The last few weeks have been hard, to say the least. Although the new year brought hope that we would begin to look to a “return to normal” after one year of the COVID-19 pandemic, things haven’t felt so positive. It is only natural to yearn for what once was - allowing my kids to participate in group sports without the worries. To do in-person learning without the fear that we will receive an email indicating our child was exposed to the virus, and to go on a dinner date with my husband (to make up for the canceled date from last year as the lockdown and worries began).

In the last few weeks, losing my own grandmother to COVID-19 reminded me of all the families that have experienced a loss of a loved one in the last year. Although this happens routinely as part of the cycle of human life, I am reminded that there has been “extra” loss of life, and likely many more families impacted by loss than would have occurred otherwise.

The loss of a loved one is experienced at different stages for most. A difficult part of this process sometimes goes unnoticed but is worth highlighting. Being a parent and responsible with the difficult task of explaining death to a child in a way that is developmentally appropriate is not easy.

The best way to approach this situation is to be aware of how children understand death and this will help you pick the right thing to say. It’s important to remember that even young children who don't understand death will react to grieving parents. Older children will themselves grieve. Parents should support their children through this process in order to resume their lives without significant distress or interruption.

Children have a different understanding of the finality of death. Your approach to discussing death will depend on your child's level of understanding of four main concepts of death:

• Irreversibility (i.e., death is permanent)
• Finality (i.e., all functioning stops with death)
• Inevitability (i.e., death is universal for all living things)
• Causality (i.e., causes of death)

Babies and Toddlers

Infants and toddlers do not understand death but do sense what a caregiver may be experiencing. It is important to take care of yourself and progress through your own grief while maintaining routines that will help foster healthy progress through the life event.

Preschoolers

Preschoolers see death as temporary. They are concrete thinkers and usually see things for what they appear and hearing things literally. It is important to avoid euphemisms like, "She has gone to sleep," or "…traveled to the great beyond." Children at this age cannot understand these phrases and can sometimes even generate fears about traveling or sleeping. Be prepared for this age child to ask again and again where the deceased is and or when they will come back. Always answer with a clear message, which of course can be softened with the mention that the memories will remain. At this stage, children typically have a hard time talking about what they feel and their fears may come out at unexpected times such as during play.

School Age

School-age children begin to understand death as a final event but can have difficulties understanding it is universal. Make sure to offer clear, simple, and honest explanations about what happened and allow them to ask questions. Help them when they have difficulties finding the right words to explain their feelings. At this age, they may not understand the causality of death and they may personify death. Sometimes at this age, they may worry they will be left alone and begin to think about the death of a significant caretaker. Things that are important to do at this point include:

• Remind your child that not everyone who gets sick will die.
• Reassure them of your health.
• Let them know how many people in their life care for them.
• Support children to do things to reduce their anxiety and be sensitive that they may not want to talk or think about the deceased because it is too painful.
• Take care of yourself and make sure you have support.

Adolescents

Adolescents understand death the way adults do but can have difficulties or be resistant to expressing their feelings. They begin to think abstractly and this can cause some difficulties which can lead to risky behavior or even guilt about being alive. Supporting teenagers in finding healthy ways to express their feelings is very important.

Being aware of normal responses to death, as well as signs that they may need professional help, is an important part of supporting the grieving child. Younger children can revert to immature behaviors or angry outbursts. These typically are a result of unexpressed emotions such as frustrations or confusion. In school-age children, difficulties concentrating, sleeping, or physical complaints including stomachaches and headaches can occur. Teens often experience a wide range of emotions including sadness, anger, guilt, and helplessness. Teens may either withdraw or do the opposite, and engage in risky behavior.

This time is difficult for the entire family and it is important to take the time for yourself to deal with the grief. Kids of any age can sense the emotions of a caretaker and respond accordingly. If you ever have a concern that the child is experiencing extreme symptoms and/or the symptoms of grief are not resolving, ask your child’s pediatrician for help.

