A red mark on your child’s cheek appears just like the one above. Can you wait to ask the pediatrician about it at their next check up? Yes, you can wait. The spider-like pinkish mark is aptly named a spider angioma. Also called by other names such as spider nevus or spider telangiectasia, the marks are composed of fine blood vessels in a radiating pattern close to the skin’s surface. When pressed, they momentarily disappear (blanching). Although in adults they can be associated with pregnancy or liver disease, having one or two is common in healthy children. Since they are harmless and often resolve in their own, we usually leave them alone.

There’s also a type of red mark called a cherry angioma. You can probably guess what shape those marks take.

Julie Kardos, MD and Naline Lai, MD
© 2018 Two Peds in a Pod®

Fight the flu! Vaccinate!

It’s time for your child’s yearly flu vaccine!

Why get the flu shot? Vaccinate against influenza (the flu) not only to avoid missed school days, but also to avoid hospitalizations and death. Last year in the USA, 172 children died from flu. You may not have heard about these fatalities because more sensational news tends to overshadow news about illness. We wish the news would inform that the vast majority of kids who died from flu had not received the flu vaccine. In addition, about half of the children who died from the flu were previously healthy and without underlying medical problems. Excluding the 2009 flu pandemic (H1N1), last year’s flu deaths represents “the highest reported since influenza-associated pediatric mortality became a nationally notifiable condition in 2004.” Kids younger than 5 years old have the highest flu complication rate of all children, so even if they do not yet attend daycare or school, bring your little ones in for a flu vaccine. Vaccinate your school-aged kids as well, for they spread the flu to more folks than any other age group.

Does it help to wait to give the vaccine? What if the vaccine wears off before flu season ends?
We wish we could predict just when the flu will hit, but sadly we cannot. Therefore, we urge you to give your children the flu vaccine as soon as your pediatrician has it available. Like all vaccines, it will take about two weeks for the protection against flu to kick in, and you never know when flu will strike your community. Did anyone catch the story about Vanilla Ice quarantined on a plane in New York with sick passengers last week? Turns out flu was on board. Don’t worry about immunity decreasing over time, infectious disease experts would not allow us to give it in early fall if they thought protection wouldn’t last for at least a few months.

If I give my children the flu vaccine every year, why do I have to give it again this year? Even we constantly-exposed-to-germs pediatricians get our flu vaccine yearly. The flu germs morph from year to year so the vaccine also changes.

Why does my younger child need a second dose this year?
As in previous years, children under nine years of age need a booster dose the first year they receive the vaccine. If your young child should have received a booster dose last year, but missed it, they will receive two doses of this year’s vaccine spaced one month apart (the primary dose plus a booster dose).

Is the nasal spray form back? Or is it only in injectable form?
The nasal spray form of the flu vaccine is back for healthy kids ages 2 years and up. However, this year, it received only a lukewarm reception from the American Academy of Pediatrics. The AAP recommends giving all children aged 6 months and older the flu SHOT, because in past years the intranasal form did not protect against the flu nearly as well as the shot did.

Not only is the nasal spray vaccine not getting a high endorsement, but some kids with asthma and kids with certain immune system problems are not allowed to get the nasal spray form. All kids can get the shot. So, pediatricians will continue to recommend injectable form of flu vaccine this year. However, with the rationale that something is better than nothing, for the severely injection-phobic family, some doctors may elect to give the nasal spray.

In the past, my child did not get the flu vaccine because he is allergic to eggs- did that change?
Even kids with severe egg allergies can get the flu shot safely in their pediatrician’s office. Now we know that allergic reactions to flu vaccine, as with any vaccine, are exceedingly rare.

We visit other people’s homes only if they are not sick. If my child’s friend doesn’t have flu symptoms, doesn’t that mean we can’t catch it from him?
Nope. You are infectious the day before symptoms show up.

Why is it worth it? The coverage is never 100 percent.
Children who get the flu vaccine but then get the flu anyway do not get sick as severely as kids who are unvaccinated. If all kids and adults got flu vaccine, then the chances of YOUR vaccinated child getting flu would be MUCH less. That’s how vaccines work.

Here we have tips on how to help your children if they get the flu.

You can read a comprehensive summary of this year’s flu vaccine recommendations from the Centers for Disease Control here.

Julie Kardos, MD and Naline Lai, MD
© 2018 Two Peds in a Pod®

Car seat safety isn’t just child’s play.

Just in time for families who plan to drive to Labor Day Weekend destinations, the American Academy of Pediatrics updated their car seat safety recommendations.

Families are now encouraged to keep their children rear facing for as long as possible, until they exceed the height or weight limit allowed by their car seat’s manufacturer. This means that some kids who are older than two years will continue to ride backwards. Dr. Lai’s own pip squeaks easily would have ridden backwards until they were three or four years old.

Regardless of age, kids facing backward in a car crash fare better than kids facing forward. A rear facing car seat prevents whip lash by fully supporting a child’s head and neck. A forward facing car seat does not restrain kids’ heads. In a crash, kids’ heads continue to move at the speed of the car until the shoulder harnesses and lap belts restrain their bodies. It makes us wish that grownups could also somehow ride backwards.

Other recommendations remain the same. For example, children can graduate from booster seats when they are 4 ft 9 inches tall and the car’s seat belt fits them properly. You can read about other car safety tips and view a link to children’s airline safety restraints in our 2017 post about car seat safety. In the post you will see a fabulous photo of a child who was saved by her car seat.

Again, no matter the age, as long as they fit, keep your children riding backwards in their car seats.

We’re thrilled that car safety has progressed over the years. Pictured here is Dr. Lai ready to go out in her 1960’s car seat :

Drive Safe!

Julie Kardos, MD and Naline Lai, MD
©2018 Two Peds in a Pod®

Now that you just read how to drop your kid off at school on the first day, you may be backpack shopping, pondering what to send your child for lunch, and knowing that your child will have difficulty waking up early for school. Never fear! Your Two Peds can help you and your kids get ready for school.

First, make sure your child’s backpack fits correctly and is not too heavy. Our guest blogger, a pediatric physical therapist, provides tips to help lighten the load.

Help your child get back on a school-friendly sleep schedule. If your child is still in summer vacation sleep mode, we provide ways to help get your child’s sleep back on track.

If your child brings lunch to school, you may need some hints on what to pack and how to beware of junk food disguised as healthy food. And this post provides suggestions for healthy snacks.

Need suggestions on how to motivate your child to want to learn? Two former school principals share their wisdom in this post.

Finally, you should know when to keep your child home for illness. This post also contains some surprising truths about when you can send your child back to school during as well as after certain maladies.

Julie Kardos, MD and Naline Lai, MD
©2018 Two Peds in a Pod®

A preschooler nibbles on her nails.

Stop nail biting! One of our readers wrote to us: “My 3.5-year-old daughter has started biting her nails to the quick. She does have a new little sister so perhaps it is stress/anxiety about that, but I don’t know what to do. Do I ignore it? Offer rewards for not biting? Please help – the habit drives me nuts and her poor little fingers are looking worse for the wear (and painful).”

As many of you have likely already discovered, telling your kid, or pleading with them, or bribing, ignoring, or yelling at them, will not help your kids stop nail biting.

Nail biting is a common childhood habit. Really common. In fact, according to this review article from 2015, it is THE most common habit seen in school-aged and college-aged kids. As many as 60% of kids, at some point, bite their nails. Nail biting usually starts between the ages of three to six years, so our reader’s child is right on target for this habit.

I am amused that many of the parents who ask me how to help their kids stop biting their nails are, themselves, nail biters. I will point out that even if we can’t stop nail biting, the concerned parent is a living example of a nail biter who still grows into a successful adult.

Assuming that your child is otherwise acting well, eating and sleeping normally, and mostly cheerful, it is not always important to identify the trigger of nail biting. More importantly, make sure your child washes their hands after playing outside and before eating (and nail biting) to limit germ spread. Check their fingers for signs of infections that can result from nail biting.

What to do

A quick internet search reveals dozens of products that you can dab onto your child’s fingers to discourage nail biting. Products with nasty tasting ingredients such as “bitter apple” tote promises such as “stop nail biting instantly.” Unfortunately, most nail biters are not deterred by paint-on products.

Usually kids have a hard time breaking a habit unless they REALLY want to break it themselves. Here are some suggestions to help:

• Offer painting nails or small rewards for not biting nails.
• Don’t be a nag.
• Establish a code word for stop biting your nails that only your child knows. The word can be a nonsense word (e.g. oogleschmertz) or a word entirely out of context (e.g. elephant). For younger kids especially, this creates an environment of humor, rather than annoyance when you are reminding them to stop biting.
• Substitute a less annoying habit for nail biting. Hand them something to keep their hands busy. Give them a squishy toy to squish or a hair scrunchy to wear on their wrist to flick.
• Offer older kids sugarless chewing gum to keep their teeth busy.

If all else fails, take heart in one study that came out in favor of nail biting (and thumb sucking). Perhaps it’s not imperative to stop nail biting after all. The study showed that nail biters and thumb suckers had a lower rate of atopic sensitization (medical term for allergic eczema) than their non-nail biting or thumb sucking peers. The researchers conclude “Although we do not suggest that children should be encouraged to take up these oral habits, the findings suggest that thumb sucking and nail biting reduce the risk for developing sensitization to common aeroallergens.” In other words, the nail biters show fewer allergy symptoms in their skin than the non-nail biters.

