Our guest blogger today is Dr. Jason Komasz. Practicing pediatrics in Pennsylvania for nearly a decade, he is the father of two and a respected colleague.

“Can’t you just call in an antibiotic for me?”
As doctors we hear this question a lot.  Parents are often disappointed and upset when we answer that question with a “No.”  Your child is sick, you missed the Saturday office hours, and now you can’t schedule an appointment until Monday morning.  There are reasons why doctors usually do, and should, answer “no” to this question.

1. Not every illness requires an antibiotic. Only bacterial illnesses respond to antibiotics and many illnesses are viral. In fact, misuse of antibiotics can lead to antibiotic resistance in our population.

2. The physical exam is very important in the evaluation of a patient.  The exam helps doctors determine if a patient needs antibiotics, and if so, what type.  If we do not see a patient, we are “flying blind.”  This puts the patient as risk for misdiagnosis and incorrect treatment.

3. Antibiotic use before a patient is evaluated can affect laboratory results. For example, after starting antibiotics, Strep Throat and urinary tract infection tests may be inaccurate and therefore obligate the patient to an unnecessary course of antibiotics.

4. All but the most severely ill patients can usually be managed at home with pain/fever control and symptomatic care (fluids, etc) until they can be evaluated by a doctor.

5. If your child is ill enough to require an antibiotic, he is sick enough to need an evaluation by a physician.  It is better to wait in an ER and receive proper care than to just treat without proper evaluation.

As always, your physician is trying to do what is best for your child.  Your doctor should always be able to offer an explanation for why he or she is choosing a particular course of action for your child’s illness.  We do not want them to suffer, just as you don’t.  Just remember, the antibiotic is not always the answer.

Jason M. Komasz, M.D., F.A.A.P.
© 2010 Two Peds in a Pod®

In honor of Father’s Day, we bring you our second “Top Ten” list.

Top ten skills you acquire as a father:

10. The ability to attract swarms of women if you walk in the park or the grocery store with your infant.

9. Tolerance of temperature extremes at the skating rink or on the ball field.

8. Not being completely grossed out by spit up on your nicely pressed shirt.

7. The ability to sit patiently through a 3 hour ballet recital, school music concert or graduation.

6. The ability to sit patiently through an endless one hour television show featuring some sort of dancing and singing animal and then to stand in an hour long line to buy the stuffed toy version of the animal.

5. The skill to coach teams for which you last played the sport twenty years ago.

            4. The ability to swing a child, “again!”, “again!”,  and “again!”

3. The ability not only to get through a day after one (or many) completely interrupted night’s sleep, but to wake up in the morning having forgotten about the interruptions.

2. An ability to seize the moment and create great memories for your child: you ignore the dishes, the garbage, and the dirty bathrooms in lieu of an impromptu wrestling match.

1. Ability to love more than you ever thought possible, and the ability (finally) to understand just how much your father loves you.

Happy Father’s Day from Two Peds in a Pod!

Julie Kardos, MD and Naline Lai, MD

© 2010 Two Peds in a Pod℠

“I need a nap!”—recognize this tired parent?

OKAY, let’s take a quick survey: how many of you have ever put your over-tired young child into the car, then driven on a bumpy road on a route known for its paucity of traffic lights, looking in the rearview mirror hoping to see a sleeping child?

How many of you have ever rocked your young child until you BOTH have fallen asleep in the chair?

How many of you have purposefully keep your child AWAKE in the car in order to get home before nap time, doing anything to keep her awake? Otherwise, you predict, if  your child falls asleep on the five minute car ride home, she will wake up when you try to transfer her to the crib. If that occurs you will lose the nap for the rest of the day and she will be MISERABLE (and, hence, so will you).

How precious is nap time? All parents know the answer to this question: VERY VERY PRECIOUS! Parents spend the time during a baby or toddler’s nap to pay bills, do laundry, prepare a meal, clean the house, spend time with an older sibling, and perhaps most importantly, TO TAKE A NAP OURSELVES.

Yet all children outgrow their need to nap sooner or later (at least, until they become parents themselves). The exact time this dreaded day comes can vary. The range is typically between two and five years of age. And children do not always give up their naps all at once. One day they do not nap, then they nap the rest of the week, then they don’t nap for a few days, then they nap one day, and so forth. Sometimes they fall asleep only if they happen to be in the car. Eventually your child will sleep only overnight and not at all during the day.

Naps are very important for young children. Not only do naps foster better cheer, better learning, and better behavior, but also good naps actually help improve night time sleep. Any parent can attest that an overtired toddler has a WORSE night sleep than a toddler who goes into bedtime well-rested. This is one of the great paradoxes of childhood. I like to explain to my patients: “Good sleep begets good sleep.”