They were doing great, breastfeeding or taking a bottle and eating some solids but now what?!??! You're expected to change everything. First off, remember that if you plan to continue to breastfeed (which is awesome if that’s your choice!), some of this won’t apply to you but some of it will.

With everything else going on, I’m here to tell you it doesn’t have to be that complicated.

Here are my 5 simple rules for transitioning to milk at 1 year of age (and only two low-stress choices for you to make):

1. Remember that there’s nothing magical about milk.

Cow’s milk is an easy source of calcium, calories, and protein but if they are eating those things then they actually don’t have to drink milk at all. Especially keep that in mind when you make the change if their milk intake falls off. It’s OK. I generally recommend 18-24 ounces per day. This should be enough to get your baby some extra calories, but not be so much that it can lead to constipation. Also remember that yogurt and cheese have similar nutritional content so they can be included in the total as well.

2. Transition to a cup before 15 months.

The closer to 1 year that you can transition to a cup, the better. Hopefully you’ve been offering some water at meal times with a cup for a while. Don’t buy any large quantities of a cup until you find out what your baby likes. Put the cup in front of them, they’ll eventually drink.

3. Decide on a milk. You have some choices.

Remembering rule  No. 1, it’s OK to give yourself some flexibility in the milk that you choose. I’m not worried about cow’s milk or dairy intake as a general rule. Depending on baby’s weight, I am Ok with either whole milk or 2% milk. Talk to your doctor about which might work for your child. There are a few milk alternatives that closely resemble cow’s milk in nutritional content (pea and soy milk are examples) but there are others that are basically water (almond milk). I don’t routinely recommend toddler formula unless medical indicated or recommended by your doctor.

4. Decide on a plan for your transition.

I’ve seen families make the change cold turkey the first day it was possible. I’ve seen families slowly transition by adding in milk alternating bottles with formula. I’ve also seen families mix some formula and some milk in individual cups. I haven’t seen any one particular strategy work better than another. I think most babies would do fine with a quick transition or cold turkey swap…but every baby is different.

5. Try not to stress too much about this.

There are plenty of things to worry about in parenting. Deciding what to give them to eat and drink shouldn’t add to your stress. Provide them plenty of fruits and vegetables. Decide on your milk choice and your method of transition and don’t stress the rest.

They will have good days and bad days (just like us).

But, I promise everything is going to be OK in the end.

According to the study, approximately 15 percent of 2-year-olds consume as much as 4 ounces of coffee daily. It’s a practice, health experts say, that comes with a dangerous dose of health risks.

The study followed 315 pairs of mothers and infants who were participating in an analysis of weight change during a child’s first week and its impact on body mass index at age 2. While examining diets, researchers found that 48 of the participating mothers were feeding their 2-year-olds coffee as part of their daily fluid intake.

Infants and toddlers of Hispanic mothers were more likely to drink coffee than those of non-Hispanic mothers, according to the study, but researchers did not examine further to determine why. Female infants were also found to be more likely to drink coffee than male infants.

Cultural practice may be one of the reasons some children drink coffee at younger ages, according to the study. In some countries, including Cambodia, Australia, and Ethiopia, children under 5 are given coffee.

“I think too much caffeine in childhood is a bad thing and worse in the case of a younger child,” said Joel Steelman, M.D., endocrinologist at Cook Children’s. “Coffee consumption by younger children is a big deal. I wouldn’t recommend parents start this practice. There are much healthier options. Caffeine could interfere with sleep – naps and bedtime. Overconsumption of caffeinated drinks could lead to symptoms of dizziness, headaches, mood changes and seizures.”

The U.S. Federal Drug Administration (FDA) has not provided guidelines on coffee consumption for children, but previous studies suggest there are potential negative health impacts, including Type 2 diabetes, depression, obesity and sleep disturbances. The American Academy of Pediatrics (AAP) recommends against the inclusion of caffeine in a growing child's diet.

