Eeew! Pictured is the raw chicken I left sitting out in a pot for a day (inadvertently, of course).  The putrid mess was teaming with germs and amongst them was probably salmonella. This bacteria is in the news because of the thousands of eggs recently recalled for contamination (Centers for Disease Control , New York Times, National Public Radio.)

Non-typhoidal Salmonella usually causes fever and crampy diarrhea.  This stomach bug mainly lurks in raw poultry, raw eggs, raw beef, and unpasturized dairy products. Luckily, salmonella does not jump up and attack humans. People are safe from disease as long as they do not eat salmonella-infested food.

In the case of my pot of rotten chicken, the obvious stench warned me that it was inedible.  However, salmonella often hides in food and it is difficult to tell what is or is not contaminated.  A perfectly fine looking egg may harbor the germ. Even before this outbreak, the Centers for Disease Control estimates in the United States as many as 1 in 50 people are exposed to a contaminated egg each year.

Luckily salmonella is killed by heat and bleach.  Even if an egg has salmonella, adequate cooking will destroy the bacteria. Gone are the days when parents can feed kids soft boiled eggs in a silver cup, have kids wipe up with toast the yolk from a sunny-side up egg, or add a raw egg to a milkshake.  Instead, cook your hardboiled eggs until the yolks are green and crumble, and tolerate a little crispness to your scrambled eggs.  Wash all utensils well. The disinfecting solution used in childcare centers of ¼ cup bleach to 1 gallon water works well to sanitize counters. Do not keep perishable food, even if it is cooked, out at room temperature for more than two hours.

A mom once called me frantic because her child had just happily eaten a half-cooked chicken nugget. What if this happens to your child? Don’t panic. Watch for symptoms — the onset of diarrhea from salmonella is usually between 12 to 36 hours after exposure but can occur up to three days later.  The diarrhea can last up to 5-7 days. If symptoms occur, the general recommendation is to ride it out. Prevent dehydration by giving plenty of fluids. My simple rule to prevent dehydration is that more must go in than comes out. 

According to the American Academy of Pediatric’s 2009 infectious diseases report, antibiotic treatment may be considered for unusually severe symptoms or if your child is at risk for overwhelming infection. People at high risk for overwhelming disease include infants younger than three months old and those with abnormal immune systems (cancer, HIV, Sickle Cell disease, kids taking daily steroids for other illnesses). Using antibiotics in a typical case of salmonella not only promotes general antibiotic resistance, but in fact does not shorten the time frame for the illness. Also, the medication can prolong how long your child carries the germ in his stool.

I ended up tying the chicken up, pot and all, in a plastic grocery bag and throwing out the whole mess.  Don’t tell my husband, he is the kind of guy who gets annoyed because I throw out germy sponges on a frequent basis. If he knew, he’d probably want me to at least keep the pot. Yuck.

Naline Lai, MD with Julie Kardos, MD

©2010 Two Peds in a Pod℠

Need ideas on what to pack in your child’s lunch bag? Beware of junk food masquerading as healthy food. Dr. Roxanne Sukol, an internist who writes the popular nutrition blog Your Health is on Your Plate , mom of three children, and friend of Dr. Kardos’s from medical school, shares her insights…

What should we pack in our children’s lunch bags?  The key to retraining our children to eat real food is to restore historical patterns of food consumption.  My great-grandparents didn’t eat potato chips, corn chips, sun chips, or moon chips.  They ate a slice of whole-grain rye bread with a generous smear of butter or cream cheese.  They didn’t eat fruit roll-ups.  They ate apricots, peaches, plums, and grapes.  Fresh or dried.  Depending on where your family originated, you might have eaten a thick slice of Mexican white cheese (queso blanco), or a generous wedge of cheddar cheese, or brie.  Sunflower seeds, dried apples, roasted almonds.  Peanut butter or almond butter.  Small containers of yogurt.  Slices of cucumbers, pickles, or peppers.  All of these make good snacks or meals.  My mom is proud to have given me slices of Swiss cheese when I was a hungry toddler out for a stroll with my baby brother.  Maybe that’s how I ended up where I am today.