Just as you invest your time and effort in taking good care of baby teeth only to have them all fall out later, you should invest your time and effort in establishing good nap habits for your young child, even though your child eventually gives up her nap. Start by making sure she can fall asleep on her own during her NIGHT bedtime routine (see our podcast on this subject) . If she can fall asleep on her own at night, she will be more apt to fall asleep in the day.  Darken the room and give her other signals associated with sleep such as her favorite stuffed animal or lullaby. Have a short “nap time routine” just as you have a night time routine. Save the serious sleep training for night time- you do not have the luxury of hours to train in the day.  If she does not fall asleep within half an hour, get her up and struggle through the rest of the day, or try again later.

If she still will not nap after several days of trying, go ahead and do whatever it takes to have a happy kid by dinner. Take that car ride, rock her to sleep… understand that the “fix” is temporary. Either she will give up the “nap rebellion” or she will give up the nap entirely. Continue to put your non-napper in bed at night earlier to make up for her lack of daytime sleep.  When your child is mostly cheerful, not throwing an unusual number of toddler tantrums, and is at least two years old, then likely she has truly outgrown her need to nap.

In the meantime, go grab some Zzzzzs. I know some of you only have time to read this post because your child is napping. So go follow suit!!

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

Ten years ago I watched a very sick, feverish toddler arch his back on my exam table while a high pitched screech weakly escaped his mouth as I tried to examine him. Attempts by his mother to cradle him in her arms only resulted in more pain.

The diagnosis –– bacterial meningitis, puss in the spinal cord and around the brain.

The culprit ––a potentially deadly germ called Streptococcus pneumonia.

A few months after I saw that toddler with meningitis, a vaccine against Strep pneumonia, under the brand name Prevnar-7, entered the market. I often wonder how outcomes would have differed for that toddler if the vaccine had been released earlier.

In addition to causing bacterial meningitis in children, this pneumococcal germ is also responsible for other forms of invasive disease such as pneumonia and overwhelming infection in the blood (sepsis). After Prevnar-7 entered the market in 2000, the number of children contracting invasive pneumococcal disease dropped by 76 percent. This decrease was seen in children under age five years, the most common age group for contracting pneumococcal disease. Vaccines at work!

The original Prevnar-7 offered protection against 7 types of the pneumococcal germ. But other types which weren’t targeted by Prevnar continued to cause infections. A new vaccine called Prevnar-13 offers protection against six additional types.

How does the release of the new Prevnar-13 affect your child? Recently, the American Academy of Pediatrics released its immunization recommendations:

–If your child has never been immunized against Pneumococcus, he will receive Prevnar-13 instead of Prevnar-7 on the same schedule as in the past. The series of four doses total are given at two months of age, four months, six months, and lastly a booster dose at 12-15 months of age. 
–If your child is under five years old but has completed the full Prevnar-7 schedule, he will need at least one dose of Prevnar-13 to be fully protected.
–If your child is in the middle of the Prevnar series, he will likely complete the series with Prevnar-13. 
–Children from 6 years to 18 years of age who are at very high risk for complications (e.g., children with sickle cell anemia and cochlear implants) may consider at least one dose of Prevnar-13 along with their usual “high risk” pneumovax 23 vaccine. 

At this point there aren’t any recommendations to immunize non-high-risk children after five years of age because for most children, the risk of contracting life-threatening illness from this germ dramatically decreases after age five.

There’s more protection out there against more streptococcal pneumonia. Go get it!

For the full AAP recommendations see the online version of the AAP Policy Statement May 24, 1010 at www.pediatrics.org.

See also: Center for Disease Control March 12, 2010 Mobidity and Mortality Weekly Report for information about the impact of Prevnar on invasive pneumococcal disease.

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠

Sand and specks of dried seaweed fly into the air. Your kids are on the beach shoveling their way to China.  “Watch out!” you yell. “Watch those shovels! The ocean is big. The beach is big. You don’t need to be right on top of each other.  There is plenty of sand for everyone.”

You sigh and go back to counting snacks and unearthing buried flip-flops.  You look back at the kids. Aw, you think to your self, they look so cute. Just as you reach for the camera, the idyllic moment is shattered. Your youngest is holding his eye and everyone, even the kid who threw sand into the injured child’s face, is crying.

Quickly you grab a water bottle and flush the irritating granules out of his eye.  Satisfied nothing is left, you ask, “Does that feel better?”  Your child ruefully nods, and resumes holding his eye.  An hour later his eye is still watering. What next?

With any eye injury, pain, watery eyes or visual changes are all reasons to seek medical care. In this case, the sand or a little wood chip probably caused a scratch on the outer layer of the eye.  This layer, called the cornea, heals very quickly. But like a scratch on any part of the body, the major potential complication is infection.

