams so that they are not embarrassed when it happens. See HealthyChildren.org article about Physical Development in Boys: What to Expect.

NUTRITION

I have a whole post on Nutrition in Kids that includes some pre-teen and teen data that you can find here: How and What to feed our kids

In general, I want you to know that with these big growth spurts that occur during puberty, nutrition becomes important! A few things to thing about:

1. They need more water! Start working toward that goal of 64oz + per day. The bigger and more active they are, the more they need!

2. They need good sources of calcium and vitamin D for their bones! If they are not getting 3 full servings (8 oz is a serving) per day of milk or yogurt or cheese or a food or drink that is known to have 30% of daily recommended value of calcium in it, then consider a calcium or vitamin D supplement. ( I like this brand: Celebrate Calcium and Vitamin D (lots of flavor choices!)

3. Protein: As a general rule for kids/teens, both boys and girls between the ages of 11 and 14, they need half a gram per pound of body weight daily. So a 100 lb kid needs about 50 grams. Here are more protein ranges based on age:

   • Ages 4-8 years: 19 grams

   • Ages 9-13 years: 34 grams

   • Females age 14-18 years: 46 grams

   • Males age 14-18 years: 52 grams

4. Iron: Very important for growth and development, can help muscle endurance, sleep and energy. Plus, girls start to lose iron when they start periods. See this list of iron rich foods from Cleveland Clinic, and if these not in your child’s diet on a regular basis, consider a supplement like Celebrate Iron or Slow Fe.

5. And try your best to encourage but also be an example of someone of has regular sources of healthy fats, fruits and vegetables and try to avoid excessive servings of foods or drinks with added sugars and processed foods.

Below are some books that are commonly used and recommended to help kids understand and prepare for the changes in their bodies, as well as some books for parenting these kids/teens!

Good luck through ALL THE CHANGES!

Keep it Real!

Kelsey Ragsdale, DO

Books for Kids on Puberty:

The Care and Keeping of You 1 - (American Girl) For Younger Girls

The Care and Keeping of You 2 - (American Girl) For Older Girls

You-ology: A Puberty Guide for EVERY Body - (3 Physician Authors)

The Boys Body Book

The Girls Body Book

Books for Parents with Kids getting ready to go through Puberty:

Untangled - Guiding Teenage Girls Through the Seven Transitions into Adulthood, By Lisa Damour, PhD

Decoding Boys: New Science Behind the Subtle Art of Raising Sons, By Cara Natterson, MD

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First things first … Anxiety is such a common emotion that we all feel at some point or another. It can be NORMAL and APPROPRIATE in certain situations.

Anxiety can sometimes contribute to issues involving the following areas of daily living:

1. Disrupted Sleep

2. Abdominal pain or decreased appetite (or in some cases, increased appetite related to “emotional eating”)

3. Focus or school performance

4. Involvement in social activities or relationships

5. Family routine or relationships

If I see a child in clinic and they or the parent feels that anxiety is affecting one or more of these areas on a regular basis (which I often describe as greater than or equal to 50% of days or several times per week), then I definitely feel that deserves more intervention. If anxiety is occasional, or situational, but not impacting areas of daily living on a regular basis, then we can still talk about resources and coping strategies.

Let me discuss what “more intervention” means.

1. Still resources and coping strategies, although at this point in the visit, I often don’t have a ton of time left to describe more than a few thoughts and give resources (hence why posts like this will be helpful, see below for said resources)

2. Referral to a therapist who does CBT.

   1. CBT - Cognitive Behavioral Therapy (Family/Parent Involved)

      1. This type of therapy has the strongest evidence in treating anxiety in kids

   2. PCIT - Parent Child Interaction Therapy

      1. PCIT has emerging evidence that is promising for treatment of anxiety and behavior concerns, so can be another option in young kids (ages 3-8)

3. Medications *may be considered for kids and teens with moderate to severe anxiety, when there has been poor response to CBT, or when CBT is unavailable. If this is part of the discussion, here are things I want parents to know.

   1. SSRIs (Selective Serotonin Reuptake Inhibitors) are a class of medications that help to increase the amount of serotonin available for neurotransmission which is helpful for modulating fear, worry and stress.

      1. Expectations: If an SSRI medication is started, it must be given everyday. You may start to see some improvements in the first 1-2 weeks, but it can take 4-6 week to get to the full effects of the medication.

      2. Side effects: Nausea, abdominal pain, loose stools, headache, sleep effects, fatigue, restlessness, weight gain. Most are mild and transient , but if significant, may be worth discussing a change in timing, dose or medication.

      3. *All SSRIs carry and FDA black box warning for increased suicidal thinking and behavior. The risk difference (drug vs placebo) is about 0.7% for suicidal ideation. Obviously discussion and monitoring is appropriate, but because potential for benefit largely exceeds the potential for risk here, this should not discourage appropriate use.

      4. *It’s never okay to stop a medication suddenly without consulting with your child’s doctor. When discontinuing, these medications often need to be weaned to prevent serotonin withdrawal symptoms (think “feeling awful” … flu-like symptoms minus fever, not sleeping well, anxious, dizzy, etc).

      5. *Personal Note for transparency for those who are nervous about recommendations for meds: I have taken medication for anxiety as an adult. I took it for close to 2 years and then was able to stop. I feel like it gave me the ability to use my coping strategies more effectively and get into the habit of using them. Kids and Teens have brains that are still growing and changing SO MUCH! I think some parents are afraid that if their child needs anxiety medication, they may always need it. THIS IS WHY THERAPY like CBT IS SO IMPORTANT! Give them the skills they need and will take with them FOREVER! Some kids need more serotonin available in their brains to help do this.

LIST OF RESOURCES - To help parents, kids and teens understand anxiety and ideas for tools and coping strategies! We ALL need these!

Help Your Child Manage Anxiety - HealthyChildren.org

Creating Calm: How to Talk With Your Child When They’re Stressed - HealthyChildren.org

*FOR TEENS: Creating Your Personal Stress-Management Plan - HealthyChildren.org

Just Breathe: The Importance of Meditation Breaks for Kids - HealthyChildren.org

Head Space for Kids in the HeadSpace App - Meditation for Kids

Anxiety Resources for Parents - Child Mind Institute - childmind.org

*My FAVORITE book for Kids to help understand what is happening in their brains/bodies when they are feeling anxious: Hey Warrior - By Karen Young

*This is an AAP recommended resource and we are trying this at my house currently for some anxiety in one of my kids: CBT Tookbox for Children and Adolscents - by Lisa Phifer

As always, PLEASE TALK with your Pediatrician if you have concerns. I have a lot of knowledge on Childhood Anxiety, but I can speak from experience as a parent with a child struggling with anxiety, it ALWAYS helps to talk to their doctor.

Good Luck! Hope this was helpful information.

Keep it Real.

Kelsey Ragsdale, DO

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*Pic of me with our puppy last summer. She has been a serotonin booster for all of us! … no pressure for anyone to get a puppy.

I cannot tell you how many times per week I get questions about “picky eating” in toddlers and kids. I get far fewer concerns from parents of teens. This could be that most kids “outgrow” their picky eating phases, or it could be that the parental anxiety over mild picky eating improves … or both!

The first thing I do when I have a concerned parent regarding lack of variety in their child’s nutrition is look at the GROWTH CHART! If I have a kid who is gaining weight and growing, I’m already feeling more comfortable. If you have a kid who is not growing well AND/OR showing really avoidant or restrictive eating patterns, this requires a more in depth visit with your pediatrician.

But for a kid who is gaining and growing, The first question I ask:

“Does your child eat a variety of food groups over the course of the week?”

If the answer is YES or even SOMETIMES, then I am even more comfortable. I encourage parents to continue to offer a variety of food groups over the course of the week and to try and not stress when the child doesn’t eat something on their plate. You may have heard this before, but I will write it here for reinforcement:

It is our job as parents to provide a variety of nutritious foods to our kids over the course of the week. It is their job to decide whether or not to eat those foods and how much.

It is our job as parents to create a positive environment at meal times and to not pressure or force our kids into eating foods. (even though I am so guilty of pressuring my kids to take 2 more bites at times.)

I also like to check to make sure the child is getting regular sources of:

• calcium and vitamin D (for bone health)

• fats and protein (needed for growth, brain health and energy, glucose metabolism)

• iron (to support red blood cell health, sleep and energy)

• fruits and vegetables (fiber for gut/digestion health, vitamins for immune system and cardiovascular health, vision, etc … see what Harvard’s School of Public Health has to say about all the benefits.)

If the answer to my first question is NO, they are not getting a variety of food groups over the course of the week, then there is more to discuss.

