Babies are gooey. Spew tends to dribble out of every orifice and the ear is no exception. Devin’s mother tipped her four month old baby’s head sideways in the office the other day and asked me what to do about the oily, yellow wax smeared around the opening of his ear canal.

Some say wax evolved to help keep bugs and other debris from reaching deep into our ear canals. Case in point: one of my least favorite memories during residency was when I picked out pieces of a cockroach entrapped in the wax of a child’s ear. The amount of wax you see on the outside is not indicative of the actual amount inside the ear canal. Chances are, the wax is not hard and does not block the ear drum.  Even if there is a large amount of wax, it is unlikely to greatly affect a baby’s hearing. Equally normal is that some babies and children don’t seem to produce any ear wax. If you are concerned about your child’s ear wax, have your pediatrician take a peek with a light. 

Despite the copious amount of wax on the outside, Devin’s ear canals were clear. “But the wax is simply disgusting,” said Devin’s mom, “Can I clean his ears? “

“Yes”, I answered. “Wipe off what you see, doesn’t matter if you use a wash cloth or cotton swab.  The special shaped cotton swabs with the safety tips are unnecessary. Anything you see is fair game.  Rest assured, you will not go too deeply into the ear canal if you only scrape off what is visible.” Dr. Kardos goes one step further and tells her patients: if you can get the wax with a wash cloth, it’s fair game. Otherwise, leave it alone.

Now suppose your pediatrician does say the wax should be removed. Place an over-the-counter solution such as Debrox in the ears (children and adults can use the same formulation) – three to four drops one or two times a day (during sleep is easiest for babies and toddlers) for a few days. The solution softens wax.  For maintenance, mineral oil and olive oil are favorite remedies. Place one drop daily in ears. In the office some pediatricians can use a water irrigation system (like a water squirter in your ear) to wash out the wax. The worst side effect is that the child’s shirt sometimes gets wet. Irrigation is a very effective for removing wax  in a school-aged or teenaged child who complains of difficulty hearing.

If you find you are constantly cleaning your baby’s waxy ears, take heart. At least there won’t be any roaches “bugging” them.

Naline Lai, MD with Julie Kardos, MD

©2011 Two Peds in a Pod®

Take a look at the February 2011 issue of Real Simple magazine. We are two of the experts cited on page 124. The good news is that some of our thoughts on the essentials of a medicine cabinet were integrated into a photo-essay piece. The bad news is that children’s cough medicine is listed as a component of the medical cabinet.  While the other contributors to the piece may encourage use of over-the-counter cold and cough medications, we discourage use.

Of concern, safety and effectiveness of cough and cold medicine has never been fully demonstrated in children.  In fact, in 2007 an advisory panel including American Academy of Pediatrics physicians, Poison Control representatives, and Baltimore Department of Public Health representatives recommended to the U.S. Food and Drug Administration (FDA) to stop use of cold and cough medications under six years of age.

Thousands of  children under twelve years of age go to emergency rooms each year after over dosing on cough and cold medicines according to a 2008 study in Pediatrics . Having these medicines around the house increases the chances of accidental overdosing. Cold medications do not kill germs and will not help your child get better faster. Between 1985 and 2007, six studies showed cold medications didn’t have significant effect over placebo.  

So why are children’s cough and cold medicines still around? A year after the advisory panel published their recommendations, FDA advised  against using these medications in children younger than two years but data about these medications in older children is still rolling in.   FDA continues to advise caution with these medications. The producers of cold medicines said at that point they would launch new studies on the safety of medication for those two to twelve years of age. In the meantime pharmaceutical companies stopped manufacturing cold medicine products for those under two years of age and changed the labels to read “for four years old and above.”

Yes, watching your child suffer from a cold is tough. But why give something that doesn’t help her get better and has potential side effects?  There is plenty to do besides reach for cold medicine.  Give honey for her cough  if she is over one year of age. Run a cool mist humidifier in her bedroom, use saline nose spray or washes, have her take a shower with you, and teach her how to blow her nose. Break up that mucous by hydrating her well- give her a bit more than she normally drinks.

If you have young children and want to make your medicine cabinet truly “real simple” then take out the over the counter cough and cold medication. 

Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®

It’s confirmed. Dr. Wakefield was a fraud. Recently, on January 5, 2011, reporter Brian Deer published a report in the British Medical Journal   exposing more flaws in the Wakefield study- the study which proposed a link between Measles, Mumps, and Rubella vaccine (MMR vaccine) and autism. Of note:

• Lawyers who were trying to win a law suit for parents who believed that the MMR caused their children’s autism paid Wakefield to do the study.
• Wakefield falsified his findings. The medical records of all 12 children in the study were inconsistent with Wakefields’s data.
• Almost half of the children in the study already showed signs of developmental abnormalities before they received the MMR vaccine. Therefore, the MMR vaccine did not cause their disabilities.
• Rather than randomly choosing the children for the study, Wakefield obtained most of his subjects through an anti-MMR campaign group.
• Ten out of twelve other authors of Wakefield’s paper have withdrawn their support of the paper.

To read about the original study and the controversy around it, please see our earlier post, “Do vaccines cause autism?” For more information about how vaccines work, please read “How vaccines work.”  To learn signs of early communication delays in your infant, please see “How do I know if my baby has autism?”

Too bad it’s too late for some children. Since Wakefield published his paper, measles cases have steadily risen in the UK. Hopefully the damage caused by Wakefield’s 1998 paper will be mitigated by more parents who vaccinate their children.

Julie Kardos, MD with Naline Lai, MD

©2011 Two Peds in a Pod℠

I often pass a parent on her way out of my office carrying an infant in an infant car seat. As I stop to elicit a goodbye smile from the baby, I check to see that the car seat straps are buckled properly. I say to the parent, please make sure that the cross strap is across his chest, not down at his lap. And please tighten the shoulder straps; I should not be able to pinch the strap above his shoulders. These are too loose.

Car seats save many lives every year. After immunizations, they are the most effective way to prevent death in children, but car seats need to be used properly. Many families travel this time of year and that means it’s time to update your car seat safety knowledge.

Until recently, experts recommended that babies in car seats need to weigh at least 20 pounds AND be at least one year old until they could face forward. Newer recommendations say babies should stay rear facing in a car seat until two years old, or until they no longer fit facing backward. The reason for this change is that in a crash, children suffer fewer injuries when they face backward. Different car seat brands have different weight and height specifications so be sure to read the literature that comes with your car seat. If the seat fits well, the middle of the back seat is the best spot to install a car seat. Rear facing infant seats are the most difficult to install correctly. Luckily, many police stations and gas stations offer programs to check if car seats are installed properly. Check with your local police.

Children should remain in car seats as long as they correctly fit. For some kids this is age four years and for smaller kids this may be five or even six years. If your child is particularly tall or obese he may require a high-backed booster soon after age three. My friend had a tall child that unfortunately ended up in a car accident recently. Again, read the literature that comes with your car seat for the height and weight limit; this is more important than the age of your child. The more restraints, the safer the seat. Five point harnesses are safer than three point. After five years a car seat should be replaced. Usually the third born ends up with a new seat. Because of the risk of hairline cracks, also replace a car seat if it was in an accident.

When your child outgrows the car seat, he graduates to a booster. Again, remember the more restraints, the safer the seat. A high backed booster is preferable until your child outgrows it. Keep your child in his booster seat until he is tall enough for the chest strap of a car’s seatbelt to lie diagonally across his chest without hitting his neck and for the lap strap to lie straight across the bony parts of his hips, not his stomach. To provide neck support and minimize whip lash, his ears should not jut up past the top of the back of the booster or car headrest. Keep children 12 years old and younger in the back seat. The force of an air bag can harm a young child. 

Parents can call 1-800-CARBELT to access the American Academy of Pediatrics car safety seat hot line for their more specific car seat questions.

To ingrain good car safety habits in your children, remember to be a role model and buckle up yourself 100 percent of the time, even if you are driving only next door. Your children are watching you.