The most common way for health care providers to find a scratch on the cornea is to place a dye (fluorescine) into the injured eye. This dye glows under black light. The dye pools wherever there is a depression or scratch on the eye. Pictured here is a photo of a child I saw in the office the other day. The scratch is marked with an arrow. If an abrasion is found, your child’s doctor will prescribe antibiotic eye drops to prevent infection.  Placing a patch over the eye has not been shown to hasten healing. However, for comfort, some children prefer putting on an eye patch for a day.

It’s a good thing our eyes are set back in our skulls, otherwise, we’d constantly have scratches on our eyes. Despite any precautions you may take, accidents still happen. Years ago a nurse I knew accidentally rolled over in bed and scratched her spouse’s eye with her diamond engagement ring.  Imagine explaining that to the in-laws.

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠

“Mom, can we do screen?”

My kids ask me this question when they are bored.  Never mind the basement full of toys and games, the outdoor sports equipment, or the numerous books on our shelves. They’d watch any screen whether television, hand-held video game, or computer for hours if I let them. But I notice that on days I give in, my children bicker more and engage in less creative play than on days that I don’t allow some screen time.

Babies who watch television develop language slower than their screen-free counterparts (despite what the makers of “educational videos” claim) and children who log in more screen time are prone to obesity, insomnia, and behavior difficulties.  The American Academy of Pediatrics recommends no more than two hours of television watching a day for kids over the age of two years, and NO television for those younger than two.

Over the years, parents have given me tips on how they limit screen time. Here are some ideas for cutting back:

• Have children who play a musical instrument earn screen time by practicing music. Have children who play a sport earn screen time by practicing their sport.
• Turn off the screen during the week. Limit screen to weekends or one day per week.
• Set a predetermined time limit on screen time, such as 30 minutes or one hour per day. If your child chooses, she can skip a day to accumulate and “save” for a longer movie or longer video game.
• Take the TV, personal computer, and video games out of your children’s bedrooms. Be a good role model by taking them out of your own bedroom as well.
• Turn off the TV during meals.
• Turn off the TV as background noise. Turn on music instead.
• Have books available to read in relaxing places in the house (near couches, beds, etc.). When kids flop on the couch they will pick up a book to relax instead of reaching for the remote control.
• Give kids a weekly “TV/screen allowance” with parameters such as no screen before homework is done, no screen right before bed, etc. Let the kids decide how to “spend” their allowance.

Not that I am averse to “family movie night,” and I understand the value of plunking an ill child in front of a video in order to take his mind off his ailment. In fact, Dr. Lai lives in a house with three iPod Touches, two iPhones, a Nintendo DS and three computers. But I do find it frightening to watch my otherwise very animated children lose all facial expression as they tune in to a television show.

For more information about how screen time affects children, see the American Academy of Pediatrics web site (www.aap.org) and put in “television” in the search box.

Let us know how you dissuade your children from the allure of the screen.

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

Eeek, you say to yourself when you see your child’s bright red cheeks. I forgot to apply enough sunscreen.  Other than the splash of color, however, your kid is acting fine and does not say his face hurts. You are perplexed…and it has been raining most of this week. 

Another reason for stomach acid-churning parental guilt?

 A day or two later, your child breaks out in a lacy, light pink rash mainly on his upper arms, thighs and chest.  So it’s NOT sunburn. It’s the common childhood illness Fifth’s disease. This illness, your child’s doctor tells you, was the fifth childhood rash to be classified. Also called Parvovirus, it won’t impact him very much. Occasionally there are mild cold symptoms, headache, or fever before the rash and the rash is not particularly itchy. Within a week the rash fades, but it can come and go for a few weeks. Sun, exercise and heat can bring out the rash. As a bonus, your child now has life-long immunity (protection) to the disease. You only get it once.

Pictured is the characteristic facial rash often described as “slapped cheeks.” Also pictured is the “lacy” rash on a child’s arm.

If the symptoms are mild, then why do we care about diagnosing Fifth’s disease?  If your child has certain types of chronic anemia, parvovirus can make the anemia much worse. But for most families, the impact of the disease is not on the child who catches it but on the child’s contacts.  If a pregnant woman contracts the disease, the disease can be lethal to the fetus.  Luckily, most women already contracted the disease in childhood and have immunity against the germ.  In adults who did not have the disease as a child, parvovirus can cause achy joints in the hands and feet.

The tricky thing about preventing spread of fifth disease is that children are NO LONGER CONTAGEOUS once they have the rash. They expose others before parents realize their children are sick. The virus is spread through respiratory secretions and saliva-another reason to teach your children to wash their hands.

