More Warm Weather Tidbits: sunscreen, swimming, bug bites, and bike helmets

Here’s a quick blast of more summer hints.

Sunscreen: Apply SPF (Sun Protection Factor) of at least 15, and use more than you think is necessary. SPF gives you an idea of how long it may take you to burn. SPF of 15 means you will take 15 times longer to burn…if you burn in one minute, that’s only 15 minutes of protection! So apply, reapply and reapply. Sunscreen is fine for even young babies. For a baby’s first application of sunscreen, test the sunscreen by rubbing a small amount (size of a quarter) on the inner forearm and watch for a reaction. Clothing and shade work best to protect the skin, but not all clothing is protective. Depending on the weave and the fabric, protection fluctuates with each piece of clothing. Look for UPF (ultraviolet protection factor) ratings. A UPF rating measures the amount of UV light that reaches your skin. Higher numbers are better. For example, a rating of 100 means 1/100 or one percent of all rays will reach the skin.

Swimming: Lessons are fun and safe for all ages (including young toddlers). Studies have shown that children who drown are more likely to NOT have had swimming lessons compared to same age children who have not drowned. Even if he graduated from swimming lessons, attend to your child around water, whether it is a swimming pool, lake, puddle or bath. Lessons are not a substitute for adult supervision. Also, do not submerge your baby underwater. Contrary to media hype, your baby will NOT automatically hold his breath.

Patients frequently ask me when pool water is safe for a baby’s skin. Frankly, I worry more about sunburn from sunlight reflecting off the water than damage from contact with pool water. Just wash her with soap and water after she is done swimming for the day. If the chlorine in a pool seems to dry your baby’s skin, apply moisturizer after her bath.

Mosquito Bites: Initially wash with soap and water. For the itch: apply hydrocortisone 1% cream or ointment up to 4 times daily. Give oral diphenhydramine (brand name Benadryl) before bedtime to prevent your child from scratching in his sleep. Signs of an infected bite include new or worsening pain, increasing redness, any pus-filled area, or red streaks extending from the bite. Swelling, itchiness, and some redness at the site of the bite are signs of local irritation but not necessarily infection.

Bike helmets: Insist on the use of bike helmets. Head trauma from falling off bikes, roller blades, scooters, and skateboards often happen in the summer when kids say they are “too hot” to wear their helmet.

I would write more, but I have to go adjust a bike helmet on my sun-screened son who is scratching his bug bite as he is getting ready to bike to a neighbor’s pool to swim, under adult supervision.

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

Childhood and Teen Depression: know the signs

It’s June, a time of hellos and goodbyes.

Change in routine can be tough. For some children and teens the transition from school year to summer unmasks depression.

The signs of depression in younger children can look different than depression in teens and young adults. Younger children are less likely to tell you that they feel sad- often because they can not pinpoint what is wrong. Of course everyone is allowed periodic “bad days”, but when there are more “bad days” than “good days” action must be taken. Below are some warning signs that your child may be depressed:

Feels down or sad much of the time

Acts angry much of the time

Acts “out of control” or has new behavior problems that seem resistant to your usual discipline measures.

Loses interest in activities which normally bring pleasure, withdraws from friends

Exhibits changes in sleep patterns-difficulty falling asleep, numerous awakenings, or excess sleeping

Has feelings of worthlessness (feelings she let a family member or teacher down, etc.)

Finds it difficult to concentrate

Performs worse in school, grades slip, or tries to avoid going to school

Shows low energy or fatigue or conversely seems restless or “hyper”

Alcohol or drug use (attempts at “self-medicating”)

Expresses thoughts of being better off dead or desires to hurt himself.

If you suspect your child is depressed, ask him the hard questions. Ask him if he is thinking of hurting himself or others. Ask if he wants to commit suicide. You will not be “planting an idea.” Asking will allow you to find the medical help he needs immediately. Not asking may lead to death. We always tell patients and their parents not to hesitate to call “911” or go to the emergency room if the patient is suicidal. After all, it is an emergency– a life is at stake.

Sometimes it’s not your child who is depressed.Your child’s friend may confide that he or she is extremely sad and may tell your child to keep the information a secret. Let your child know that her friend is giving a “cry for help” and that it is appropriate to share information with adults.