Deborah Schutte, M.D., cardiologist and medical director of Cardiology at Cook Children’s, said her chief concern regarding toddler coffee consumption is the cardiovascular effect, particularly increased heart rate and high blood pressure.

“It boggles my mind why any parent would give a toddler caffeine. Toddlers are wired enough, why would anyone want to add to that?” Schutte asked. “My concern with caffeine and toddlers is more about tachycardia and arrhythmias. Caffeine can cause the heart to pump at an unnatural pace, resulting in palpitations.”

Schutte also points out that giving toddlers coffee could lead to dehydration, particularly since caffeine is a diuretic.

A 2013 study found that 2-year-olds who drank coffee or tea between meals or before bedtime were three times more likely to be obese in kindergarten.

“Just because there are no guidelines, doesn’t make it OK,” Schutte added. “What people don’t consider is that there is caffeine in drinks and food that we don’t always realize, such as chocolate and coffee- flavored ice cream, so caffeine levels can sneak up on you.”

According to the FDA, the average American adult consumes approximately 300 mg of caffeine each day - the equivalent to between two and four cups of coffee.

Canadian guidelines recommend no more than 45 mg of caffeine for children ages 4-6. This is equivalent to one 16 ounce can of soda.

If parents are already giving their toddler coffee, it’s possible to wean their child off the caffeinated beverage, Steelman said. He recommends parents talk to their pediatrician about a weaning off caffeine schedule.

The answer is complicated.

Yes, it's very important for toddlers ages 1-3 to interact with other kids their age and challenge their balance, strength and coordination. Sports are a great way to promote these skills and literature shows that athletes who play sports at a younger age are more likely to be active adults than their peers who don't participate in sports.

However, organized sports  may not be the best solution for children 3 and under, and aren't the only way to teach our children these skills. The list below describes activities for toddlers and some benefits of these activities for their development.

Swimming: Helps strengthen the arms and legs, as well as improve coordination since the child has to use both arms and both legs at the same time. Learning swimming at an early age helps promote good water safety habits later in life. You can practice swimming in a "parent and me" swimming class. 

Dance: Improves balance, coordination, strength and flexibility. You can practice in a class setting or by having a "dance party" or playing a game of "freeze dance" at home.

Biking: Between ages 2 and 3, kids should be able to begin riding a tricycle. For young kids, there are tricycles that offer a parent guide bar to help kids move and steer. You can practice biking in your neighborhood or on trails.

Soccer: Most teams start between ages 3-5; however, kicking a ball in the backyard with your toddler is a great way to help them learn to run, develop core strength and balance on one foot for a short period of time.

Basketball: Helps kids develop hand-eye coordination when dribbling and shooting and improve running and jumping skills, as well. You can play with an adjustable hoop in the driveway, or sing up for a community team (which will generally begin between ages 3-5).

T-Ball: Teaches running, balll skills and coordination skills. Using larger balls for young children will help them be successful with catching and throwing.

Yoga: Helps improve flexibility, which is very important since toddlers are growing quickly and develop tight musles quickly. Yoga can also improve strength (especially in the core muscles) and balance. Several toddler yoga videos can be found online, and classes are available throught out the DFW area.

Gymnastics: Another way to gain strength, balance and flexibility, gymnastics is a sport that children can begin learning as early as 18 months old. Many gyms have special toddler and preschool classes, as well as "parent and me" classes.

Yard games: The old staples of "tag" and "hide and seek" are great for teaching turn taking and problem solving, as well as practicing and running and climbing. Taking your child to a local playground also offers a wide variety of ways to practice climbing stairs, running, swinging, balance, etc. 

With all of these, safety is a primary concern. Toddlers are at high risk of injury when practicing new things. Contact your pediatrician if you feel like your child is having difficulty learning new skills and they may refer you for evaluation by a physical therapist to evaluate your child and help them learn these new skills.

About the author

Jodi Burgett PT, DPT, CPST, is the clinical coordinator of Neurodevelopmental Physical Therapy at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield.