Time for a Two Peds photo quiz.

What is up with this baby’s belly-button?

It’s called an umbilical hernia, which is an out-pouching at the belly button, caused by loose belly muscles.

In the womb, babies’ belly muscles migrate across the abdomen and meet in the middle. Sometimes they don’t meet up before birth, causing a small bit of the gut to out-pouch. Usually more noticeable during crying, umbilical hernias do not hurt, nor do they get “stuck” out like a groin hernia (located at the scrotum or labia) and thus they are not a medical emergency. In fact, they do not even need treatment.

Fortunately, umbilical hernias tend to close up on their own by age five years, often much sooner. Don’t do what my grandmother suggested, which was to place a quarter on top of my son’s umbilical hernia and then tie it into place with a belt-like contraption. This does NOT hasten the hernia’s resolution.

Sometimes if an umbilical hernia is particularly large, it fails to regress after a few years, and at that point, for cosmetic reasons, a surgeon can repair it.

We see many babies with umbilical hernias in our office, and we are happy to reassure parents about them. If you were wondering, my son who had the umbilical hernia as a baby, now has a belly button that looks exactly the same as his twin who did not an umbilical hernia. Both are “in-ies.”

Julie Kardos, MD and Naline Lai, MD
©2015 Two Peds in a Pod®

“Let’s skip this ride.”

Should I vaccinate my child? Yes, yes, yes!

The recent measles outbreak originating in Disneyland among mostly-unvaccinated children and adults highlights how important it is to continue to immunize children against preventable infectious diseases, even if we think they are rare.

There are many deadly diseases we can’t prevent, but we do have the power to prevent a few. We now have the ability to prevent your children from getting some types of bacterial meningitis, pneumonia, and overwhelming blood infections. With vaccines we can prevent cases of mental retardation, paralysis, blindness, deafness, and brain infections. Immunizations are a safe way of boosting children’s natural immune systems. Yet some of our parents continue to doubt the benefits of vaccines and to fear harm from them.

Let’s look at another kind of prevention.  You would never drive your car without putting a seatbelt on your child. Even if you don’t know anyone who was in a fatal car accident, you still buckle you and your child up. You may know a kid who emerged from a car accident with only a scrape, yet you still buckle you and your child up.

You may never know a child who is paralyzed by polio or who died of whooping cough, but it does happen and can be prevented. Just like with car accidents, it’s better to prevent the injury than to play catch-up later. Dr. Kardos’s grandfather routinely rode in the front seat of his car without his seatbelt because he “had a feeling” the seatbelt might trap him in the car during an accident. Never mind that epidemiologists and emergency room doctors have shown people are much more likely to die in a car accident if they are not wearing a seat belts, he just “had a feeling.”

We know no one likes a needle jab, but for most vaccines, no one has invented any better way of administration.

When it comes to your children, parental instinct is a powerful force. We routinely invite our patients’ parents to call us about their children if their instincts tell them something might be wrong, and we always welcome and at times rely on parents’ impressions of their children’s illnesses to help us make a diagnosis and formulate a treatment plan.

However, in the face of overwhelming evidence of safety and benefits of vaccines,  we pediatricians despair when we see parents playing Russian roulette with their babies by not vaccinating or by delaying vaccinations. We hope fervently that these unprotected children do not contract a preventable debilitating or fatal disease that we all could have prevented through immunizations.

There is no conspiracy here. We both vaccinate our own children. We would never recommend any intervention where the potential for harm outweighs the potential for good. We have valid scientific data that every year vaccines save thousands of lives. One of them could be your child’s life.

Should you vaccinate your child?

YES!

Julie Kardos, MD and Naline Lai, MD

©2015 Two Peds in a Pod®

Updated from our earlier 2011 post

Visit these posts for more infomation about vaccines: How Vaccines Work, Evaluating Vaccine Sites on the Internet, Do Vaccines cause autism? and Closure: there is no link between the MMR vaccine and autism

Also, please visit  the recent Institute of Medicine’s analysis of vaccine side effects.

“You just can’t understand worry until you have a child of your own.”

Welcome to cold and flu season. Now that flu and many other illnesses are circulating, we want to help you answer these questions: How will I know if my child is too sick? When do I need to worry? When should I call the pediatrician?”