Do they take a multivitamin (MTV) with iron consistently? For a kid who is lacking a consistent food group, finding a way to supplement the nutrients that may be lacking on a regular basis is probably worthwhile. What is my favorite MTV with iron? Well, since gummies are not always the most consistent form of delivery/absorption of nutrients and dentists do not like their effects on teeth, my favorite MTV with iron is the good ‘ol Flintstones Chewable Multivitamin with Extra Iron. If they don’t like that one, there are a few other chewable options out there. The reason I like the extra iron, is because the 2 most common nutritional deficiencies I see in kids are:

1. Low Iron

2. Low Vitamin D (not that I check levels very often, but I assume most of us are not getting as much in the winter months from less sunshine, and may depend on dairy intake)

I like these resources for dietary sources of iron and Vitamin D:

Iron: Cleveland Clinic - 52 Foods High in Iron

Vitamin D: USDA Food Sources of Vitamin D

(For more info on nutrients to consider when feeding our kids, see my previous post: How and What to feed our kids!

Once I feel I have addressed adequate growth and offering ways we can make sure the child can get essential nutrients, next is HOW TO APPROACH THE PROBLEM of stubborn or selective eating patterns. Here are my top 5 Picky Eating Tips:

1. Get your child involved in food preparation/cooking. Teach them rules in the kitchen and let them help! Make it fun and colorful. Let them serve or feed you the food they prep and watch you enjoy it!

   1. For Younger Kids

      1. Let them help rinse Fruits and Veggies (young kids love the sink)

      2. Slice up fruits/veggies and then let your child help chop or cut up slices with Kid-Safe knives or food shape cutters. Let them pick up the pieces they prepare with fun food picks or fun utensils.

         1. Kids’ Chef knives - Kuhn Rikon (We have had these since my 10 y/o was 2 y/o/)

         2. Kids’ Food Shape cutters

         3. Fun Food Picks

         4. Fun construction utensils

   2. For School-Aged Kids

      1. Let them help cut up fruits or veggies, practicing with kid safe knives until they get older or more proficient. Let them help measure, pour, mix, whisk ingredients. Let them help push the button on the kitchen appliance with supervision. Give them some control!

      2. It’s important to let them know that mistakes and messes happen in the kitchen, and it’s okay. Teach them how to help clean up any messes made.

2. Taste Buds and Science Experiments

   1. Okay, this is more for 5+ year olds. I love to tell my patients to look in the mirror and see their taste buds on their tongue. Kids’ taste buds can change SO much and SO fast, but we won’t know unless they do science experiments on their taste buds to test them. It may be worth helping make a list of foods they are nervous to try, and having a “Family Taste Bud Science Experiment” evening where everyone tries the new food and reports on what their taste buds like or don’t like. It’s okay if they don’t like the food, because you can always repeat the science experiment later and see if they have changed.

3. Give them a choice. Kids love to have control as much as adults do! Let them pick part of the meal when you meal plan so that you know there is a safe food for them on the table, or let them pick a meal each week.

   1. For younger kids, I would give 2 choices to keep it simple. Examples: Peas or carrots? Apple or blueberry? Cheese or yogurt? Noodles or bread?

   2. For older kids, I recommend having them come up with a list of their favorite meals or snacks, but have them practice making sure it is balanced, meaning it includes a fat/protein source, an energy food (think breads, pastas, rice, complex carbs), and a fruit or vegetable.

4. Don’t give up! Be persistent, but keep it low pressure. It can take 15 or more times for a child to try and decide to like a food. If your child doesn’t like a bite of “insert disliked vegetable”, you could offer a one bite serving on their plate once a week and it doesn’t have to be dramatic. Also, try offering it different ways (raw, steamed, roasted, with dips or cheese).

5. Eat together! This one is BIG! It doesn’t have to be every night, but try to sit down at meals on a regular basis with our child, with the same foods on your plate, and let them see you trying and enjoying foods and mealtime. Talk about things you are looking forward to, or something funny that happened that day. Try not to talk about what everyone IS or IS NOT eating.

See these links for more, evidenced based info on Picky Eating in Kids.

HealthChildren.org: How do I help my picky eater try more healthy foods?

Chop.edu: Feeding a Picky Eater: The Do’s and Don’ts

Once again, if you have a kid who is not growing well AND/OR showing really avoidant or restrictive eating patterns despite, or if this is causing consistent stress at mealtimes and in your home after considering the information above, this requires a more in depth visit with your pediatrician.

Good Luck! Hope this was helpful information.

That’s it for now. Keep it Real.

Kelsey Ragsdale, DO

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I want to note that during this time of year it can be hard to differentiate between common cold and seasonal allergy symptoms. After all, they can both include:

• stuffy or runny nose

• cough

• sore throat

• mild fatigue

A common cold can sometimes involve fever whereas allergies should not include fever UNLESS a child/teen has developed a secondary infection as a result of ongoing congestion (like a sinus infection or ear infection).

Seasonal allergies can also include itchy and watery eyes and dark circles under their eyes. They can trigger asthma symptoms. They can even cause behavior or focus issues due to discomfort and sleep disruption in some cases (though colds can do this, too! Keep in mind, these issues would be more seasonal and associated with obvious allergy symptoms)

If you are a parent, like me, who has a kid who has suffered in previous seasons from allergies, then you may be wanting to get ahead of the effects that these symptoms can cause and looking to decrease symptoms.

Seasonal Allergy Action Steps:

1. If your child (like mine) also has some indoor allergens like dust, try to keep these under control before seasonal allergy season starts. Outdoor pollens can also be brought inside on shoes, clothes and pets. Keep windows closed when pollen counts are up. Wipe down pets after being outside for a while. Vacuum, dust and wash bed linens regularly. Love a good HEPA filter air purifier! This is the one we have in a few rooms in our home!

2. After making sure you are doing your best to limit exposure to known allergy triggers, if your child has any nasal congestion or drainage, the FIRST 2 PRODUCTS I would start include:

   1. Nasal saline spray

   2. Flonase (or fluticasone) nasal spray

      These are commonly recommended treatments for nasal congestion, drainage and postnasal drip and with lots of good evidence behind both for safety and efficacy! I think of nasal saline as rinsing out the nasal passages and breaking up the mucous. Fluticasone nasal spray is a steroid nasal spray that helps decrease inflammation or swelling and can help decrease drainage including postnasal drip.

3. For general allergy symptoms, I would also start one of the following long-acting antihistamines to help decrease the histamine our immune system is releasing, which is driving the allergy symptoms … listed in my personal order of preference:

   

   

   

4. EYE Allergies

   1. You can’t miss this! Both eyes are red and puffy from itching, often more watery but sometimes can get a little crusty.

   2. Step 1: Wash hands and rinse off after being outside.

   3. Step 2: When you see your kid rubbing and itching, hand them a clean and cool compress/wash cloth to hold over their eyes instead! This will calm the itch and inflammation and avoid additional swelling caused by rubbing.

   4. Step 3: Give your long-acting antihistamine (see above)

   5. Step 4: Use OTC antihistamine eye drops.

      1. Zaditor Antihistamine Eye drops … OR …

      2. Pataday Antihistamine Eye drops

      3. I like this simple video I found by NYP.org for how to administer eye drops in kids!

Important! If symptoms are affecting your child and NOT improving with available OTC remedies, ALWAYS see your pediatrician for evaluation!

When to consider an Allergy Referral?

If you have tried all of your pediatrician’s recommendations and OTC remedies and your child continues to suffer daily from their allergy symptoms, it may be time to consider seeing an allergist to discuss further evaluation and treatment options.

Some Additional Resources:

If you are looking for a good Instagram Follow with evidence-based Allergy information for kids, I like @allergykidsdoc - Dr. Dave Stukus, MD

HealthyChildren.org article on Seasonal Allergies

CHOP.edu article on Seasonal Allergies

Good Luck! I hope this information helps your child this allergy season!

That’s it for now. Keep it Real.

Kelsey Ragsdale, DO

*Pic of Spring in Paris - we were lucky to visit friends and family over Spring Break this year!

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Any parent of a toddler has likely experienced a classic toddler tantrum. Tantrums are developmentally appropriate in toddlers, but that doesn’t make them any less frustrating to deal with in certain situations. This parental frustration can lead to negative reactions and cycles, sometimes even reinforcing the tantrum behavior or resulting in a parent tantrum (though these are less developmentally appropriate). I have thrown my own version of parent tantrums that I am not particularly proud of (and I can always trace it back to being really overwhelmed, exhausted or anxious).

See Healthychildren.org - Emotional Development: 2 year olds

Why do tantrums happen? Generally speaking, they are caused by

But there are also common triggers or preceding circumstances which can include: Tired. Hangry. Stressed. Frustrated. Fearful. Disappointed. Sensory Overload. Attention-Seeking. (these triggers can all can apply to older kids and adults, too!). Sometimes understanding the preceding situation can help parents mitigate tantrums … but not always.

There are always going to be the seemingly ridiculous situations that feel/are unpredictable! Example: Child asks for a cup of water. Parent hands child a cup of water … in a blue cup. Child breaks down into a fit because they wanted the pink cup. (Sound familiar?)

So, what can you do? First things first, consider the basics: Food and Sleep. If your child is always melting down before dinner, I recommend being prepared with a plate of nutritious snacks. For older toddlers and kids, put out a cutting board and kid safe knife and soft foods or slices they can practice cutting and eating while you cook dinner. If your child is always melting down at bedtime, try moving bedtime earlier and try to keep a consistent bedtime routine.

Then, remember these 6 strategies that can help!