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod?

Addendum: Please note that the official updated car restraint policy of the American Academy of Pediatrics as of March 2011 include the above recommendations of staying rearfacing until age two years and avoiding riding in the front seat until at least age thirteen years. In addition, more specific guidelines about boosters were added: children should stay in a booster seat until the car’s seat belt fits properly, at the minimum height of 4’9″ and between 8-12 years of age.

Graco was founded nearly 70 years ago, and Evenflo and Child Craft have been around even longer. In fact, most of the prominent baby supply manufacturers have been in the baby business for decades, so I am always appalled when their products are recalled. Haven’t they perfected the art of manufacturing safe baby products yet? Drop-down side cribs are the latest example in faulty designs. In the past year, manufacturers announced the recall of many drop side cribs. Ultimately, last week, the Consumer Product Safety Commission completely banned drop-down side cribs  because they have been implicated in the deaths of at least 32 infants since 2001. 

Recalls occur slowly. Here’s an example. My husband and I discovered some of the plastic pieces which held up the mattress support for our firstborn’s crib had cracked in half when we tried to set up the crib for our second born. Thinking we had used too much force to snap the pieces into place, we simply ordered more parts and put the crib together. Not until after my third child was born, five years after my first, did a recall on this crib go out. Other families experienced some of the pieces snapping while babies were in the cribs and the mattresses fell to the ground.

Through the years, I’ve noticed most recalls are only for a handful of reasons. Look at your children’s toys and equipment for these potential dangers before the recall occurs:

• Head entrapment – The most common story is that the baby slides through a leg hole of a stroller or baby carrier and his neck gets stuck. A baby also may strangle when his neck is wedged between parts of a piece of equipment. This problem occurred with drop-down side cribs. The recommended width between crib rails is 2 3/8 inches (the width of a soda can) because a child is more likely to trap his head in any larger of an opening.  Make sure there are no openings or potential openings larger than 2 3/8 inches.

• Choking – Any part that can be pulled off and fit into a toilet paper tube is a choking hazard.

• Restraint failure – Equipment is often recalled for inadequately restraining a baby, e.g. loose swing straps.

• Lead ingestion – Lead needs to be consumed to cause poisoning so anything your baby chews on, including railings, are suspect. Lead check kits are readily available; the one I use is leadcheck.com.

If your child is injured because of faulty equipment, even with an injury which seems inconsequential, remember to report the problem to the consumer product safety commission and to the manufacturers.  

Forget waiting for the recall. It could be years. Don’t buy something that makes you suspicious in the first place.

For more baby proofing hints, please see our post The In’s and Out’s of Baby proofing.

© 2010 Two Peds in a Pod℠

Dashing through the mall, having traded your one-horse open sleigh for a minivan, you have secured gifts for all creatures, including the mouse. Now you are ready to  leave on a plane tomorrow to spend the holidays with forty of your closest relatives.

How will you avoid illness this holiday season? How best to travel with children? We take you to a couple posts to help you out: Traveling with Children, and A happy, healthy holiday part 2: more holiday sanity hints .

We wish you all good health this season.

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod℠

Today our dear friend, pediatrician, and mom, Wendy Lee shares insights and personal experience on how to tell your child he is adopted.

My husband and I had waited three long years for “the phone call” letting us know who would become our baby.  Only three short weeks prior to boarding a plane to China, we got the news we would not be bringing just one beautiful girl home from China, but TWO. Twins. We should have known right at that moment we would begin living a life of improvisation.

As with all parenting, there are endless numbers of issues to tackle.  One unique to families formed by adoption is how and when to tell your child he is adopted.  There are many differing opinions on how to do this right, but all agree children should be told.  It wasn’t so long ago that “the experts” deemed it to be psychologically damaging for a child to know about his adoption, and recommended not revealing this information.  Thankfully, things have evolved, and we are faced not with if, but how, to best share the news about adoption.