Here is how to approach your own ill child.

First and foremost, trust your parental instincts that something is wrong.

Think about these THREE MAIN SYSTEMS: breathing, thinking, and drinking/peeing.

Breathing:

Normally, breathing is easy to do. It is so easy, in fact, that if you take off your child’s shirt and watch her breathe, it can be hard to see that she is breathing. You should try this while your child is healthy. Normal breathing does not involve effort. It does not involve the chest muscles.

If your child has pneumonia, bad asthma, bronchitis, or any other condition that causes respiratory distress, breathing becomes hard. It becomes faster. It involves chest muscles moving so it looks like ribs are sticking out with every breath:  click on the photo in this article to see this. The chest itself moves a lot. Kids’ bellies may also move in and out. Nostrils flare in attempt to get more oxygen. Sometimes kids make a grunting sound at the end of each breath because they are having difficulty pushing the air out of their lungs before taking another breath in. Also, instead of a normal pink color, your child’s lips can have a blue or pale color. Pink is good, blue or pale is bad. Children old enough to talk may actually have difficulty talking because they are short of breath. Any of the above signs tell you that your child needs medical attention.

Thinking:

This refers to mental or emotional state. Normally, children recognize their parents and are comforted by their presence. They are easy to console by being held, rocked, massaged, etc. They know where they are, and they make sense when they talk.

Change in mental state, whether it comes from lack of oxygen/shortness of breath, pain, or severe infection, results in a child who is inconsolable. She may not recognize her parents or know where she is. Instead of calming, she may scream louder when rocked. She may seem disoriented or just too lethargic/difficult to arouse. Being very combative can also be a sign of not getting enough oxygen. In a baby, extreme pain can cause all these signs as well.

Drinking/peeing:

While this varies somewhat depending on the age of the child, most kids urinate every 3-6 hours or so. Young babies may urinate more frequently than this and some older kids urinate perhaps 3 times daily. You should know your child’s baseline. Normal urine reflects a normal state of hydration. If you don’t drink enough, you will urinate less.

If your child has fever, coughing, vomiting, or diarrhea, she will use up fluid in her body faster than her baseline. In order to compensate, she needs to drink more than her baseline amount of liquid to urinate normally. A child will refuse to drink because of severe pain, shortness of breath, or change in mental state, and may go for hours without urinating. This is a problem that needs medical attention. Occasionally a child will urinate much more than usual and this can also be a problem (this can be a sign of new diabetes as well as other problems). Basically any change from baseline urine output is a problem.

A note about fever:

Any infant 8 weeks of age or younger with fever of 100.4 F or higher, measured rectally, requires immediate medical attention, even if all other systems are good. Babies this young can have fever before any other signs of serious illness such as meningitis, pneumonia, blood infections, etc. and they can fool us by initially appearing well.

In older babies and children, we take note of fevers of 101F or higher. Some kids can look quite well even at 104F and others can look quite ill at 101F. Fever is a sign that your body’s immune system is working to fight off illness. In addition to fever, it is important to look at breathing, thinking, and hydration because this will help you determine how quickly your child needs medical attention. A child with a mild runny nose and fever of 103 who can play still play a game with you while drinking her apple juice is less ill than a child with a 101 fever who doesn’t recognize her parents. Read more about fever here.

To summarize, any deviation from normal breathing, thinking, or drinking/urinating (peeing) is a problem that needs medical attention, even if no fever is present. In addition, any illness that gets worse instead of getting better is a problem that needs medical attention. Also, remember to let your child’s doctor know if your child is missing any vaccines.

Finally, all parents have PARENTAL INSTINCT. Trust yourself. Ultimately, if you are wondering if you should seek medical advice, just do it. If parents could worry every problem away, no one would ever be sick.