Again, if your child comes down with Fifth’s disease, remember to tell any pregnant contacts (teachers, friends’ moms, etc) so that they can let their obstetricians know about their exposure.

As a precaution when I was pregnant, my obstetrician checked my parvovirus immunity.  “Wow,” he said, “those are some of the highest levels of immunity I have seen.” When it comes to parvovirus, I suppose a history of being around sick kids can be good for you.

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod^℠

Here is a photo of a lovely plant nestled along side the bicycle path my family rode on over the weekend. Recognize it? “Leaves of three, let them be!”- That’s right, it’s either poison oak or poison ivy. In this case my iphone captured poison ivy in its late spring glory. As we rode along I barked at my family to avoid the poison ivy, reminded them about Lyme ticks, rubbed in sunscreen, fitted bike helmets and fretted over everyone’s hydration status.  Nothing is more jovial and carefree than a bike ride with your pediatrician mom!

A parent recently wrote us to about her three and one–half year old child’s scheduled field trip to a nature center.  “I really wanted my child to attend,” the parent wrote,” but felt uncomfortable without attending with him.  I asked if it would be okay if I went, but was told no because it would be distracting to the children. In addition, I had to sign a release of responsibility…  Most of his classmates are attending and the parents don’t seem to be concerned.”

Next week Dr. Kardos’s child will go on a class trip to a farm.  Last week one of Dr. Lai’s children went with her class to a colonial plantation.  Spring field trips often are the highlight of a child’s school year and take learning to a different level. Sometimes you are asked to chaperone as a parent, but what if you aren’t invited along? Particularly for parents of young children, it can be disconcerting when their children are taken out of a familiar structured class environnment. Here are some steps you can take to insure their safety:

Check adult to child supervisory ratios. Developmentally appropriate ratios should be kept whether in the classroom or on trips.   According to Caring for our Children (the national health and safety performance standards for out-of-home child care programs), for three year olds the maximum recommended child: staff ratio is 7:1, for four and five year olds the ratio is 8:1, for 6-8 year olds the ratio is 10:1,  and for 9-12 years old 12:1

Ask teachers how they keep track of children. Often groups will have children wear the same brightly colored t-shirt.  Usually, children are counted at several points during a visit.

Ask if previous class trips to the same place have gone smoothly. Chances are, the supervisory teacher has been to the site so many times that she knows every nook and cranny.

Check how the children will be transported.  Ideally, they are transported with age appropriate restraints. If they will be traveling in the traditional school bus, review bus safety with your child including sitting down and facing forward during the ride.

Be comfortable with the school’s emergency procedures and notifications.

Remind your child to continue his good health habits even if you are not present. For instance, wash hands prior to eating and after going to the potty.

Get to know the adult supervisors.  Connecting with the adult to whom you are entrusting your child will make you feel more comfortable when your child leaves school grounds.

Go ahead and visit the field trip site ahead of time if you need to visualize your child at his field trip. Who knows, you may emerge with plans to go again for a future birthday party.

Remember your goal is to grow a confident kid. Send the signals to your child that he will have a fun time- not that you will be watching the clock every second he is gone. Otherwise, he may approach the trip, and later other new situations, with trepidation rather than anticipation.

If there are medical or behavioral concerns, discuss them with your pediatrician and the adult supervisors before the trip. Since my own children have food allergies, I call teachers in advance to make sure there is an adult who is,if needed, comfortable administering an emergency shot of epinephrine. If you know your child has ADHD and needs constant redirection, perhaps additional adult supervision (not necessarily yourself) can be arranged.

Remember too that the reason parents need to sign permission slips before their children attend field trips is that parents have a choice. If you are not convinced about the value of a particular trip, by all means do not send your child. 

Like many steps toward independence, a field trip can be a growing experience for a child but nerve wracking for a parent. Reassure yourself that you are not sending your child off to an unsafe environment and then take pride when she returns confident, safe, and sound, and asking when she can go on another field trip.

Naline Lai, MD

© 2010 Two Peds in a Pod

I heaved a sigh of relief. My children and their friend 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 band aids. 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 band aids 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 infection is to wash out a wound. 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 skin (Staphylococcus or Streptococcus) find an opportunity to enter the body. 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, a deep cleansing is more important than ever.
While infection is rarely introduced from whatever cuts the child, exceptions include cuts caused by animal or human bites (the human mouth is particularly filthy) or 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, but at home soap and running water are effective. Stay away from hydrogen peroxide because it can irritate rather than help the skin. Stay away from rubbing alcohol because it hurts and is not necessary if soap and water are used.

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

© 2010 Two Peds in a Pod®