Just as with many aspects of child rearing, it is often best to take cues from your child.  If your child is younger, as were our girls (thirteen months old at the time we first met them), it is a good time to discuss adoption openly so it takes on a normalcy.  We read a full library of children’s books to them about adoption, and show the girls pictures and videos of our trip over and again.  We speak with them about our “Gotcha Day” (the day we got them and they got us).  And we celebrate this day each year with some of the families who traveled to China and got their daughters on the same day.  We talk about their birth parents in China and celebrate their heritage which, although similar to ours, is not exactly the same (I am Korean, and my husband is Cambodian). 

We gave ourselves a little pat on the back one day when we told our children one of our friends was going to have a baby, and they in turn asked which plane the parents were going to ride to get the baby.  They certainly thought adoption was a normal way to have a baby, but now we were faced with telling them other ways this could happen!  

As children grow, they enter new stages which may require improvisation.  A child’s age and temperament will guide you in your discussions regarding her birth and adoption.  Some children will never have any questions and will be satisfied with the here and now.  Others will have lifelong struggles to try and understand their history.  At certain stages, children will want nothing else but to fit in.  Being adopted, at that point, may set them apart from others and become something they will not want to advertise.  While “Gotcha Day” right now is another opportunity for our girls to have cupcakes, presents, and company, at some point it may be a day that reminds them of what they have lost and how they are different from their friends. They may choose not to celebrate this day any longer.  For some children, curiosity about their birth parents will be all-consuming and for others, it may just bring fleeting thoughts. 

Regardless of the age, stage or temperament of your child, my advice is to be truthful, open, supportive and positive. As your child grows, you will share more information. At some point, probably during his/her adolescence, your child should be given all the information that is known regarding his or her history, even if it may be difficult to share.   Discussions will move from simple explanations to potentially heart-wrenching, tear-ridden sessions where answers aren’t available.  I think whatever reaction your child will have to this part of her past, the longer she has to process it, and the longer you have to deal with your child’s emotions in this regard, the better it will be for all.

Wendy C. Lee, MD, FAAP
General Pediatrician

Presently full-time mama to two beautiful twin girls adopted from China

Anxiously awaiting a third child from Korea

© 2010 Two Peds in a Pod℠

Breastfeeding moms often ask us what medications they can take and not adversely effect the baby. The most complete database we have found is LactMed . Hope you won’t  have the need to refer to it too often.

At a baby’s six month old check-up I advise parents to have their child start drinking from a cup.

Some respond with surprise,” A cup? So young? How exciting! Do you mean a sippy cup?”

“No,” I explain. “A regular, open face cup.”

Then I get incredulous looks. “But how will our baby manage that?”

Just like your baby “learns” how to eat food off a spoon, she will have to practice. You will have to help her at first. Just put water in the cup. Who cares if water spills? You see how by this age she naturally puts her hands together and pulls most things to her mouth. With practice, she will learn to drink out of a cup. Just like everyone else did before sippy cups were invented.

“But when,” parents ask me, “should we introduce the sippy cup?”

The reality is, sippy cups satisfy a parent’s desire to be neat and to avoid mess. Sippy cups are not a developmental stage. Did I use sippy cups with my own kids? Yes I did, especially with my twins, because anything I could do to decrease mess in my home I welcomed with open arms. But it is perfectly okay to never introduce sippy cups to your child.

Because sippy cups are spill-proof,  it is tempting to leave one out all day for your child. If the cup contains water, this practice is safe. However, many toddlers have ended up with a mouth full of cavities in their brand new baby teeth after sipping milk or juice all day long out of sippy cups. Constant sweet substances on the gums can sink in and affect baby teeth. Just as we advise parents of bottle fed babies to avoid allowing the child graze from the bottle all day and to avoid falling asleep drinking a bottle, young children should not be drinking sugar-containing drinks, including milk, all day from a sippy cup.