1. STAY CALM

   We have to model emotional regulation if we expect our children to learn it over time.

2. REDIRECT or DISTRACT

   Maybe move outside or to a different area in the house OR offer to let them pick a song to play or sing OR have a basket of calming sensory toys nearby that you could use OR offer to read a book OR see if they want to draw/color.

3. MAKE SURE THEY ARE SAFE

   If your child is throwing a tantrum near stairs, standing on furniture, or near objects that they could kick or break - move them to a safer area, remove objects that they might injure themselves or someone else with

4. DO NOT REINFORCE aka REMOVE ATTENTION

   Tantrums are learned behaviors. This means that our reactions to behaviors, good or bad, can be reinforcing because our kids LOVE to get our attention. Also tantrums are hard to tolerate, especially in public, so if we give them what they want in that moment to get a tantrum to stop, they will continue to tantrum in the future. Biting Example: If a child is biting and gets a big reaction out of you, sometimes this reinforces the biting because they got your attention. If you can anticipate this, I would clearly state:

   “We do not bite others, but you can bite food or a safe teething toy” (redirect) or “I would love to play with you when you are ready to not bite” and then walk away or stop giving them your attention

5. GIVE POSITIVE ATTENTION

   Rather than waiting for the negative behaviors to trigger our attention, try to give positive attention when your toddler is doing positive things.

   “Thank you for throwing that away, it was so helpful!” or “Great job getting in your jammies tonight, now we have more time to snuggle and read.” or “You did such a good job calming down!” ALWAYS PRAISE THE CALM DOWN!

6. GIVE THEM TOOLS TO CALM DOWN in a “CALM DOWN BOX”

   Often trying to talk to, explain or reason with a child who is in a tantrum can fuel the fire. If this is a recurring issue, I will often recommend breaking this cycle by parents making a “Calm Down Box” that they can set in front of the child and walk away (but still within sight). IMPORTANT, there needs to be a practice session with this when the child is calm so that they understand how it can be used. Also, it’s great if the child can be involved by having them decorate the outside of the box with stickers or colors to identify that this is his/her box (I would make one for each child if you have more than 1 toddler). Inside of this box can be a number of “tools”, but the younger the child, the fewer there should be. Start simple! You can adjust as they get older or swap age appropriate items in. If they are able to calm down using something in the box, give them a few minutes and then go over and PRAISE them! Here are some ideas:

   1. A soft stuffy to snuggle

   2. A favorite book

   3. A calming distraction like a glitter globe or sensory tube (These are cute Feelings Sensory Bottles or these Sensory Fidget Tubes)

   4. A Pinwheel that they can blow, which helps facilitate deep breathing which is huge in emotional regulation (with supervision outdoors, Bubbles are a great option for this).

   5. Something that plays music (like Music Radio Toy for younger toddlers by Baby Einstein +Hape) or Vtech Soothing Songs Fox.

   6. Paper and Crayons to use art and color to calm down

   7. A punching pillow to get out frustrations

   8. Sensory toys for older toddlers 3+ like these Snap Fidgets or Mini Magnetic Tiles

Reasons to see your pediatrician:

1. Your child is regularly having multiple tantrums per day

2. Your child is 5 years or older and having regular tantrums.

3. They are injuring themselves or others or damaging property

4. They are having headaches, stomachaches or anxiety

For more information, see HealthyChildren.org: Top Tips for Surviving Tantrums

Love these articles from The Child Mind Institute: How to Handle Tantrums and Meltdowns and How Can We Help Kids With Self-Regulation

I also like this article, see When to Worry about Toddler Temper Tantrums at hopkinsmedicine.or

That’s it for now. Keep it Real.

Kelsey Ragsdale, DO

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Important Foot Note! If your kids have pronated feet, this can lead to:

• Tightness in their heel cords/calves (I have kids try to squat down while keeping their heels on the ground, see pic below. If they can’t, they may have tight heel cords)

• Tripping and falling more when they are young

• More complaints of leg pain

• Older kids and athletes can get a common cause of Knee Pain (Patellofemoral syndrome, see more important information on this below for ATHLETES).

All 3 of my kids have foot pronation (yes, those are pics of my kids below)! In fact, one of them was also a toe walker and ended up getting tight heel cords and had to do some physical therapy (see story below).

When my middle was about 4 years old, we noticed she was toe walking A LOT! Actually, I was so busy with my 6, 4 and 2 year old plus work and life that I wasn’t super focused on how much she was toe walking until my (non medical) brother made some comment about how awesome his calves would look if he spent as much time up on his toes as she did! I started paying more attention after that smart ass comment (love you, Matt) and realized she was also tight … would fall out of a squat, unable to keep her heels flat. She was also my kid who would sometimes wake up crying with leg pains after a really active day. We started physical therapy and the PT recommended some shoe inserts to help her pronation, in addition to therapy that helped stretch her heel cords and reinforce that pattern of heel-toe walking instead of toe walking. We also focused on keeping her in supportive tennis shoes both indoors and outside, because it is harder to toe walk with supportive/structured shoes on compared to being barefoot.

*Important to know: Infants and toddlers have flat feet and pronation … this is NORMAL. Of course! Those chubby feet haven’t had to bear weight until they start walking, and it takes time for that arch to develop. If you think your kid has foot pronation, it is worth making sure that their daily tennis shoes have medial support to lift that part of the foot a little and help with foot and ankle alignment. Also, LOTS of toddlers go through phases of toe walking … I would talk to your pediatrician about toe walking if your child is almost exclusively walking on their toes instead of a heel-toe walking pattern after the age of 2.

HealthChildren.org Flat Feet & Fallen Arches: When Treatment is Needed?

I was emailing recently with 2 of my favorite pediatric physical therapists in town at The Children’s Spot, Beverly and Abby! They were so kind to share 2 of their commonly used handouts which I have attached at the bottom of this post. The first one is all about foot pronation and calcaneal valgus and describes different types of orthotics they recommend. The second handout has QR codes for Amazon foot orthotics they recommend.

These are two of my favorite kid inserts for pronation - the 1st is also on the PT recommended handout. The 2nd was recommended by a Sports Medicine doc I saw speak at a conference. Keep in mind you need to pull out the current shoe insole before you put in the orthotic insert.

1. Younger and School aged kids over the counter orthotic inserts: Kids Orthotic Inserts on Amazon

2. Older kids and athletes, good for those soccer or baseball cleats, too: Superfeet Green Inserts on Amazon (also have one for Wide feet)

ATHLETES with chronic recurring knee pain, consider this … the following triad is a perfect recipe for knee pain in runners/athletes:

1. Foot pronation

2. Tight hamstrings (back of thigh muscles)

3. Weak quadriceps (thigh muscles)

This triad causes poor alignment from foot to knee and adds stress to the knee during running and exercise. This can lead to something called Patellofemoral Pain Syndrome or (Runner’s Knee). See Hopkins Medicine - Patellofemoral Pain Syndrome (Runner’s Knee) for more information and a video.

NOTE: If leg pain is limiting participation in sports, causing a limp, not improving or worsening, or disrupting sleep, you should always call your pediatrician.

Treatment should include the following, in addition to rest and ice and NSAIDS like ibuprofen or naproxen if needed for pain.

1. Inserts to help foot pronation and alignment - See links above

2. Stretching Hamstrings - See this helpful link from Children’s Wisconsin

3. Strengthening quadricep muscles - See this helpful link from Cleveland Clinic for 5 Best Exercises for Runner’s Knee

   ---

   As always, if you aren’t sure or have concerns, please call and see your pediatrician instead of Dr. ChatGPT.

That’s it for now. Keep it Real!

Kelsey Ragsdale, DO

PT Handouts

PT Amazon Orthotics

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But first, let’s understand the basics of What Causes Acne:

1. Hormones shift with puberty

2. Oil production in their skin glands increases, clogging pores

3. Bacteria (that already live on the skin) LOVES the oil and increases, causing redness and irritation

(Anyone else get told eating greasy food or too much chocolate would increase their acne when they were growing up?? There is not enough consistent data to make significant diet restrictions when it comes to acne. See the American Academy of Dermatology’s stance on Diet and Acne. My advice … if you notice a consistent trend where if you have too much of certain foods your acne worsens, then try to limit those foods in excess. And always, drink enough water!)

And a quick note about all those products in the mini fridge or cabinet that our tweens and teens THINK they need … sometimes added fragrances or oils or certain ingredients can contribute to clogged pores and skin irritation which can cause acne breakouts. You really want to focus on products that are labelled “non-comedogenic" or “won’t clog pores” and “oil free”.

When it comes to Acne Treatment and buying over the counter products, it’s really important to understand what ingredients are doing for our skin because it can help us prioritize and simplify the acne care routine.

• Salicylic acid: Unclogs pores and exfoliates the skin, helps with whiteheads and blackheads

• Benzoyl Peroxide (BPO): Helps kill acne causing bacteria and decrease oil. Can be used on face and body (think of this for back and chest acne)! Start with lower strength products, around 2.5 - 4% to help avoid side effects like dry, irritated skin … then you and can work up to some that contain 10% benzoyl peroxide if needed. Keep in mind, BPO will bleach fabrics, so use an old towel and pillow case and make sure skin is fully dry before putting clothes on.