When my own children were toddlers, I gave them tiny cubes of frozen tofu to grasp and eat.  I packed school lunches with variations on the following theme:  1) a sandwich made with whole grain bread, 2) a container of fruit (usually apple slices, orange slices, kiwi slices, berries, or slices of pear), and 3) a small bag of homemade trail mix (usually peanuts + raisins).  The sandwich was usually turkey, mayo and lettuce; or sliced Jarlsberg cheese, sliced tomato, and cream cheese; or tuna; or peanut butter, sometimes with thin slices of banana.  On Fridays I often included a treat, like a few small chocolates. 

Homemade trail mix is one terrific snack.  It can be made with any combination of nuts, seeds, and/or dried fruit, plus bits of dark chocolate if desired.  Remember that dark chocolate is good for you (in small amounts).  Dried apple slices, apricots, kiwi or banana chips, raisins, and currants are nutritious and delicious, and so are pumpkin seeds and sunflower seeds, especially of course in homes with nut allergies.  Trail mix can be simple or involved.  Fill and secure baggies with ¼ cup servings, and refrigerate them in a closed container until it’s time to make more.  I would include grains, like rolled oats, only for children who are active and slender.

If possible (and I do know it’s a big “if”), the best way to get kids interested in increasing the amount of real food they eat is to involve them in its preparation.  That might mean smearing their own peanut butter on celery sticks before popping them into the bag.  It might mean taking slices of the very veggies they helped carry at the weekly farmer’s market.  Kids are more likely to eat the berries in their lunch bag if they picked them themselves.  There’s a much greater chance they’ll eat kohlrabi if they helped you peel it, slice it, or squeeze a fresh lemon over it.  That’s the key to healthy eating.

What do I consider junk food?  Chips of all kinds, as well as those “100 calorie packs,” which are invariably filled with 100 calories of refined carbohydrate (white flour and sugar) in the form of crackers (®Ritz), cereal (®Chex), or cookies (®Chips Ahoy).

You can even find junk food snacks for babies and toddlers now:  The main ingredients in popular ®Gerber Puffs are refined flour and sugar.  Reviewers tout: “You just peel off the top and pour when you need some pieces of food, then replace the cap and wait for the next feeding opportunity.” [Are we at the zoo?] “He would eat them all day long if I let him.” [This is not a benefit.  It means that the product is not nutritious enough to satisfy the child’s hunger.]

Beware not only of drinks that contain minimal amounts of juice, but also of juice itself.  Even 100% fruit juice is simply a concentrated sugar-delivery system.  A much better approach is to teach children to drink water when they are thirsty, (See my post entitled One Step at a Time) and to snack on fresh fruit when they are hungry.  Milk works, too, especially if they are both hungry and thirsty!

© 2010 Roxanne B. Sukol, MD, MS

TeachMed, LLC

http://yourhealthisonyourplate.com

Reprinted with permission in edited form for Two Peds in a Pod

Roxanne B. Sukol, MD is a 1995 graduate of Case Western Reserve School of Medicine.  She is board-certified in Internal Medicine and practices in suburban Cleveland, Ohio.  With special interests in the prevention and management of diabetes and obesity, Dr. Sukol writes the blog Your Health is on Your Plate .  Because her patients (the grown-ups) are the ones packing the school lunches for our patients, we thank her for this post.

Julie Kardos, MD and Naline Lai, MD

Debunking myths about soy, our guest blogger today is esteemed pediatrician Dr. Roy Benaroch. In practice near Atlanta, Georgia, he is an assistant clinical professor of pediatrics at Emory University, a father of three, and the author  of The Guide to Getting the Best Health Care for your Child  and Solving Health and Behavioral Problems from Birth through Preschool . We enjoy his blog The Pediatric Insider  and we think you will enjoy the except below.

Drs. Lai and Kardos

_____________________________

From LeeAnn: “Are soybeans (edamame) safe for my 11 year old daughter to eat? I have heard that they can ‘mess with’ her hormones?”