“But I only give my kids water mixed with a tiny bit of juice in the sippy cups,” I hear parents say. Yes, kids (and grownups) need water, but watered down juice is not the same as plain water. Watered down juice is sugar water, and it harms teeth just like straight-up juice. In addition, drinking watered down juice teaches kids that all beverages need to be sweet. Sweet drinks do not actually quench thirst; rather, they make kids feel thirstier. Remember that unlike adults, babies and toddlers have not formed unhealthy habits yet, so teach them that water and milk are for drinking. The only exceptions are electrolyte solutions that are used to prevent dehydration during vomiting and juice once a day (prune, pear, or apple) for constipated children. For nutrition, fruit is much healthier than fruit juice.

So put water in the open faced cup and allow your baby to imitate you and drink out of it. Then, around your child’s first birthday when most parents wean their children from breast milk or formula to cow milk, put the “big boy milk” or “big girl milk” into a cup.  Aim for all open cups by at least two years of age. If you decide to use sippy cups, as I did, for neatness sake, do not forget practice with a regular cup. Get rid of the sippy cup whenever you are tired of washing those moldy valves and tired of rescuing them from your drain or garbage disposal.  You might have a “sippy cups are for car rides” policy and use open cups at home.

What about straw cups? Well, think of it this way. Do you plan to travel around with straws in case your child becomes thirsty? Sure it’s fine to teach your child to drink out of straw. It’s healthier than a sippy cup because most of the milk will bypass most of the teeth. But again, it is easiest in the long run to teach your child to drink out of a regular cup so that in any situation you know you can offer your child a drink.

All kids are messy. The younger you practice with your child, the sooner she will be drinking out of a regular cup like a pro. Just in time for finger feeding which means self-feeding—more mealtime mess!

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod℠

Two Peds in a Pod turns today to guest blogger Dr. Alan Woolf, Director of the Pediatric Environmental Health Center at Children’s Hospital Boston and president-elect  of the American Academy of Clinical Toxicology, to tackle the question, “Should you feed your kids organic fruits and vegetables?”

Nutritionists are urging parents to feed kids one and one-half cups of fruit and two and one-half cups of vegetables daily and the American Academy of Pediatrics suggests whole fruit rather than juice to meet most of the daily fruit requirements. 

 Are they worth it? Will non-organic produce harm your kid? No easy answers here. American consumers demand a bountiful supply of blemish-free, perfect fruits and vegetables. We want unspotted shiny red apples, brightly colored large oranges and arrow-straight asparagus. Farmers want to give us just that. Since pests attack crops causing blemishes, worms, blight, and other forms of costly crop damage, farmers have been using pesticides for years to increase crop yield, profit, and visual marketability. 

The US Dept of Agriculture (USDA) regulates the agricultural procedures and labeling that use the buzz word organic. Obviously every business wants to put that word on their product if it means consumers will run out and buy it. The USDA will certify farms that use organic methods. But even the USDA’s definition of organic allows a percentage of synthetic chemicals to be added to products labeled organic. Also organic does not mean that the food contains increased amounts of essential minerals and vitamins or is more nutritious for you. And remember that organic produce doesn’t necessarily come from small, cuddly, local, family-run farms. Most large, international agribusinesses are touting organic foods for sale these days.

That being said, you still need to be cautious. In pediatrics we often invoke the “precautionary principle.” The idea is that if you don’t exactly know what a chemical will do to a child’s health because there aren’t enough scientific studies out there, then you assume that what it is capable of is bad and so, if possible, try not to expose them, just as a precaution. 

When you can, buy from local farms or stands where you can ask them their growing practices, or else just grow your own. If you decide to buy organic foods, you should eat them right away. They may not stay edible as long without preservatives. Again, no matter what type of food you buy, wash, wash, wash.

Finally, alternative “greener” farming techniques, integrated pest management (IPM), and more resistant varieties of plants have increased crop yields, in many cases without using as much pesticide. That’s good news for all of us. Breeding of genetically-engineered plants require less use of pesticides, but they may not be acceptable to most consumers. That’s a whole column in itself!

The bottom line: My wife and I will try to buy organic foods when we think of it, but we don’t obsess over it when we forget. 

Alan Woolf, MD, MPH, FAACT, FAAP

Director, Pediatric Environmental Health Center, Children’s Hospital Boston

© 2010 Two Peds in a Pod®