• Adapalene/ Retinoids: Unclogs pores and decreases oil. This helps with blackheads, whiteheads, and pimples. The most significant side effect is dryness of the skin so start with a few times per week and then gradually increase to daily. Also use an oil free moisturizer daily to help with dryness.

• Hydrocolloid pimple patches: These cover the pimple and absorb oil and bacteria.

• Azelaic acid: Can help with acne and help fade dark spots that can linger after acne spot is clearing (post inflammatory hyperpigmentation)

See the following important notes on how to use topical acne medications from the Society for Pediatric Dermatology (they have a great patient handout on Acne):

Sometimes, medication needs to be prescribed to treat acne. This can include retinoids, topical or oral antibiotics, birth control pills, spironolactone, or isotretinoin. See The American Academy of Dermatology’s overview of the diagnosis and treatment of acne, including information about these medications and when they may be considered.

A few tips to help expectations and chances of success:

• Do not SCRUB your skin, this can cause further irritation

• Do not squeeze and pop pimples (I know I know I know … you cannot help yourself) … but truly, it will decrease the success of your acne treatment

• Be consistent and patient, it can take 6-8 weeks to see improvement, and 3-4 months to see complete clearing of the skin.

Sample Treatment Plans

Below you will find several links to products that I would recommend for acne treatment and I’m hoping the above information helps you decide when and what to use. AS ALWAYS, talk to your pediatrician if things are not working or if you aren’t sure what is best for your teen’s skin. (I use CeraVe myself, which is why you will see this brand on repeat!)

That’s it for now. Keep it Real!

Kelsey Ragsdale, DO

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*Disclosure: As an Amazon Associate I can earn from qualifying purchases at no extra cost to you.

Foam Facial Cleanser - CeraVe (*This is what I use … and what my 10 year old uses … no acne yet, but I’m getting her in the routine of washing her face during showers)

Acne Control Cleanser w/ 2% Salicylic Acid - CeraVe

Neutrogena Acne Body Wash w/ 2% Salicylic Acid

Oil Controlling Moisturizing Gel Cream - CeraVe

Ultra Light Moisturizing Gel - CeraVe

Ultra Light Moisturizing Lotion w/ Sunscreen 30 spf - CeraVe

Gentle Clear Complexion Clearing Acne Cleanser w/ Benzoyl Peroxide 2.6% - Cetaphil

Acne Foaming Cream Cleanser w/ Benzoyl Peroxide 4% - CeraVe

PanOxyl Acne Foaming Wash - Benzoyl Peroxide 10% - Face and Body

PanOxyl Overnight Pimple Patches

CeraVe Blemish Barrier Patches (*We also use these, gentle enough for my 10 yr old if she gets a pimple)

Differin Gel - Adapalene gel 0.1%

Differin Acne Skin Care Kit - has both Adapalene gel 0.1% and a Cleanser for face/body with Benzoyl Peroxide 5%

I have to talk about it… We all do it… For some, it’s harder than others. No matter your age or size … it is part of our daily lives (or almost). It can even affect your child’s mental health and quality of life! I am addressing questions or concerns about stooling patterns and constipation on a DAILY basis at work and I spend so much time explaining why kids get constipated and what to do about it.

There is an impressive brain gut connection that can really impact the process of pooping. This video may seem silly for some, but it is an AWESOME way for parents and kids to understand what is happening in our bodies when we poop and how constipation can easily become chronic or even turn into bigger issues like stooling accidents.

*The Poo in You - Youtube video by GIKids

Fortunately, constipation is not a consistent issue in our house, but I still made my kids watch this video because it’s so educational for parents AND kids!

From a very young age, constipation can become a problem. Sure there are those of us who may have occasional constipation after too much cheese or during travel. But the constipation I want to talk about today involves the kind that is persistent, recurrent, and associated with pain or discomfort or even accidents. This kind of constipation creates a negative association in the brain, and so the brain tells the body to avoid doing this natural thing that is causing the pain. Sure, we can try to increase hydration, fiber, or try giving a probiotic but there is NOT DATA to suggest that going above and beyond normal recommended amounts of water, fiber, or taking a probiotic will treat chronic constipation in kids. If the discomfort or issues are persisting, despite our best efforts, then we need to use medicine to help. The risk of not treating constipation can result in a negative feedback cycle that can be more difficult to overcome and may take several months or even years.

A common situation that presents to me in clinic is a child that is avoiding stooling because the stool is too big or hard. Sometimes, especially in young children, it just takes ONE painful stool to trigger holding behaviors. The more they avoid it and hold it, the more the stool can build up in their belly and the more their colon can stretch to accommodate the stool. Then the next time the child tries to have a poop it is even bigger, harder and hurts … thus the cycle of wanting to hold/avoid continues.

*I strongly recommend talking to your pediatrician early if you are noticing recurrent constipation!

Abdominal pain is a common symptom of constipation, especially in older kids. Sometimes there is not a complaint of pain with stooling, but there is abdominal pain. When I ask about their stooling patterns, the child is only pooping once every couple days and only when I ask, will tell me that it sometimes is hard and hurts. Sometimes a child will tell me they stool almost every day, but they aren’t getting enough of their stool out, so it can build up over time.

If a child only poops once every few days but is eating and growing well and not complaining of regular tummy aches, then this can be normal for that child.

Pediatricians just LOVE to ask about the details! See The Pediatric Bristol Stool Form Scale for Children below pulled from Constipation in Children - Healthychildren.org. The goal is type 3 or 4!

(Image courtesy Patrick T. Reeves, MD, FAAP, adapted from Lane et al.)

• Common stages that constipation develops:

  • Infants: After starting solids at 6 months. 1st remedy: PRUNES! (or 1 oz of 100% prune or pear juice mixed with 1 oz of water)

  • Potty training: Some kids hold it because too busy to stop and sit, then it gets hard or hurts, then they hold it more. 1st remedy: Schedule TOILET SITS after meals with positive reinforcement in place. This is the time our bodies are primed to let a stool out because of the gastrocolic reflex. Food hits the stomach, the colon wants to move and empty. I commonly recommend reading a book to them to distract and relax them for a few minutes or giving them a sticker activity book to work on for a few minutes while they sit. Give MiraLAX if you need to keep the stool softer, start with 1/2 capful in 6-8 oz of clear fluid/juice mix and titrate dose if needed to keep stools a soft peanut butter or soft serve ice cream consistency (more on dosing and MiraLAX info below!)

  • Starting school: Some kids don’t want to poop at school! Super common. They hold it, but by the time they are ready to poop at home, its hard, or it doesn’t fully come out, and this can back up over time. Try to check in with your school aged kids about their poops. I KNOW I don’t always know when my kids are pooping or what they look like, but they are so used to me asking, it doesn’t even phase them! (Still annoys my husband when I choose dinner as the time to check in … hee hee). Remedy: MiraLAX OR Magnesium hydroxide chews are my go to remedies to keep stools soft and regular. For kids who aren’t willing to finish their MiraLAX doses, Magnesium chews like Dulcolax or Pedialax chewables can work well, just make sure they still drink water with them.

*NOTE FOR PARENTS OF BABIES UNDER 9 MONTHS who are not stooling everyday. It is COMMON for babies (especially breastfed babies) to go through a phase of infrequent stooling and straining but it is NOT constipation if when they do go, the stool is SOFT. One of our kids went through a phase around 3 months where they would only poop once every 10-14 days!!! We called it “Poop Watch 2020”. This is commonly attributed to something call infant dyschezia where the baby has an inability to coordinate relaxing the pelvic floor while bearing down. They generally outgrow this as they mature, typically by 6-9 months of age. Occasionally, if the baby has gone >7 days and they are uncomfortable and not eating as well, I will recommend belly massages and some rectal stimulation with a rectal thermometer with a little Vaseline on the tip, or try the Friday Baby Windi Gas Passer. For infants with hard nuggets and straining suggesting true constipation, I start with prunes or prune or pear juice like mentioned above, and if still persisting may consider small doses of MiraLAX for infants 6 months and older or a prescription medication called lactulose. If they are really straining and unable to stool, sometimes a pediatric glycerin suppository is needed. Just ask your pediatrician!

NOTE: MiraLAX has been recommended by the NASPGHN (North American Society for Pediatric Gastroenterology, Hepatology and Nutrition) as 1st line medication for both disimpaction and maintenance treatment of constipation. We have quality data, multiple systematic reviews and clinical trials showing safety and efficacy in even young kids and infants 6 months and up. (A double blind, randomized controlled, multicenter trial involving patients 6 months to 15 yr demonstrating safety and efficacy across this age range PubMed Link)

*Here is this AMAZINGLY COMPREHENSIVE Download/Handout by GI Kids … it’s long but oh so thorough! It includes everything from general information on constipation, fecal soiling, nutrition, fluids and fiber, toilet training tips, a water tracker, and bowel management tool.