You want to see a freakshow? Try googling this topic. I found one essay, on a “news” site, that blamed soy products for everything from stroke to vision loss to homosexuality. On the other hand, other authors love soy: it will apparently prevent heart attacks, improve the symptoms of menopause, and help flush the toxins out of your body while improving your sex drive (women) and fracture healing (men.) On one site, in two adjacent paragraphs, I found a breathless author worrying that soy could cause breast cancer, followed by a second paragraph extolling its virtues in preventing breast cancer.

Please.

Soybeans contain a group of chemicals called “phytoestrogens” (sometimes called “isoflavones”) that are chemically somewhat similar to human estrogen hormones. In the 1970’s and 1980’s, some research showed that in the laboratory, these compounds could activate human estrogen receptors, presumably causing estrogen-like effects. So that’s the germ of truth.

But these phytoestrogens activate human estrogen receptors very, very weakly. They’re also easily broken down by cooking and processing, and by enzymes in the human body. It would take a tremendous amount of soy, eaten every day, to have anything close to a genuine hormonal effect. No human study has shown anything close to a measurable effect of consuming soy, at least not in ordinary amounts.

So: enjoy your edamame, tofu, and soy burgers. If you want to be super-careful, just don’t do all of this on the same day.

The Pediatric Insider

© 2010 Roy Benaroch, MD
Printed with permission in Two Peds in a Pod

We welcome guest blogger Dr. Alissa Packer who informs us about Cryptosporidium.

-Drs. Kardos and Lai

Here in the state of Utah we are starting to see cases of Cryptosporidium crop up. “Crypto” is a nasty bug that hides in water (both drinking and recreational), is resistant to chlorine, and caused a massive diarrhea outbreak in 2007.  Crypto is present throughout the United States and originates in the stool of an infected human or animal. The little germs then hunker down in the closest water, soil, or food, just waiting for their next host. 

If your little one becomes that next host you can look forward to diarrhea, vomiting, stomach cramps, fever, nausea and weight loss. Symptoms occur 2 to 10 days after becoming infected. These symptoms typically last, on and off, for 1 to 2 weeks. Not everyone exposed will develop symptoms–some lucky ones will be just fine.

So, does that mean you need to ditch your summer pass to the pool? Give up your fresh raspberries?  Skip that trip to the lake? Probably not. Find out how your local pool treats for crypto and what their policies are regarding swim diapers. Ultraviolet (UV) treatment is better than chlorine, and requiring swim diapers is probably a good thing. Thoroughly wash all fresh fruits and vegetables. Use common sense with good hand washing. And make sure the lake water is adequately treated before drinking it—or better yet, bring your own drinking water.

If you think your child may have crypto, visit your pediatrician so he or she can test your child’s stool. The test is a little tricky and may require a few different stool samples over several days.  If it turns out to be crypto there is a medication called nitazoxanide that can help. Also try to keep your child tanked up on fluids. A hydrated child is a happy child.

Hopefully we won’t see the same kind of outbreak we did in 2007…but if we do, you’ll be prepared.

Alissa Packer, MD
Dr. Packer is a pediatrician and mom in West Jordan, Utah. She loves kids- both the snotty nosed and the well kind, the outdoors, and good books. The above post was expanded from her original post in her wonderful blog at: southpointpediatrics.blogspot.com .  

©2010 Two Peds in a Pod℠

Earlier in the month I attended a developmental pediatrics conference in Philadelphia. The keynote speaker, Barry Zuckerman MD, professor and chairman of pediatrics at Boston University, raised a set of thoughtful questions. Parents can use the answers as a starting point for understanding how they were raised. Here are some of the questions with modifications:

        -What was it like growing up? Who was in your family? Who raised you?

        -Do you plan to raise your child like your parents raised you?

        -How did your relationship with your family evolve throughout your youth?

 
–How did your relationship with your caregivers (mother/father/aunt/grandparent/etc) differ from each other? What did you like or not like about each relationship?

 
–Did you ever feel rejected or threatened by your parents? What sort of influence do they now have on your life?

 
–Did anyone significant die during your youth? What was your earliest separation from your parents like? Were there any prolonged separations?

 
–If there were difficult times during your childhood, were there positive role models in or outside your home that you could depend on?