Julie Kardos, MD and Naline Lai, MD
© 2015 Two Peds in a Pod®
updated from original posting on 11/12/2009, revised 2018

Continuing our series on the essentials of life…

If you have a newborn, stop reading and go back to feeding. It’s too early for your baby to sleep through the night. All babies lose a little weight in the first couple days of life, but then they are expected to gain. In fact, you may find that you need to awaken your baby to eat every couple of hours to eat in order to stabilize her weight loss. (see our prior post on breast feeding your newborn and our formula feeding post). While you feed your newborn, listen here to understand newborn sleep patterns:

Click here for our podcast – Sleep During the First Six Months

So, when to expect your baby to sleep longer at night? Usually after three months, your baby naturally takes more milk at each feeding and thus lasts longer between feedings. And once your baby is at least six months old, your baby may be able to sleep through the night. Set reasonable expectations. For some babies, sleeping through the night means six hours, for others ten.

At six months, object permanence fully emerges. Your baby will understand that you are somewhere even when you are not within sight. This is why he laughs hysterically when you play peek-a-boo with him. If he is dependent on you rocking him or feeding him to fall asleep, then he will look for you every time he awakens for help falling back to sleep. Also, don’t be fooled into thinking that because your baby nurses or drinks from a bottle at every night time wakening, he must be hungry. Usually he’s just looking for a way to fall back to sleep.

Training starts with making sure your baby knows how to fall asleep on his own. Make sure he can fall asleep on his own at the beginning of the night. Then train for the middle of the night. Above all, make sure you and your partner are on board with the same training strategy.  Keep bedtime roughly the same time every night, and start the bedtime routine before your baby is crying from exhaustion so he can enjoy this time with you. A typical bedtime routine for an older infant is bath (if it is a bath night), formula/breastfeed, wipe gums/brush teeth, read book, lullaby, kiss, and then bed. The exact order and events do not matter much, just finish the routine BEFORE your baby falls asleep. Lay him down on his back awake so that he has an opportunity to fall asleep on his own.

Don’t be frustrated if you try to sleep train for a few days and give up. There is no such thing as “missing” a golden window of opportunity to sleep train. If it’s not working out this week, try again next week.

Ultimately, use these principles behind a soothing, consistent bedtime and bedtime routine all the way through high school!

Sweet dreams.

Click here for our podcast- Sleep from 6mo to toddler

Naline Lai, MD and Julie Kardos, MD
©2014 Two Peds in a Pod®

this post has been updated, please visit here

Despite what your grandmother says, teething is not the underlying cause of diaper rash. The underlying cause of all diaper rash is, well…the diaper. Whether your baby wears cloth or plastic diapers, the first treatment for diaper rash is to take the diaper off.

Yuck, you say? We agree. This first treatment isn’t practical. Luckily there are other ways to combat the common diaper rashes:

Contact rash- This diaper rash appears as  patches of red, dry, irritated skin. Poop smooshed  against a baby’s sensitive skin is the main source of irritation for this type of rash. Contact rash is often accentuated where the elastic part of a plastic diaper rubs against the skin. Experiment to see if one brand of disposable diapers causes more irritation than others or if the detergent used for a cloth diaper is the culprit.  Even the soap on a wipe or the friction from scrubbing off poop can exacerbate a contact rash.

Treatment: If you see a rash, use a soft, wet cloth with a gentle moisturizing soap to clean off poop or splash water gently on your baby’s bottom. Try to avoid rubbing an already irritated bottom—splash and dab, don’t  scrub. Just urine in the diaper? Just pat or fan dry the bottom and change the diaper. Don’t bother to wipe all of the urine off. After all, urea, a component of urine, is used in hand creams. In addition, after  every diaper change apply a barrier cream (one containing zinc oxide or petroleum jelly) to prevent your baby’s skin from coming into contact with the next round of irritants.

Yeast rash– This rash is caused by a type of yeast called Candida. The rash typically looks beefy red on the labia or the scrotum. “Satellite lesions” or tiny red bumps surround the beefy red central rash. Babies on antibiotics are particularly susceptible to candidal rashes. Yeast love warm, wet, dark environments  so  remove the diaper as much as possible to create a cool, dry, light environment.

Treatment: Since yeasts are a type of fungus, yeast rashes respond to antifungal creams such as clotrimazole (sold over the counter as Lotrimin in the anti-foot fungus aisle) or nystatin (prescription). Treatment can take as long as 2-3 weeks.

Pimples– Sometimes you will see a pimple, or a several pimples, in the diaper area . Pimples that look like they have pus inside of them are usually caused by overgrowth of bacteria that live on the skin or around poop. Sometimes a tiny pimple transforms into a boil, or abscess.   Suspect an abcess when a pimple grows, reddens, and becomes tender. 

Treatment: In addition to usual washing poop off with soap and water, apply an over-the-counter topical antibiotic cream or ointment to the pimples with diaper changes. Soak your baby’s bottom in a bath a couple of times a day in warm water. If you suspect a boil or abscess, take your baby to her doctor who may drain the infection and/or prescribe a prescription topical or oral antibiotic.

Eczema– If your baby has red, dry, itchy patches on her body she may have eczema and eczema  may appear anywhere… including in the diaper area. 

Treatment: In addition to applying barrier creams, treat eczema in the diaper area with hydrocortisone 1% ointment four times daily for up to one week.  

Viral– Viruses such as molluscum contageosum may cause flesh colored bumps in the diaper area. Other viruses, like the ones which cause hand-foot-mouth disease, may cause red bumps in the diaper area. Be suspicious of hand-foot-mouth disease if your see red bumps on your child’s hands and feet as well as sores in her mouth.

Reasons to bring your child to her doctor: If you are unsure of the cause or treatment for your baby’s diaper rash, then it’s time to call your pediatrician. Don’t worry… no one will think you are acting rashly. 

Julie Kardos, MD and Naline Lai, MD
©2014 Two Peds in a Pod®

We have seen many patients with nasty colds lately, and we know that a few cases of flu recently popped up in our area of the United States.  Take a look at  “Top Ten Ways to Prevent Colds and Flu,” a post we wrote recently for Mom365, to get your kids through cold and flu season. 
 
To keep yourself updated on the status of the flu, check the  Centers for Disease Control flu tracker.

The bad news: thus far three pediatric deaths from flu were reported for this 2013-2014 flu season. The good news: the latest allergy guidelines say that even egg-allergic kids, unless they have a history of anaphylaxis (difficulty breathing) to egg, can safely receive the flu vaccine. Talk to your child’s doctor if your egg-allergic child has never received flu vaccine.

Stay healthy and WASH YOUR HANDS,

Julie Kardos, MD and Naline Lai, MD

©2013 Two Peds in a Pod®

Parents ask us about fever more than any other topic, so here is what every parent needs to know:

Fever is a sign of illness. Your body makes a fever in effort to heat up and kill germs without harming your body.

Here is what fever is NOT:

· Fever is NOT an illness or disease.
· Fever does NOT cause brain damage.
· Fever does NOT cause your blood to boil.
· Unlike in the movies and popular media, fever is NOT a cause for hysteria or ice baths.
· Fever is NOT a sign of teething.

Here is what fever IS:

· In many medical books, fever is a body temperature equal to or higher than 100.4 degrees Farenheit.
· Many pediatricians, consider 101 degrees Farenheit or higher as the definition of fever once your child is over 2 months of age.
· Fever is a great defense against disease, and thus is a SIGN, or symptom, of an illness.

To understand fever, you need to understand how the immune system works.

Your body encounters a germ, usually in the form of a virus or bacteria, that it perceives to be harmful. Your brain sends a message to your body to HEAT UP, that is, make a fever, to kill the germs. Your body will never let the fever get high enough to harm itself or to cause brain damage. Only if your child is experiencing Heat Stroke (locked in a hot car in July, for example), or if your child already a specific kind of brain damage or nervous system damage (rare) can your child get hot enough to cause death.

When your body has succeeded in fighting the germ, the fever will go away. A fever reducing agent such as acetaminophen (e.g. Tylenol) or ibuprofen (e.g. Motrin) will decrease temperature temporarily but fever WILL COME BACK if your body still needs to kill off more germs.

Symptoms of fever include: feeling very cold, feeling very hot, suffering from muscle aches, headaches, and/or shaking/shivering. Fever often suppresses appetite, but thirst should remain intact: drinking is very important with a fever.

Fever may be a sign of any illness. Your child may develop fever with cold viruses, the flu, stomach viruses, pneumonia, sinusitis, meningitis, appendicitis, measles, and countless other illnesses. The trick is knowing how to tell if your child is VERY ill or just having a simple illness with fever.

Here is how to tell if your child is VERY ill with fever vs not very ill:

Any temperature in your infant younger than 8 weeks old that is 100.4 (rectal temp) degrees or higher is a fever that needs immediate attention by a health care provider, even if your infant appears relatively well. For kids over 2 months of age, take the temperature anyway you’d like, just let your pediatricians know how you took it.

Any fever that is accompanied by moderate or severe pain, change in mental state (thinking), dehydration (not drinking enough, not urinating because of not drinking enough), increased work of breathing/shortness of breath, or new rash is a fever that NEEDS TO BE EVALUATED by your child’s doctor. In addition, a fever that lasts more than three to five days in a row, even if your child appears well, should prompt you to call your child’s health care provider. Recurring fevers should also be evaluated.

Should you treat fever? As we explained, fever is an important part of fighting germs. Therefore, we do NOT advocate treating fever UNLESS the side effects of the fever are causing harm. Reduce fever if it prevents your child from drinking or sleeping, or if body aches or headaches from fever are causing discomfort. If your child is drinking well, resting comfortably or playing, or sleeping soundly, then he is handling his fever just fine and does not need a fever reducing agent just for the sake of lowering the fever.

A note about febrile seizures (seizures with fever): Some unlucky children are prone to seizures with sudden temperature fluctuations. These are called febrile seizures. This tendency often runs in families and usually occurs between the ages of 6 months to 6 years. Febrile seizures last fewer than two minutes. They usually occur with the first temperature spike of an illness (before parents even realize a fever is present) and while scary to witness, do not cause brain damage. No study has shown that giving preventative fever reducer medicine decreases the risk of having a febrile seizure. As with any first time seizure, your child should be examined by a health care provider, even if you think your child had a simple febrile seizure.

Please see our “How sick is sick?” blog post for further information about how to tell when to call your child’s health care provider for illness.

Julie Kardos, MD and Naline Lai, MD

rev © 2015 Two Peds in a Pod®

Even if breastfeeding is going great for you early on, it’s still normal to feel more tired than ever before. Today, pediatrician and breast feeding expert Dr. Esther Chung gives motivating advice on nursing:

Breastfeeding has many health benefits for babies, mothers and society.  Babies who are breastfed have lower rates of ear infections and diarrheal illnesses. They are at lower risk for asthma, obesity and even leukemia.  Mothers who breastfeed are also at lower risk for breast and ovarian cancer and they have less postpartum bleeding. 

Remember in our post about the early weeks of breastfeeding where we encouraged you to stick with it because it gets easier? Dr. Chung concurs:

For some women, breastfeeding comes easily.  They experience little discomfort, their babies latch on easily, and they produce a lot of milk.  For most, breastfeeding is challenging in the first 1-2 weeks following birth, but by the time the baby is 4-5 weeks old, breastfeeding is easy.  Having patience and trusting that your body will produce enough milk are the keys to breastfeeding success.  Maternity hospitals that employ trained professionals with International Board Certified Lactation Consultant (IBCLC) credentials have higher rates of breastfeeding.  After leaving the hospital, families can find IBCLCs in their neighborhood by entering their zip code into the International Lactation Consultant Association website, http://www.ilca.org/i4a/pages/index.cfm?pageid=3432. 

Dr Chung’s Tips to Successful Breastfeeding

• Hold your baby skin-to-skin on your chest. This means your baby’s body is in direct contact with your skin.  You may choose to wear a gown that opens in the front and your baby should wear a hat and diaper to minimize heat loss.  Skin-to-skin contact allows your baby to maintain a normal temperature and prepares him/her to feed.  As a result, most babies will search for the breast and breastfeed.
• Initiate breastfeeding within the first hour of life. 
• Request that your baby stay in your room (“rooming in”) so you can breastfeed when your baby is ready.
• Request that your baby only breastfeed – no bottles, no formula.
• Expect to breastfeed throughout the night.  Rest while your baby is resting.
• Take your baby to see his/her health care provider 2 to 3 days after leaving the hospital/birthing center.
• Find out how your workplace supports breastfeeding mothers – for example, do they provide a lactation room or other facility for mothers to pump milk during breaks?
• Discuss with your baby’s health care provider and/or your breastfeeding support group the many ways to maintain your milk supply after returning to work.
• Learn more about breast pumps, which you can rent or buy.  Some health insurance will cover related costs.