For chronic constipation with fecal soiling, I’m working on making a simplified handout for my patients that involves a Constipation Treatment or Action Plan … YES, just like some people have an Asthma Action Plan. Currently, I just write down the plan. These exist already, I just haven’t used one consistently. Here is one with a cute handout our local Children’s Mercy created. I also like this one from Cincinnati Children’s.

I’m going to give an example of what this may look like. Please keep in mind that the dose I recommend would vary based on the child’s AGE AND WEIGHT, so I am using X variable.

EXAMPLE:

Child comes in with history of chronic constipation and having regular smears of stool in their underwear. After asking questions and examining the child, the first thing I am likely to recommend is what I refer to as a Mini Cleanout. (Mini, because the child is mini and we are not talking colonoscopy prep here!). I generally expect that these will be done over a weekend when the child can be home and close to the toilet.

Then, we need our maintenance regimen so that the child’s colon can empty regularly and return to a normal caliber and function over several months. We also need that long to break the negative, uncomfortable association the child’s brain has with pooping. If I have a kid with really chronic issues, I prepare parents that our maintenance regimen may need to last 6-12 months.

Don’t forget that toilet sits after meals is a huge part of the maintenance plan! Remember the gastrocolic reflex that occurs in our bodies: food hits our stomach, and our colon wants to move and empty.

• Mini Cleanout over 2-3 days. Give X capful of MiraLAX mixed into 6-8 oz of fluids, drink within 30 minutes of mixing, give 2-3 times per day for 2-3 days. If they get such diarrhea that they cannot make it to the bathroom, cut the next dose in half or space out the doses, but do not stop the cleanout. The goal is to unload the colon!

• Maintenance:

  • Toilet sits after meals with positive distraction and reinforcement

  • Sitting in a Squatty Potty position with hips and knees flexed and feet supported

  • Senna Exlax chocolate X square before bedtime nightly (this gives movement and some squeeze back to the stretched out colon while the child sleeps so that the stool can keep moving.

  • MiraLAX or Magnesium chew: X amount in the morning daily to keep stools soft. Always tell parents they can titrate the dose to achieve soft easy to pass stools. If too much, cut the dose in half. If still too hard, it’s likely okay to increase a little, but if it’s not helping, ALWAYS check with your pediatrician! Dulcolax or Pedialax

  • And sure, make sure they are drinking enough water and having good fiber in their diets, too!

I hope this helps if you are a parent or caregiver of a child having a hard time! Do not forget to check out the video above and the GI Kids Handout! Great Resources for those who need them!

That’s it for now. Keep it Real!

Kelsey Ragsdale, DO

Our experience:

Since my daughter was 3-4 years old, I started noticing her having trouble following instructions at times, needing frequent repeated instructions to start or finish a task, struggling with transitions from one activity to another, and would do impulsive things like run down the street despite clear safety boundaries discussed repeatedly. Here’s the thing, I just described a lot of NORMAL 3 yr old behaviors! Most 3-5 year olds have short attention spans, need repeated instructions, struggle with transitions from preferred to non preferred activities and can be impulsive! She was counting, knew her shapes and colors, had an awesome vocabulary, loved books and learning and was very social! We weren’t getting concerns from teachers, so we were not worried.

It wasn’t until the 2nd half of kindergarten that a teacher expressed significant concern and we were noticing increased negativity toward going to school, complaining of headaches, increased meltdowns at home and with relatives. She was getting redirected frequently at school to try and keep her on task, and she was trying so hard to behave and focus and learn that by the end of the day she was totally spent. Despite our best efforts to make sure she was getting quality sleep, eating a nutritious diet and getting plenty of physical activity and limiting screen time, she was still struggling. I had a consultation with a child psychologist and ultimately got her evaluated through her pediatrician, which confirmed she had combined type (both inattentive and hyperactive/impulsive) ADHD. School was becoming such a negative association for her and we were worried it was affecting her learning, so we decided to trial medication to help her focus. Full transparency … despite being a pediatrician who prescribes ADHD medications for my patients on a daily basis when I’m in the office, this decision was SO hard at the time. Part of me thought “am I doing this to make it easier on us?” while the other part thought “I’m so afraid of the cumulative effects of ongoing negative interactions, frustrations, poor self esteem, school anxiety, etc”. Ultimately, we tried a medicine. It helped her focus, but she wasn’t gaining weight and she would have pretty significant rebound symptoms when the medication wore off after school, so we decided to try something else. Over the next few years we ended up trying different forms and doses of methylphenidate. Stimulant medications are the most widely used medications to treat ADHD. We tried short acting, long acting, capsules, liquid … by working with her doctor, we tweaked doses to minimize side effects and optimize her focus. This was frustrating! She’s sensitive to medication. It would feel like things were going okay for awhile, but then she would grow and change, and the work and expectations would increase, and then we would need to adjust something.

I know some parents have had negative experiences themselves or heard of someone else’s negative experience with ADHD medication. All I can say here is that if it was negative, then likely the medicine or the dose was the wrong fit. It is a process that involves patience and preparation for some trial and error. I am SO protective of side effects, and tell parents all the time:

“My goal is that your child feels like themselves, and that they can focus well enough so that they are able to learn to their full potential.”

Fast forward to 2nd grade … we were missing something. She has always loved books, but wasn’t reading with the same fluency or skill level as her peers, despite SO MUCH PRACTICE! We would read together every day. She would see a word 10+ times in a book, and we would help her with it, but then on the last page she still couldn’t read the word. She would flip some letters, but they were the usual ones that kids can flip a little later, and her spelling was tough. We had her evaluated for dyslexia and this diagnosis was also confirmed.

Did you know that approximately 50% of children with ADHD have a coexisting condition or coexisting learning disorder.

Through a combination of tutoring, parent training and behavior management, school accommodations and medication … along with efforts we have made in our home surrounding routine, sleep, activities, nutrition, checklists … I feel like we are managing. Some days and weeks are better than others. It is hard! BUT … she seems to be thriving at school, she LOVES to read and has made amazing progress, she works so hard and in general, she is a happy kid! We have had to change the way we thought we were going to parent, and we are still learning. Even though I’m a pediatrician and I have a lot of resources and knowledge on ADHD, it is still hard!

So here are the things I would want a parent to know while they are navigating the process of evaluation and then management and treatment options.

*Also, please BOOKMARK this resource: It is SUCH a comprehensive resource list: ADHD Toolkit for Parents & Caregivers - Resource Links via Chadd.org.

Step 1: Call your pediatrician and schedule an appointment to have a conversation about your concerns especially if they have been present for >6 months. IF they feel an evaluation for ADHD is warranted, they may have you and your child’s teacher(s) fill out some assessment forms. These are the Vanderbilt Assessment forms for Parents and Teacher that I use for kids AGES 6-12. If your child is >12, they may need an evaluation through a psychologist and/or a Conners ADHD Rating scale can be used. Diagnosis after the age of 12 is a little trickier, because symptoms should be present at younger ages but maybe didn’t cause impairment in function until an older age, and because anxiety and/or depression can sometimes look like ADHD, but also sometimes they coexist. Once the forms are filled out, most pediatricians will have you come back in for another appointment to discuss results and next steps.

Step 2: Discussion of diagnosis, management and treatment options. I generally focus on the following:

• Education on diagnosis

  • This includes educating the child! My explanation typically goes something like this:

    • “After talking with your parents and teachers and looking at some information about the way your brain works, we figured out that you have something called ADHD. It means that your brain works differently than some people, but I know a LOT of other kids and adults who have ADHD too! It does NOT mean that you aren’t smart … in fact, most people with ADHD are super smart! It means your brain can work really fast, and when it moves too fast, it can make it easy to forget, or to get easily distracted, or make it hard to focus on things. But the cool part of your brain is that if you LIKE something, it actually makes it a lot easier to focus on it (like Legos, sports, art or music for example). But we also have to be able to focus on things we don’t always like, so this can make it frustrating. Sometimes another part of ADHD is being impulsive or having a hard time controlling our body or brain. Sometimes we say or do something before we really think about it, but it’s harder to control. This might look like blurting out an answer before we are called on, or interrupting other people when they are talking, or getting out of our seat before we are supposed to. I want to talk about some of things we can do to help so that you are able to learn and have more control, or not feel too frustrated.”

  • Understanding ADHD and/or Causes of ADHD- HealthyChildren.org and

  • About ADHD - Chadd.org

  • ADHD - What you need to know - National Institute of Mental Health

• Parent training and behavior management

  • Parent training will help you understand your child’s behaviors and target them through clear and consistent directions and limits. It will help you understand effective positive reinforcement systems as well as discipline and behavioral techniques.

  • Our local Children’s Mercy Hospitals and Clinics offers Behavioral Parent Training groups that I commonly recommend if you have a 3.5-5 y/o or 6-12 y/o with ADHD, virtually for KS and MO resident families.

  • There are on online education resources for parents at Chadd.org

  • Check with your pediatrician for recommended therapists or counselors

• Discussion of medications

  • Not ALL kids with ADHD need medication if their symptoms are mild, they are keeping up in school and they are happy and feeling good socially and emotionally. However, if they are struggling in school despite behavioral management or accommodations, they are having regular negative experiences that are affecting their self esteem, having school or social anxiety, or it is affecting their quality of life or causing health risks, I think medication should be part of the conversation.