Some of these questions may be tougher than others to answer. Ultimately you are not your parents (although you may feel otherwise when you hear a familiar phrase escape your own lips), and likewise your children are not you. Parenting techniques that worked, or did not work, for your parents will not necessarily work, or not work, for you. However, stopping to reflect on your own youth will help you understand why you parent the way that you do.

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠

Unfortunately, constipation and potty training go together.

This should come as no surprise. Let’s consider the two favorite words of two and three-year-olds:
“Mine,” and “No.”

Now think of how these words apply to a toddler who is starting to understand the purpose of the potty. The well meaning parent says, “Honey, we want you to put your poop to the potty.”

For many toddlers, the answer is… “NO! MINE!”

The problem begins when the toddler is determined NOT to give up her own poop. The longer your child holds in the poop, the harder and more difficult it will be to pass the poop. Thus, a vicious cycle begins. Your child finds pooping painful and scary. This cycle must be interrupted. Here are some tips:

Stop potty training and go back to diapers.

Before you groan at this suggestion, hear this story:  The parents of one 2 ½-year-old were pleased that all “pee pee” was making it into the potty, but dismayed that she demanded a Pull-Up for poop. I suggested that she should wear diapers full time, and when pee AND poop go in the potty, then the princess underwear would come back. The child responded to me, “That isn’t very nice!” But guess what? That night, she pooped in the potty. Of course, her baby sibling is due in a few weeks, so we’ll see if success continues…  but regression with new babies is a topic for another blog post.

Make the poop easy to pass.
Use natural interventions: increase water throughout the day and give undiluted juice such as prune, pear, apple, or pineapple (the other juices don’t hurt but do not actually help the cause) once a day. Offer fresh fruits, fresh vegetables, and high fiber cereals (just read the labels, try for more than 3 grams per serving).  Encourage exercise.

Practice regular potty/toilet sitting.

Catch the poop when it’s naturally likely to come.  The most likely time a toddler will poop is just after eating because of the gastrocolic reflex, a reflex which causes the bowels to move after eating. After every meal, have your potty trainer sit for 2-5 minutes. Treat this as a house rule. Read a book on the potty or tell stories to help pass the time.

Teach your child to prioritize pooping over playing.
If kids “really have to go” but they are busy playing, they will hold in the poop to avoid interruption. Watch for signs of a need to defecate such as squirming (better known as the potty dance) or hiding. To avoid a power struggle, say something like, “The poop wants to come out, let’s go,” rather than, “Do you want to go to the potty now?” and reward the child for sitting, not for producing.

Some over-the-counter products can help. You should discuss dosing, timing, risks, and benefits of each with your child’s health care provider before choosing. Medicines include:

• Mineral oil: mix with something that tastes good such as juice or chocolate milk.  The brand Kondremul tastes sweet and is hidden easily in milk because it’s white. Mineral Oil makes poop so slippery that even a determined toddler will not “hold it.”
• Polyethyleneglycol (PEG) 3350 (Miralax):  with a prescribed amount of liquid, it has no taste and pulls extra water into the bowels so that the poop stays soft.
• Glycerin suppositories:  can be the “quick fix” step before you have to resort to enemas, which are more traumatic.
• Children’s laxatives such as Milk of Magnesia.
• Senna-containing products – in the past there were concerns of bowel dependency with long-term use. This concern has been questioned by specialists. Ask your doctor about the products.

At one potty training child’s three year birthday party, the poor birthday boy spent half his party trying to pass a large hard poop, the result of several days of withholding. After one small glycerin suppository and a large amount of anxiety, he rejoined his friends; leaving his parents feeling guilty that they had not paid attention to his pooping frequency prior to the party. While the goal is for our children to be completely independent potty users, we have to help our potty trainers by keeping track of the frequency and consistency of their poop in order to prevent a withholding/painful pooping/constipation cycle from starting.

Be alert to potential medical causes of constipation (as opposed to behavioral or situational) and consult your child’s health care provider if you can’t seem to remedy the problem.

In the world of young potty trainers, try to avoid power struggles, “keep things moving,” make things soft and easy, and remember that this too shall pass.

Julie Kardos, MD with Naline Lai, MD
© 2010 Two Peds in a Pod®
updated 2017

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℠