Let’s face it: We all are creatures of habit. The key is to make sure the habit is not self-detrimental. Every childhood habit does not need to be broken immediately, even if it drives us parents crazy.

Julie Kardos, MD and Naline Lai, MD
© 2018 Two Peds in a Pod®

Nine-year-olds love collecting little treasures.

It’s a funny thing about nine-year-olds. You may look at your own nine-year-old and think: where did my baby go? Gone is the nine-MONTH-old who worried about approaching strangers and howled when you walked away. Now you have a nine-YEAR-old who may shoo you away when you drop her off at a friend’s house.

Yes, some nine-year-olds may seem embarrassed by their parents, yet they absolutely want you around on the sidelines. They want you to attend their sporting events or school concerts and to organize their birthday parties. Just try not to take it personally when they want to spend more time with friends.

Nine-year-olds can get a little stinky, even if puberty is years away for many of them. Be sure to let them know that their bodies will change gradually over time. Get them deodorant and remind them to use it. Talk to girls about periods because some start around 10 years of age.

Because of increased attention span and intellectual growth, nine-year-olds will reliably carry out chores and perform many self care tasks. Encourage them to be more self sufficient. You will be happy for the help and you will build your nine-year-old’s self-esteem. On the academic side, they read chapter books and often enjoy non-fiction books. At this age, they enjoy a variety of clubs, team activities, and hobbies.

Remember the basics:

-Eat: Teach basic nutrition

-Sleep: Most nine-year-olds need around 11 hours of sleep per night.

-Pee/poop: While nine-year-olds use the bathroom independently, occasionally ask your child if they are constipated, and ask if they try to “hold it” all day in school. If the answer to either one of these questions is yes, see our post on these topics.

-Love/guidance: Just like you did when they were toddlers, remember to praise your nine-year-old for positive behaviors such as saying “please” and “thank you” or for helping you clear the dinner table. Once they know that you approve, they will repeat those behaviors. Nine-year-olds are known for whining for long periods of time. Dr. Lai remembers her son whining about losing screen time. He would suddenly appear out of nowhere and whine two inches from her face wailing,”Why? Why? Why?” Watch out, if you give into a whining kid, even sometimes, you’ll end up encouraging their whining. Think slot machines— even though gamblers usually lose at slot machines, they continue to play them because SOMETIMES gamblers do win.

If you have not done so already, teach your nine-year-old to use a phone and teach them whom to call in an emergency. Some kids this age come home to an empty house for a little while until parents return from work. Review what you expect them to do while they are alone.

Reminder about car safety: Many should still be in booster seats because they are not yet 4 ft 9 inches tall. They should NOT sit in the front seat of a car; the back seat is still safer for them.

Nine-year-old kids are still part of the golden age of parenting— too old to take a nap, but too young to drive. Enjoy spending time with your nine-year-old doing things that interest both of you. Enjoy their enthusiasm and increased ability to understand higher concepts. Time spent with parents or other caregivers who enjoy them contributes to building their resilience.

Speaking of nine-year-olds, please celebrate with us NINE YEARS of Two Peds in a Pod®! We are enjoying the journey and hope that our advice can help build resilience and self-confidence in the parents we write for! Our best present from you is your continued presence.

Happy Ninth Birthday to your nine-year-old and to Two Peds in a Pod®!

Julie Kardos, MD and Naline Lai, MD
©2018 Two Peds in a Pod®

How can you tell if your child’s scrape is infected if his skin is already bright red?

I heaved a sigh of relief. My children greeted my husband and me at the door. The children had just baby-sat themselves. I thought everyone was unscathed until I saw one of my children covered in bandages. Cuts and scrapes? Apparently, although I had admonished them not to ride anything with wheels and not to climb on anything above the ground, the child with the bandages had tripped over her own feet during a benign game of four square.

“Did you wash the scrapes?” I asked.

“Yes,” the kids said, proudly nodding. They knew the first line of defense against a wound infection is to wash out cuts and scrapes. But as it turns out, they had only dabbed the cuts with wet paper towels. Aghast, I propelled the injured child off to the bathroom and hosed down the cuts. Too many times I have seen a minor scrape turn into a major skin infection.

When a wound is not thoroughly cleansed, the bacteria which normally live on intact skin (Staphylococcus or Streptococcus) find an opportunity to enter the body through the wound and cause infections. Even a mosquito bite can turn into a raging, puss-filled mess if scratched often and not cleansed enough. These days, some children carry on their skin a type of Staphylococcus called MRSA (Methicillin Resistant Staphylococcus Aureus). Since this germ can be tough to treat when it causes an infection, a thorough cleansing is more important than ever.

While infection is rarely introduced from the actual object that cuts the child, exceptions include cuts caused by animal or human bites (the human mouth is particularly filthy) and cuts caused by old, dirty or rusty metal. Tetanus lives in non-oxygenated places such as soil. So for deep or very dirty wounds, make sure your child’s tetanus vaccine is up to date.