  • The most common medications to try first are stimulants, which may including methylphenidates (like Focalin, Concerta, Ritalin, and others) or amphetamines (like Adderall, Vyvanse, and others). These medications help to increase certain neurotransmitters in their brain known as dopamine and norepinephrine. Our brains use these neurotransmitters to help improve focus and attention, help control impulsive behaviors, help decrease hyperactivity, and can help improve executive functioning (EF will have its own post in the future!). These medications come in various forms:

    • Short acting: start working within 20-30 min and wear off within 3-4 hrs

    • Long Acting or Extended Release: start working within 30-60 min and wear off within 6-10 hrs

    • Liquids, Capsules (that can be opened and sprinkled onto applesauce), Tablets, Patches

    • Some people only take medication on school days, but I would argue that mild side effects generally subside the more consistently they take the medication, and for kids with moderate to severe symptoms, are likely to benefit from weekend dosing, too.

  • There are also some non-stimulant medications: Intuniv (guanfacine), Strattera (atomoxetine), clonidine, Qelbree. These can be used alone or in combination with a stimulant to help manage symptoms. There are also short acting and extended release versions of some of these, but most of these meds are taken every day and may last 24 hours, and may get to a steady level in the body after a few weeks. I think about using or adding non stimulants in my patients who do not tolerate stimulants because of side effects, who have a lot of impulsivity, and/or have significant sleep issues.

• Academic accommodations

  • I write notes all the time for families to bring to school, indicating a diagnosis of ADHD has been made and to provide accommodations as needed. I recommend a meeting is scheduled with teacher and school staff such as a school psychologist or special education director to discuss a plan. Kids who have a diagnosis of ADHD may qualify for an IEP or 504 plan (both are accommodation plans) through the public school district. Please see this information on Educational Rights. If you child attends a private school, they may still qualify but often private schools have staff support to develop a special education plan that is similar.

  • Common classroom accommodations include extended time for test taking, testing in a separate environment to minimize distractions, one on one or small group time for instructions/assignments. See other Classroom Accommodations at Chadd.org OR School Accommodations from HealthyChildren.org

Step 3: Things you can do at HOME

• Prioritize the following:

  • Good sleep hygiene and routine

  • A balanced diet and supplement essential nutrients if unable to achieve a balanced diet (I have another post How and What to feed our kids that includes essential nutrients or supplements to consider)

  • Regular physical activity

  • Homework help for ADHD tips

  • Special one on one time: try to set aside a few minutes each day for special one on one time with your child that involves positive interaction, focus on and praise the positive things they have done that day and always remind them how much you love and support them, no matter what.

The most important thing to remember is that you are not alone in navigating the world of parenting a child with ADHD. Focus on reliable, evidenced based websites and resources and do not forget to talk with your pediatrician to get personalized advice! I promise there will be more posts on this topic!

That’s it for now. Keep it real!

Kelsey Ragsdale, DO

Remember those days before kids where we could stay up late on a Friday but sleep in on a Saturday, binge study for a test or stay up late getting extra work done and only get 3-4 hours of sleep but it was okay because we could “catch up” with a nap or on another night, or actually get 1 hour of extra of sleep during daylight savings when the clocks “fall back”? … Barely. Were those days even real?

*FYI, this is a LONG post! If you want the highlights and don’t care to read about my sleep journey, scroll down and catch the ALL CAPS tips or links below! You will find info about healthy sleep routines, how many hours of sleep kids need, and information about melatonin and how low iron stores can impact sleep.

In full transparency, I feel like my sleep journey as a pediatrician mom has been a humbling one.

When my oldest was a baby, she was a cat napper who had a very small window between tired and overtired. We did some sleep training around 6 months. I had been holding her to sleep at bedtime because I had such bad mom guilt from not getting to see her during the day while I was at work and she was at daycare. Then she was exhausted by 5:30 pm because she had taken a few 20-30 min naps all day (total FOMO baby!). I knew that we all needed better sleep, and after a few rough nights of letting her cry so that she could learn to self soothe to sleep, we were able to break the sleep onset association we had developed by holding her to sleep.

At the time (2015), I read the book Healthy Sleep Habits, Healthy Child - by Marc Weissbluth, MD. I learned that an overtired baby is going to fight sleep more and have more interruptions in their sleep cycles at night, and so we started putting her to bed EARLY (most nights it was a 5:30-6 pm bedtime)! I will say, this is still ONE OF MY BIGGEST SLEEP TIPS FOR BABIES that I give around 4 months IF they are not getting restorative naps (consistently less than about 40-45 min) … Move the bedtime earlier so that they are less overtired when you put them down. This was so hard as a working-outside-the-home parent. I would try to leave work early so that I could be with her for even 1 hour before she would go to bed. However, once she started sleeping 12 hours a night, my anxiety and guilt slowly started to improve. I knew she needed that sleep for growth and development! And I knew (with reminders from my colleagues), that it was a phase and that eventually she would nap better, get older, and I would get more time with her in the evenings.

My oldest was 23 months old when we had our 2nd, and you guys, our 2nd was THE DREAM baby. I don’t remember having to let her cry or sleep train because we were diligent about making sure she had opportunities to fall asleep unattended between 2 and 4 months and she figured it out.

TIP FOR INFANT PARENTS: That 2-4 month window of time is the best time to be giving babies consistent opportunities to self soothe to sleep - putting them down sleepy but awake, not overtired, in an environment primed for sleep (no movement, dark, crib, on their back, sound machine if needed). Start with this for bedtime and the first nap of the day, but it won’t happen every time! Just keep trying.

HealthyChildren.org - Getting your baby to sleep

I can confidently say, when it comes to sleep, I think some babies are just GOOD and EASY babies! Some babies require a little more structure, consistency, intention and work. Some babies require A LOT of these things. Plus, there are so many variables that can affect their/our sleep: illness, teething, reflux, travel, stress, etc, etc, etc.

Sleep Training Info - by Dr. Craig Canapari, MD

Don’t get too annoyed with me for bragging about my 2nd. When she was 27 months old, we had our 3rd, and you guys … our 3rd was my WORST sleeper! (let’s just say he didn’t sleep through the night consecutively until after 11.5 months old!) Looking back, I know there were several factors that contributed. First, I was pretty sure he was going to be our last baby from the beginning (but the poor sleep may have sealed the deal), and I think I got cocky … thought my 3rd would be flexible because he had to be, thought ‘I’m a pediatrician and seasoned mom … I got this’. Then, remember what happened in March of 2020 when he was about 4 months old?

To say 2020 was a stressful year is the understatement of the century. I was working full time, coming home and sneaking in through our basement to shed my work clothes and shower before the kids could touch me because I was so afraid I would bring something home to my family. Also, TWO of our children had surgeries that year. My oldest was diagnosed early onset scoliosis, a Chiari malformation at the base of her brain/skull, and a syrinx (cyst) in her spinal cord. My youngest finally started sleeping through the night the month before her big surgery. I believe in divine interventions, and I think this was one of them! My memories of sleep training are blurry from that year, but I do remember that by 4-5 months he was able to go down easily at bedtime (thank you, thumb sucking), but it was the middle of the night wake ups that we had a hard time getting rid of! I think I was so stressed and exhausted that I would do whatever it took to get him back to sleep the fastest, which was feed or hold him, and he came to expect this and rely on one of us to get back to sleep.

As they get older, sleep changes SO MUCH and SO FAST! They go from 4 to 0 naps in the first 4 years (ish). As soon as you feel good about being in a rhythm, they change, or life happens. Oh, and they get REALLY GOOD at manipulating bedtime by the ripe age of 2! I always felt like it took ONE night of letting them stray from the routine OR we accidently fell asleep lying in bed with them (from pure exhaustion), and suddenly we had to retrain them to not expect that every night. We have used bribes and positive reinforcements and probably threats. We’ve done the things you read not to do, but we always try to get back to the things we are supposed to and the HEALTH SLEEP ROUTINE BASICS:

1. Have a routine and be consistent: bath, jammies, brush hair and teeth, read, sound machine on and lights off, kisses goodnight.

2. Try and have a calm and comfortable sleep environment.

3. Model good sleep routines and show your kids that you also prioritize good sleep (I’m not always great at this one!)

4. AVOID THE OVERTIRED KID!

5. AVOID screens at least 1-2 hours before bed. I think there are kids out there who get a short show every night before bedtime at part of their routine, and are still great sleepers, but if that’s not your kid, then cut out the pre-bedtime screens.

6. Get them outside and keep them physically active! But also beware of overscheduling their evenings with activities.

See HealthyChildren.org for more Healthy Sleep Info! The link includes great info, but also the chart below, which I love because I get asked about this all the time!

Our youngest still wants us to stay in the room until he is asleep. We agree to sit for a few minutes and explain that after those few minutes, we have to leave to go do our own task (laundry, shower, etc), but we agree to stay upstairs and come back and check on him after. I’m going to be honest, even a few months ago we were still sitting or laying in his room until he was asleep. And it still occasionally happens. And he still occasionally sneaks into our room in the middle of the night.

