A note to our followers


I would like to thank our regular follows and apologize for the delay in publishing a new post. Both Dr. Brewer and I have been busy over the last month. I opened a new pediatric practice and Dr. Brewer welcomed a new baby girl to her family.

Thank you for your patience and support.

Dr. Heather Joyce

It is Safe to Play Outside in this Heat?

We all know about the scorching temperatures across the country. Even here in Denver where it’s relatively mild until August, we’ve already been dealing with 100 degree heat!

Every year there are heat-related deaths on the sports field.  This happens particularly in August when the heat is at its worst and fall related sports are getting into full swing.  How does this keep happening you ask?  Well … state high school sports associations have been slow to adopt rules to make practices safe in extreme heat (although things are dramatically better than they used to be).  And of course, kids sports prior to high school age are often not legislated at all in terms of rules regarding practicing/playing in the heat.

So when does it become unsafe to practice outside?  And what precautions should be taken? Generally, when the heat index (which takes into account relative humidity) climbs above 100, practicing and playing outside assumes a much larger risk of dehydration, heat illness, and heat stroke.  When the heat index is 90-100, ample water should be provided, and athletes should have unrestricted access to it (for example, there shouldn’t only be one water break per practice).  And the heat index should be re-checked one or more times during a practice or game if the heat index is approaching 100.

If the heat index is 100-104, you should begin to think about canceling outdoor activities.  Water breaks should be mandatory every 30 minutes, and toweling down with ice cold towels should be encouraged.  And when the heat index is 105 or above, play or practice should be stopped and moved inside.  Two-a-day practices (common practice in fall sports like football) should be reconsidered when the heat becomes an issue, and certainly, practicing when it is cooler earlier in the morning is a smart idea.

What are the consequences or the heat and how do athletes get in trouble?  Severity of heat related medical problems ranges from dehydration, to muscle cramps, to heat exhaustion, to heat stroke.  With each step, an athlete gets progressively sicker and important attention needs to be paid to an athlete progressing towards heat stroke.  The biggest indicator that an athlete is headed toward trouble is if he or she starts acting abnormal (aka altered mental status). They may become combative, aggressive, and clearly not act like themselves.  If medical personnel are available at that point, the athletes temperature should be taken and they should be immediate immersed in an ice bath if possible.  And call 911!

The heat shouldn’t be ignored when your child is playing a sport outside. As a parent, you definitely have a role if you think limits are being pushed in play or practice!

Rachel Brewer, MD

Breastfeeding – Is it Safe to Exercise?

So … you’ve decided to breastfeed.  You also want to get back in shape following your baby.  While breastfeeding is a huge topic of conversation, there’s not as much talk about breastfeeding and exercise.   Here’s a few questions you may be asking …

Will baby refuse the breast after exercise?  You may have heard that babies don’t accept breast milk as readily after mom has exercised because of a buildup of lactic acid.  However, most studies have found no difference in acceptance of the breast, even after maximum intensity exercise.  Research has also not shown a noticeable increase in lactic acid buildup after moderate exercise.  Even with maximum intensity exercise where there is a minimal increase in lactic acid in breast milk, there are no harmful effects for the baby.  While there may be a change in taste of breast milk from lactic acid, babies will not subsequently refuse to breastfeed because of it.  More plausible reasons for why your baby may refuse to breastfeed after you exercise are issues such as the salty taste of sweat on your breast post-workout.

Is the composition of antibodies of breast milk affected by exercise?  Exhaustive exercise does cause IgA levels (a type of antibody) to decrease for a short amount of time.  However, these levels return to normal within an hour – a decrease in IgA levels in one feeding per day is not likely to be significant.  Moreover, moderate exercise does not affect antibody levels.

Is your milk supply affected?  In short, no.  In fact, some studies have shown that women who exercise regularly had a slight increase in milk supply.  However, if you exercise to the point of exhaustion, or train for an event such as an Ironman, your body may be depleted to the point where producing milk is its last priority.  Bottom line – moderate, regular exercise should not affect your milk supply.

What types of exercise are best?  There really is no “best” type of exercise for breastfeeding moms.  It’s really more about what you enjoy and what makes you feel good.  Because breastfeeding moms are a bit more top heavy, things like running may be more uncomfortable, but it can still be done with the right type of support/attire.

What attire provides the most support for breastfeeding moms?  The key to being comfortable while exercising is finding a good supportive bra that fits you.  I would suggest getting measured at a sports specialty store for women (e.g. Athleta, Title Nine, etc) so that you know exactly what you need.  It really does make a huge difference.  You can avoid the two sports bra routine if you find the right bra that fits you 🙂

Other tips …  Definitely try to breastfeed right before a session of exercise.  Clearly, this is more comfortable, especially for weight bearing activity like running.  You may develop plugged ducts if you  lift weights involving repetitive upper arm strengthening (if that happens, start with lower weight/reps).  And make sure you drink and stay well hydrated!!

Rachel Brewer, MD

Poison Ivy

A huge part of summertime fun is playing outside. Naturally curious, most children love to explore overgrown areas of the yard or park. Unfortunately, poison ivy thrives in these areas. The rash that develops after exposure to poison ivy is a contact dermatitis to the chemical urushiol and can usually be treated symptomatically with home remedies.

Prior to summertime excursions, look at pictures of poison ivy and teach children to avoid it. Tell your children to count the leaves on plants and look for the “three, almond shaped, sharp-teeth leaves” that are classic for poison ivy. Dress your child in protective clothing – long pants, shirts, and shoes with socks for outdoor adventures.

If  your child comes into contact with the plant and you notice prior to the rash appearing, wash the area well with soap and water. Remove the clothing that your child was wearing and wash it in hot water.

If the urushiol absorbs into the skin, a red, itchy, blistering rash may appear. It usually appears in straight lines because of the way the plant comes into contact with the skin, but may be diffuse and appear spreading. The rash does not spread with itching or breaking the blisters, but if your child’s skin comes into contact with urushiol again (from clothes/pets/repeat exposure), it will continue to spread. Urushiol will continue to occupy any surface if it is not washed off, including dead poison ivy plants.

Home remedies to try if your child develops a rash:

1) Cool oatmeal baths

2) Calamine lotion

3) Vaseline

4) Cool compresses

If itching is severe and keeping your child from sleeping you may try diphenhydramine (Benadryl) or 1% hydrocortisone cream to the red areas.

The rash typically lasts 1-2 weeks, but may last as long as 8 weeks, depending on how your child’s skin absorbs the urushiol and reacts to it.

The rash may become infected with bacteria if you child is itching it, so seek medical care if they develop fever, yellow or white drainage, yellow crusting, severe swelling or warmth to the area. Also, your child may require strong antihistamines or oral steroids if the rash spreads to the face, mouth, eyes, genitals or involves the entire body.

Heather Joyce, MD

Water Safety Tips

Summer is almost here!  Once Memorial Day hits, pools around the country will be filled with young children.  The number of children drowning skyrockets during the warmer months.  Since the beginning of the decade, an average of more than 800 children 14 years and younger have died as a result of unintentional drowning each year.  Also, during that time span an average of nearly 4000 children sustained near drowning-related injuries each year.  Follow these tips to keep your kids safe around water.

*In-ground public pools are not the only places that drownings tend to occur.  Pools that pose the greatest risk of entrapment are children’s public wading pools, hot tubs, or other pools that have flat drain grates or a single main drain system.  Teach your kids never to play or swim near drains or suction outlets.  Install protection to prevent entrapment if you own a pool or hot tub.

*Actively supervise your kids around water at all time.  Even if it is just a small wading pool in your backyard.  Have your cell phone nearby to call for help in an emergency.

*If you own a pool, make sure it has a four-sided fence and a child-proof gate to prevent a child from wandering into the pool area unsupervised.  Hot tubs should be covered and locked at all times when not in use.

*A door alarm to a pool area comes in handy to alert you if a child does wander into a pool area unsupervised.

*Teach your children never to go near a pool or body of water without you or an adult present.

*Teach your children how to swim … whether this is through swimming lessons or you showing them skills, it’s important to teach kids how to tread water, float, and swim to shore or the edge of the pool if needed.

*Learn CPR.  If you learn it and are prepared, you’ll likely never need it.  Don’t find yourself unprepared in an emergency situation.

*If you are gearing up to head out to the lake or another body of open water, always have your child wear a life jacket approved by the US Coast Guard.  The life jacket should fit snugly and not allow the child’s chin or ears to slip through the neck opening.

And here is a great resource of water safety and tips on preventing all types of injuries in kids.  Be safe this summer, have fun … and enjoy the water!!

Rachel Brewer, MD

A Potty Training Strategy

Potty training can be a very exciting or a very frustrating time for both parents and children. Making potty training stress-free is an exercise of patience for a parent, but does make the process easier in the long run. There are many options for potty training your child, but the real secret is consistency and perseverance. That being said, I do have a favorite method that stresses positive reinforcement with relatively quick results.

Step #1: Introduce the potty early (12-14 months). Let your curious toddler explore the bathroom, watch you or other siblings use the potty and get them a small potty to experiment with. Every time your toddler shows interest in the potty, give positive feedback with smiling, clapping, hugs/kisses (whatever makes you look silly and gets your child excited)!

Step #2: Start encouraging your toddler to sit on the potty without a diaper on. I do this before or after bath time, when they are already comfortable being naked. If they are resistant, then wait longer and try again. When they do sit on the potty or actually pee, increase the positive reaction to a full on party! Continue this step until they make the connection between the potty and peeing/pooping. Your child is physically ready to move on to Step #3 when they can go 2-3 hours with a dry diaper and they know (and can tell you) when their diaper is soiled.

Step #3: When you and your child are ready – meaning you have a few days at home, your child has made the pee/poop/potty connection, and is physically ready – you can start the real potty training process. Prepare to stay at home for 2-3 days and take away the diapers. You can keep your child naked or in “big boy/girl underwear” during the day. I suggest staying in a room with floors that are easy to clean during this time and only giving drinks with meals and snacks. Put your child on the potty every 1-2 hours and 10-20 minutes after eating or drinking. If they do go pee or poop on the potty, do the same as before and have a huge party or reward them with something they like, IMMEDIATELY. The first day, they will most likely have several “accidents”. When they do, calmly clean it up and take them to the potty. You will notice less “accidents” as the days go on and on the 3rd-4th day, most people can attempt outings without diapers. They do make plastic covers for carseats, which I suggest investing in!

Most children are not ready for naptime/nighttime potty training when they start daytime potty training. It is normal for some children to have nighttime accidents until late childhood. Make sure to explain to your child that diapers and/or pull ups are only for sleeping and underwear is for the daytime. I do suggest putting a waterproof mattress cover on their bed at this time, because some are ready and willing to try nighttime training out. You will know they are ready when they wake up dry most mornings. Make sure not to sabotage their efforts by giving drinks before bed!

If potty training is not going well and either you or your child is frustrated, buy another box of diapers and try again in 1-2 months. Do not pressure your child during this time and go back to positive reinforcement for exploring the potty. Make sure to save the real parties for the fantastic moments that they do go pee or poop on the potty!

Heather Joyce, MD


It’s that time of year again…itchy, red eyes, runny nose, sneezing and hives. Allergies make many children and parents miserable. The best treatment for allergies is allergen avoidance, so keep your children inside all spring, with the windows closed and the air conditioner on – IMPOSSIBLE! However, you can try reduce a child’s time outside and make sure not to run an attic fan/house fan with the windows open. There are many other treatments, but they all involve using medications. Antihistamines are still the best medications we have available to treat allergies. There are several available over the counter now. I typically recommend a trial of diphenhydramine (Benadryl), which means giving an appropriate dose every 6-8 hours for a couple of days and monitor for symptom improvement. If symptoms are better, your child may benefit from a long acting antihistamine. I do not recommend long term therapy with diphenhydramine (Benadryl), because it can cause sleepiness and adverse behavior effects on children. Long acting antihistamines include loratadine (Claritin), fexofenadin (Allegra), certirizine (Zyrtec), desloratadine (Clarinex). See your doctor before starting a long acting antihistamine, because they all have different and specific dosing for children of different ages. If your child has allergies and asthma, there is another medication available called montelukast (Singulair) available by prescription.

Treatments for specific allergy symptoms include:

Watery, red, itchy eyes:

– Use a cool, wet washcloth to soothe your child’s eyes and to keep them from rubbing

– Try an antihistamine eye drop, there are some available over the counter and others that are available by prescription

– Gently remind your children not to rub their eyes, this can lead to infection

Runny nose or congestion:

– Nasal saline several times per day

– Nasal steroid available by prescription

Rashes – hives or dermatitis:

– Cool bathes

– Cotton long sleeve clothing

– Vaseline or Aquaphor

Springtime is the best time to play outside. Allergies affect many children, but there are several treatments available to make life more tolerable when the plants and flowers are all blooming. Make sure to see a physician if your child develops difficulty breathing, wheezing, or severe eye swelling when their allergies flare.

Heather Joyce, MD