Despite what many believe, wiping the surface of a cut with a wipe is not adequate to cleanse a wound. “Irrigate, irrigate, irrigate,” a wise Emergency Department physician explained to me when I was a resident in training. “I have never had someone return with a wound infection,” she said proudly. In the emergency room, saline is usually used. At home, soap and running water are effective. Stay away from hydrogen peroxide and rubbing alcohol because they can irritate rather than help the skin.

After washing your child’s cuts and scrapes, you can use bandages to help prevent further exposure to germs and to avoid irritation from clothes or from your child’s scratching, probing fingers. Infections, if they occur, can set in 2-3 days after your child gets her wound. Remove the bandage daily and check the wound for signs of infection such as pus, increased redness, warmth and pain. Wash the wound again, and then replace the bandage. You could also apply topical antibiotic such as Bacitracin to further help prevent wound infection.

So, even if your child just took a shower, wash him again if he scrapes himself. The sooner you irrigate even the tiniest of wounds, the better.

An ounce of prevention is worth a pound of antibiotics.

Naline Lai, MD and Julie Kardos, MD
© 2018 Two Peds in a Pod®

ick, a tick

I was grumpy all morning after realizing that my dog was out of tick repellent. Really grumpy. I did not like the thought of having to remove a tick from my dog.

After all, on the East Coast of the United States, we are seeing ticks galore. All month long, parents who have had to remove a tick have been bringing us presents such as the one pictured here. Yes, that is a tick you see nicely trapped in tape. Sometimes when parents bring us a tick, it’s still clinging to the child and they ask us to remove it. To save you a trip to the doctor’s office, here is a quick refresher on how to pluck the bugs off:

How to remove a tick:

1. Take a deep breath and pretend that it’s just a speck of lint—not an ugly critter with a bloated stomach and writhing legs.
2. Use tweezers and firmly clasp the head. If the tick is tiny, you will end up grabbing the entire body.
3. Pull the tick straight up and off. Hint: Press down on the skin on either side of the tick so that the skin doesn’t pull up when you pull the tick off. This lessens any pinching sensation your child may feel.

How NOT to remove a tick:

Please do not try to burn a tick off—you’ll just burn your child’s skin.
Avoid suffocation techniques such as covering a tick with petroleum jelly (Vaseline) or nail polish. These techniques are not very effective, they allow the tick to stay on for a longer period of time, and also they may cause the tick to become slippery and difficult to grasp.

What to do after you have removed the tick:

After removal, if the tick’s head is left behind, don’t go digging for it. Just like a tiny splinter, your skin will naturally try to expel it. Soaking the area in warm water will help the process along. Don’t worry about disease transmission: there is not any disease stuck in a tick’s head.

Wash the skin where the tick was using soap and water as you would any cut to prevent a skin infection. A small, minimally tender, pimple-like bump is a common reaction which may linger for a few days. This bump is an irritation response of the skin. If the tick was a deer tick (typically the size of a poppy or sesame seed), watch for the rash of Lyme disease that appears as a flat, pink, round patch about a week later. The patch may clear in the center and grows to at least 2 1/2 inches across.

My daughter told me that once, a girl at her lunch table had a tick on her. None of the kids could pick it off and the girl sat screaming until the lunch lady came over to help her. Maybe you’ll be the lucky adult called over to help next time.

Just remember…pretend it’s a speck of lint.

Naline Lai, MD and Julie Kardos, MD
©2018 Two Peds in a Pod®

Teach your child to recognize poison ivy: “leaves of three, let’em be!”

Recently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, the rash of poison ivy is NOT contagious. You can “catch” a poison ivy rash ONLY from the plant, not from another person.

Another myth buster: You can not spread the rash of poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch:

Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.

Hydrocortisone 1%-  This is a mild topical steroid which decreases inflammation.  We suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day

Calamine lotion – a.k.a. the pink stuff- This is an active ingredient in many of the combination creams.  Apply as many times as you like.

Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti-itch properties. Some doctors recommend giving it twice a day- ask your pediatrician.

Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub. Alternatively buy the commercial ones (e.g. Aveeno)

Do not use alcohol or bleach– these items will irritate the rash more than help

The biggest worry with poison ivy rashes is the chance of infection.  Just like with an itchy insect bite, with each scratch, your child is possibly introducing  infection into an open wound.  At night, turn up the air conditioning and put your child into pajamas that cover up the poison ivy. Kids who don’t scratch in the day often scratch subconsciously at night. Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.

However, infections cause pain – if there is pain associated with a poison ivy rash, think infection.  Allergic reactions cause itchiness- if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure to poison ivy.  Infection usually occurs on the 2nd or 3rd day of scratching.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

Naline Lai, MD and Julie Kardos, MD
©2018 Two Peds in a Pod®