So I think it’s obvious, we have not done the sleep thing perfectly. It is hard to adjust and be consistent when you yourself are tired. Plus … LIFE happens! We are all doing the best we can, but this is meant to give some perspective and information, or if you feel like your current sleep situation with kids is not sustainable and they are not getting the sleep that they need!

Now let’s talk about MELATONIN! Another topic I get asked about ALL THE TIME.

First of all, know that the most data we have on melatonin use for kids and in children and teens with Autism and/or ADHD. To really understand some very helpful and comprehensive information about how melatonin works and the data behind it, please check out: Melatonin for Children? A Guide for Parents - by Dr. Craig Canapari, MD

Second of all, is melatonin safe to use? In general, yes, it CAN BE SAFE! But like all things, there can also be possible risks - including:

• The risk of overdose in kids has increased >500% in the last 10 years

• There are typically mild side effects that most commonly include morning drowsiness, bedwetting, headache, dizziness, nausea

• The FDA regulates it as a food supplement, so it does not have as much testing as a medication would have. There have been concerns about inconsistencies with dosing, labelling and absorption. ***If possible, try to get a USP Verified preparation.

• Long term? We don’t have a lot of studies out there, but there was a study released by the Journal of American Academy of Child & Adolescent Psychiatry in 2021 that looked at 80 children with autism spectrum disorder taking prolonged release melatonin for insomnia. The study followed them for 2 years and did not show any evidence of effects on weight, height, body mass index, or pubertal development.

So have my children taken melatonin? Yes. Mostly, my child who has a diagnosis of ADHD. My other 2 have had it but do not get it consistently. We have used it for all 3 during/after travel or sometimes for a week after daylight savings. My daughter with ADHD get 0.5 (occasionally 1 mg) within an hour of bedtime almost every single night. We have tried it earlier, but for some reason, it seems to work the best for her if we give it before brushing teeth and reading books. This has helped her fall asleep at least 30-45 minutes earlier than she would without it, despite consistent routine, limiting screens, and good physical activity. Sleep is so important! This is a risk benefit decision we have made with the help of her own doctors. Currently, we feel there is lower risk and greater benefit given her dose and her experience! Will she need it forever? I don’t think so. But for now, I figure 0.5 mg does not seem to have any side effect and she has been on it for >5 years with no notable issues. We have not noticed issues with growth or early pubertal development. If you have a child with ADHD, ASD or insomnia concerns - talk to your pediatrician. Also, educate yourself with the resources I have linked, including this Melatonin Dose Calculator by Dr. Craig Canapari, MD.

Now let’s talk about IRON! *THIS IS A COMMON ISSUE I SEE IN MY CLINIC

I mentioned in my last post that low iron stores (ferritin) is one of the most common nutritional deficiencies that I see in kids. This is how it comes up:

I have a parent come in with their child, typically anywhere from a young toddler to an early elementary aged child, and they tell me that their child is:

• waking up on a regular basis in the middle of the night or

• they are having frequent nightmares or night terrors or

• they toss and turn at night or

• they wake up and complain of their legs hurting on a regular basis but then are active and not limited by leg pain during the day

Then I ask if their child eats red meat or other iron sources (dark poultry meats, beans, green leafy vegetables, iron fortified cereals) on a regular basis? *I also ask about snoring, sleep routine and habits, etc. Often times, the child has not consuming good iron sources on the regular. If the sleep issues are really disruptive, I will often recommend we check labs, for 2 reasons:

1. If they are not consuming good iron sources and not sleeping well, could they also have iron deficiency anemia? so we may need to check a complete blood count.

2. If their ferritin level is truly low or suboptimal, it tells me that I may need to recommend a higher dose of iron supplement to increase the level to a more normal/optimal range, which will OFTEN improve or resolve their symptoms and sleep.

If the sleep issues are not super consistent or disruptive, I may just suggest an iron supplement without checking labs, because I know they aren’t getting enough in their daily intake, and see if this improves the intermittent symptoms. If it doesn’t or if the symptoms worsen, labs may be needed to determine if a higher dose is needed.

Mayo Clinic - How much Iron do kids need at baseline

Shoot, I thought I was done but I KNOW there are people who are wondering about MAGNESIUM, so here is a link to help further your education and a quick blurb.

*Most kids do not need magnesium supplements to help them sleep. Don’t do lotions with magnesium, absorption is variable. HOWEVER, it should be discussed IF your child has conditions such as: obesity, celiac disease, or type 1 diabetes OR extremely picky eating habits (including kids with ASD who have really restrictive diets) OR ADHD

Magnesium for Kids' Sleep - by Dr. Craig Canapari, MD

Hopefully this has made SOME of the sleep information out there feel a little more clear and a little less confusing.

That’s it for now. Keep it real!

-Kelsey Ragsdale, DO

***Links to sleep related products

*Disclosure: As an Amazon Associate I can earn from qualifying purchases at no extra cost to you.

REMEMBER! Good sleep hygiene and routine are the PRIMARY WAY to ensure successful sleep patterns in most kids. Here are a few things that may be considered after talking with your pediatrician!

It’s Never Too Late to Sleep Train Book - by Dr. Craig Canapari, MD

Blackout Curtains

Sound Machine

Liquid Iron (15 mg) for infants and toddlers by Nova Ferrum Yummy!

… also comes in Chocolate flavor (I have not tried it this flavor, but have had patients give me good reviews)

Celebrate Iron Chewable 18 mg

Celebrate Iron Cherry Chew 45 mg (2/3 of my kids like this kind!)

Slow Fe Iron tablets 45 mg

Children’s Chewable Melatonin (1 mg) by Zarbee’s

*At this time, I don’t recommend magnesium because the evidence is not as strong in kids compared to adults and the forms and doses are less reliable.

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I could talk (and write) about food and our kids’ interactions with food, literally, for days and days! I promise to make this as straightforward as I possibly can, and I promise you will get more on this topic in the future. So where to start:

Start young, be consistent and persistent

When I talk about feeding your baby food starting around 6 months of age, there are only a few rules I give parents (SKIP THIS SECTION IF YOU HAVE KIDS >12 MONTHS):

1. No honey until 12 months! (There is a risk of botulism, which is a toxin that can attack our nerves, and their guts are too immature to protect them from the toxin spores, even in small amounts).

2. No choking hazards! Food needs to be either pureed OR soft and small, easily squished between 2 fingers. I love giving this resource to families:

   Solid Starts App: helps parents determine how to offer different foods safely based on the age of the baby. Solid Starts App

3. Introduce one food at a time. Give a small amount daily for at least 3 days in a row before the next new food. This way, if they have a reaction to a food, we know which one caused it. (From experience, when it’s your 3rd kid, inadvertently more combinations are given earlier. If they have a reaction, then we backtrack to figure it out, it’s not the end of the world!)

4. Introduce all those high risk allergen foods! In our office, we talk about “the big 6!”: eggs, dairy, soy, peanut, tree nuts, fish. Delaying introduction of these foods does NOT prevent food allergy. However, talk with your pediatrician if your baby has severe eczema or egg allergy because testing for peanut allergy may be recommended.

5. Your goal by 9-12 months is that your baby has been exposed to a large variety of foods with different tastes, textures and colors is practicing with finger foods. They should be having food 3 times per day and eating some of the same foods you are eating (but maybe deconstructed versions so that they are not choking hazards) and including more balanced meals at breakfast, lunch and dinner.

Check out HealthyChildren.org and their article on introducing solids for more information on this stage of feeding!

WHAT NUTRIENTS DO ALL KIDS NEED?

SEE a few PICKY EATING TIPS BELOW!

I focus on the following:

1. Calcium and Vitamin D: These are necessary, and go hand in hand, working together to build strong bones as our children grow. Starting at 1 year, we recommend 3 servings per day (8 oz is a serving). This is total, so including milk, yogurt, cheese, or dairy alternatives that are fortified. Talk with your pediatrician if your child does not consume dairy or fortified alternatives! ALSO, KEEP THIS IN MIND: Too much dairy/calcium blunts our body’s IRON absorption, so AVOID excess dairy. I tell families no more than 16-20 oz of milk per day if your child also consumes yogurt and/or cheese most days.

2. IRON: This is a big one! Our blood needs iron to support a healthy hemoglobin, which is what helps carry oxygen to all of our cells and gives us energy. Low hemoglobin (=Anemia), can cause paleness, fatigue, pica (eating paper, ice chips, dirt). I would say Iron and Vitamin D deficiency are the most common deficiencies that I see. See this Mayo Clinic article that shows how much iron kids need at different ages. Most teens need around 15 mg of iron per day, with girls needing a little more because they are losing iron when they have periods. Teens involved in sports may need closer to 25 mg per day. If your child gets tested and their ferritin (a lab marker of iron stores) is low, your pediatrician may recommend even higher doses based on their weight! HealthyChildren.org - Iron

   IMPORTANT NOTE: The most common clinical symptoms we see in kids from low iron stores is fatigue, restless sleep and frequent complaints of leg pain. If you have a kid who wakes up in the middle of the night on a regular basis, sleeps like a crazy person tossing and turning, complains of leg pain regularly or is more tired compared to their peers and/or more pale … it is definitely worth talking to your pediatrician about whether labs are needed.

3. Fruits & Veggies: We should be offering 5 servings per day to our children. That means one at breakfast, and 2 at each lunch and snack or dinner. Will they eat all of them? Maybe not. BUT, they are an important source of fiber and vitamin C, A, potassium, folate which have life long health benefits!

   MyPlate - Veggies and MyPlate - Fruits

   1. TIP: For infants and toddlers who do not seem to like a fruit and/or veggie, be persistent with LOW pressure offerings (even just a 1 tsp offering on their plate … so that it doesn’t make too much of a mess when it ends up on the floor), and talk to your pediatrician about giving a daily Multivitamin if they are very limited on their intake.

   2. TIP: For 2.5 year olds and older - I LOVE to recommend ***kid safe knives and fun utensils or food shape cutters and their own cutting board so that while you are prepping dinner, they can sit in the kitchen with you and take sliced up fruits or veggies and practice their shopping/cutting skills. This helps fine motor skills AND it provides FUN INTERACTION with food that they may or may not be thrilled to put in their mouth … and it may help their willingness to try it because they have control over it. My other tip for kids who can use utensils (18 mo+) is to have them help feed YOU your fruits or veggies on your plate, and be sure to turn on your theatrics to show how much you are enjoying the taste! (wink wink)

      (*** links to these products below)

   3. TIP: For school aged kids, I like to teach them about their Taste Buds. I talk about how when you start losing teeth and getting new teeth and going through growth spurts, your taste buds can change “at lightning speeds” … WAY faster than parents’ taste buds. BUT, sometimes we have to do science experiments to figure out if our taste buds have changed yet or not. I also like to suggest a family taste testing GAME. Everyone sits at the table with a food presented 3 different ways (example - raw broccoli w/ ranch as a dip option, steamed broccoli with cheddar cheese, and roasted broccoli). Each person tries a tiny bite of each type, then votes on which one was their favorite and which was their least favorite, or maybe ranks each one with a thumbs up, medium, or down. You can compare how different people in the family have different taste preferences. ALSO, let them learn how to help cook in the kitchen. The ONLY way they will learn, is with practice with you and/or other caregivers. I could do a whole post about the skills gained by kids in the kitchen: mental, physical and emotional skills!

   4. TIP: Older kids. Again. Get them involved in planning and cooking the meals!

4. Protein: Yes, our kids need protein. However, they don’t need as much as you may think. Some studies suggest that most kids in the US get over twice the amount of protein their bodies need. The National Institute of Medicine has a good chart, but this is what you need to know for their daily needs:

   Ages 1 to 3: 13 grams

   Ages 4 to 8: 19 grams

   Ages 9 to 13: 34 grams

   Females age 14 to 18: 46 grams

   Males age 14 to 18: 52 grams

Now, let’s talk about just a few of the things to monitor to avoid excess and to have in moderation.

1. Added Sugars: On average, the goal should be to keep ADDED sugars to no more than 25 grams per day. Pay attention to your yogurt, cereals, processed snack foods here. These added sugars can add up so quickly. See HealthyChildren.org for more tips here!

2. Saturated fats: I talk to parents more about this if I know there is a family history of high cholesterol. See HealthyChildren.org for more details on Fat, Salt and Sugar

3. Salt: Too much salt on a chronic basis can cause high blood pressure which can contribute to risk of stroke and heart attacks as we get older. We do not keep salt shakers out. If our kids request salt to be added to food, we will let them get a pinch of sea salt or kosher salt.

I know that feels like a lot. What I’ve learned over the last 10+ years of parenting, is that I can’t be perfect and I don’t have control over what my kids eat. I DO have control over what they are offered and available to them at home, so I strive for some balance here. Also, kids go through phases. One week, I will think one of them is being so adventurous with their eating while another is being so picky, and then a week or so later, they will flip. One of my kids eats like a hobbit in the mornings (so many breakfasts) but then hardly eats at dinner time. He is growing, so I don’t worry too much.

In my medicine cabinet, I have iron supplements, a multivitamin with iron, vitamin D, and Omega 3 fish oil supplement***. I do not give any of these daily because I don’t have super picky eaters on the regular. However, I do give them as needed. If I had extremely picky eaters with limited variety of food groups on the regular, I would be more consistent with a multivitamin with iron and fish oil daily. The iron and vitamin D are the 2 that I give my kids most often. In the winter, I give vitamin D more often because I know they aren’t getting as much sunlight, and some weeks I worry that their iron intake isn’t enough.

I’m working on a future post about a list of 26 easy and balanced meals (for 2026), that our family is using to help meal plan this year. Every weekend, each member of our family picks 1 meal off the list which gets us 5 out of 7 dinners for that week. My current goal is to have the kid who picked the meal for that night help with cooking the meal while the other 2 kids are in charge of helping with dishes/clean up and setting the table to give more structure to how we are assigning chores and tasks, and to make sure our kids are practicing their cooking/meal time skills each week. I realize there will be some seasons of life where it is harder to all be home at the same time in the evenings for dinners, but I’m hoping with a little planning ahead and flexibility, we can maintain our family meal times (mostly) together.

Good luck to all the caregivers out there! Feeding kids is not for the faint of heart!

Real Kids’ Health: Recommended Kid Friendly Kitchen/Feeding Products and Nutritional supplements

*Disclosure: As an Amazon Associate I can earn from qualifying purchases at no extra cost to you

Recommended Supplements:

*AS ALWAYS, DOUBLE CHECK WITH YOUR PEDIATRICIAN IF YOU AREN’T SURE HOW MUCH YOUR KID NEEDS based on the resources and information shared in my post.

Vitamin D for Baby (Ddrops) 400 IU

Vitamin D for kids (Nordic Naturals) 400 IU (I know, this is a gummy

Vitamin D for kids (Renzo’s) 1000 IU (chewable, I would cut these in half if you are looking to avoid a gummy)

Calcium/Tums 750 mg

Celebrate Iron Supplement - Chewable 18 mg

Celebrate Iron Supplement - Cherry Chew 45 mg

Slow Fe Iron supplement - (if your kid/teen can swallow pills)

Multivitamin w/ Iron … good old Flinstones’

Omega/ Fish Oil supplement

Recommended Kid Friendly Kitchen Products

Kids’ Chef knives - Kuhn Rikon (we have had this set since my oldest was 2, and my kids still use them!

Kids’ Food Shape cutters (cookies, sandwiches, veggies, fruit) - great for toddlers!

Fun construction utensils

Fun Food Picks

Tot Grape Cutter OXO

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Hello and Welcome to Real Kids’ Health!

I am Dr. Kelsey Ragsdale, a general pediatrician in Kansas City. My most important titles to know me by include Mom of 3 (2 girls and a boy, ages 10, 8 and 6 as I’m starting this), Wife, Daughter, Sister, Friend. I am writing to share evidence based information, reliable resources, links to products that may be helpful and experience as both a mom and pediatrician. The posts I write are for general information, not for personal medical advice.

Topics that are near and dear to me:

1. Nutrition

2. Sleep

3. Allergies and Asthma (two of my kids have these)

4. Scoliosis (my daughter has a rare form that was diagnosed when she was 5!)

5. ADHD and learning differences (my daughter also has ADHD and Dyslexia)

6. Anxiety

7. Pediatric Obesity

8. Constipation

1. Why now? Why here?

I have been in practice for almost 12 years. My 20s were an educational grind. I got married in 2013, graduated residency and joined a private practice in 2014. My 30s were a blur. My husband and I were busy having 3 babies in just over 4 years and juggling all things parenting while keeping up with my busy pediatric practice and his busy finance career. I turned 40 last year, and felt a distinct shift in myself … like I can and want to have more time for my personal and professional goals and priorities. Of course I still have our family and parenting goals and priorities, which is why this felt like the place to start sharing.

My clinic time is 80-90% full time with call. Most of my routine well visits for patients are only 20 minutes! This is a frustration for many pediatricians, because of ALL the preventative and anticipatory advice there is to be given, in addition to addressing questions and concerns. there just isn’t enough time. I also cannot nor do I want to take the time to share information via multiple posts per day/week on social media platforms. BUT … I REALLY REALLY want to share more of my experience alongside good quality pediatric evidence, information and advice.

2. This Community

My goals for this community:

TRANSPARENCY!

SUPPORT!

EDUCATION!

BALANCE!

HUMOR!

KINDNESS!

3. What and When?

I will be writing about pediatric nutrition, feeding our families, tips and tricks. I will write about common pediatric topics and diagnoses (see my list above, plus so much more!). I will write about what to look for, understanding the why, the what to do or remedies for at home, and the when to call your pediatrician. I hope to be posting once a week, on average, because life is busy!

Free subscribers will get:

• weekly posts

• links to evidence based resources

• links to specific commonly recommended products that may be helpful in addressing common pediatric issues

Paid subscribers will get:

• weekly posts

• links to evidence based resources

• links to specific commonly recommended products that may be helpful in addressing common pediatric issues

• PLUS resources I am developing which may include meal plans, guides, checklists, action plans that you can download or print

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