Returning to school and work may pose challenges for some women.  In 24 states, there are laws related to breastfeeding and the workplace (see http://www.ncsl.org/issues-research/health/breastfeeding-state-laws.aspx). Section 4207 of the Affordable Care Act is a federal law that requires all employers to provide time and space for women to pump milk, but employers with less than 50 employees can apply for exemption if there is undue hardship (see http://webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=24540).

Esther K. Chung, MD, MPH, FAAP

Currently a Professor of Pediatrics at Jefferson Medical College and Nemours, Dr. Chung won the 2009 Physician of the Year Award from the Pennsylvania Resource Organization for Lactation Consultants (PRO-LC) and the 2008 Special Achievement Award from the Pennsylvania Chapter of the American Academy of Pediatrics (AAP), for breastfeeding advocacy work. A member of several breastfeeding advocacy groups including the International Lactation Consultants Association, she frequently lectures nationally to healthcare professionals on breastfeeding topics.

For Two Peds in a Pod’s suggestions for how to continue breastfeeding when returning to work,  see our earlier post on this subject. Drs. Kardos and Lai

©2012 Two Peds in a Pod®

Many families know from the start  they plan to formula feed their babies. For some, this decision is based on the mom’s medical condition which precludes breastfeeding. Some base the decision  on cultural beliefs, some on personal preference. Still others have tried to breast feed but nursing does not work out.

Whatever the reason, any maternal guilt over not breastfeeding should be left behind once the decision is made to bottle feed.  We point out, “Just think of all of those college graduates who were formula fed as infants!”

Here are some tips for formula feeding:

1. Remember that babies may not be equally hungry at all meals. Sometimes newborns are full after drinking just ½ an ounce, other times they may suck down 2-3 ounces.
2. Formula takes a little longer to digest than breast milk, so while some formula fed babies eat every two hours, others feed every 3-4 hours.
3. You only have to sterilize the bottles the first time you use them. After that, washing them with warm soapy water or putting them in your dishwasher will get them clean enough.
4. If using powder formula, you may mix it with tap water to whatever temperature your baby prefers. If you drink tap water, no need to boil the water first for your baby or to buy bottled water or “nursery water” or any other special gimmicky water. For those adults who routinely boil or filter their own drinking water, continue to do the same for your infant.
   
5. When rewarming formula do not put a bottle of formula directly in the microwave Microwaving produces hotspots and most plastic bottles are not microwave safe. The American Academy of Pediatric’s advice is to rewarm a bottle in a bowl of lukewarm water. But, we know in real life, everyone smiles at us and sneaks off to use the microwave. If you must use the microwave, first transfer formula into a microwave safe container, heat for only a few seconds at a time and then mix the formula very, very well and transfer back into a bottle. Before giving the bottle to your baby, test the formula’s temperature on the inside of your wrist. This is all moot if your baby takes formula at room temperature… try room temperature… you never know.
   
6. Let your baby decide when she has had enough to eat. Don’t force her to finish up the last drop—this is the infant equivalent of your insisting on a clean plate. Teach your baby to eat when hungry and stop when she is no longer hungry. Parents have to be okay with “wasting” some formula. Make up more than you think she will need and throw out the rest.
   
7. Standard FDA-approved cow-milk based formula with iron meets most babies’ needs. Some parents have coupons for one brand over another, or prefer to buy the store brand over the name brands. Fine to toggle between brands or types of formulations (eg ready-to-feed vs. powder).
   
8. Do NOT give your infant “low iron” formula, homemade formula, goat milk, or regular cow’s milk. Call your child’s doctor if you are worried that your baby is not tolerating her standard infant formula.
9. The American Academy of Pediatrics recommends giving babies formula until one year of age, at which time you can transition your baby to whole cow’s milk. No need to go onto the toddler formulas.
   

Enjoy feeding your child. Hold her close and allow her to study your face as you feed her. Talk or sing during her meals. Formula and
breast milk have the same calorie count and a similar nutrition content. Love and food can come through a bottle. Ultimately, what works within your family is what is right for your family.

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®