Children and teens can have “real” depression just like adults and they need treatment from an experienced health care professional just like adults do. Consequences of untreated depression, just like adults, can include loss of enjoyment in life, estrangement from friends, school or job failure, and untimely death from suicide.

Naline Lai, MD and Julie Kardos, MD

Hand Held Health Hazards: your kids and their devices

This spotted the other day- tendonitis. In plain English, wrist pain at the base of the thumb from the strain of playing too much Nintendo DS/iPod touch or texting on your phone with your thumbs.

Imagine what the iPad will bring.

Naline Lai, MD 2010

© Two Peds in a Pod

Subduing stress: relaxation techniques

As the school year comes barreling to an end, I always find an assortment of students parading through my office with stress related ailments. Struggling to keep up in class can be extremely stressful for a child. Whether the child is college aged or elementary school aged, concerned parents want to know how to prevent their child from internalizing stress. Today, psychologist Dr. Sandy Barbo provides us with relaxation techniques to deflect tension. The mom of two college-aged daughters, Dr. Barbo has worked with children and their families for over twenty years. – Dr. Lai

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Hurry, hurry, hurry!!! Off to soccer practice, or the orthodontist’s office, or swim class, or a scout meeting, or a violin lesson. Don’t forget homework, that spelling test… oh no! Wasn’t there a special poster project due soon? Quick, run into Staples to get that poster board. Oh, and yes, we can’t forget to grab some take-out because with all the rush, who had time to make dinner?

Sound familiar? We tend to live very busy lives these days and our children’s schedules reflect that in all the many activities they engage in. Even our youngest and smallest have schedules!

Busy-ness can lead to stress, but so can a host of other experiences our children live through day to day. Our kids have to juggle performance in school (getting assignments done, managing academic and extracurricular challenges), survival in social groups (peer pressure,bullying, overcoming shyness), and even the occasional external stress that filters down from the adult world (news of a disaster, parental job stress, illness in an extended family member).

How do we as parents help inoculate our kids so they can better manage the various stresses and anxieties that come their way? There are many possibilities. Here are a few:

One of the easiest and most effective stress busting strategies you can teach your child (and yourself!) has to do with the deep, diaphragmatic breath. Lie down on the floor with your child or sit upright in a comfortable chair. The trick is to align the chest above the pelvis. Make a diamond shape with your thumbs and index fingers.Show your child how to position the belly button in the middle of the diamond. Now instruct her to slowly take in a deep, filling breath so that the belly starts to raise her hands up as far as they can go. Slowly, exhale and allow the belly to sink back down. When empty, fill up again slowly, but comfortably. For some kids, it helps them to imagine they are filling a balloon with their breath and then letting it all out. When you’ve completed 3 belly breaths you’ve created a “mini”. And “minis” are wonderful as they can be done almost anywhere, anytime, incognito! Remind your child on the way to school, “Let’s do a mini”; or before going into an anxiety provoking situation; or even at the end of the day, in bed to help settle everyone down. The deep breath counters our body’s response to stress and is incompatible with anxiety which provokes shallow chest breathing. Try modeling “minis” for your child and encourage him to practice them at least 3 times each day. When you teach your child how to do “minis”, he’s learned a powerful stress buster that he can put to use whenever or wherever the need arises.

Don’t forget the good old fashioned belly laugh. We know that humor helps us reframe and relieve stress, but the deep belly laugh is also diaphragmatic and forges a healthy mind/body connection. Don’t be bashful. Suggest a tickle fest. Have a book of age-appropriate jokes around that you can share with your kids. Belly laughs are infectious. It almost doesn’t matter what silly idea starts them. Show your kids that the sillies can get the better of you too and laugh all of yourselves to the point of exhaustion.

We tend to hold our tension in our “stress triangle”the area between the shoulders and up towards the neck. Show your kid show to gently press their shoulders up towards their ears, then roll them back and relax along with those wonderful deep breaths they’ve already learned. Also, indulge in massage. Rub between your child’s shoulders. At bedtime, offer a foot massage.

Another helpful de-stressor at bedtime can be a guided imagery exercise. You become your child’s guide. Help her create her imaginary safe, relaxed place by engaging all of the senses. Pick, or have your child pick, her favorite vacation setting. Beach? Be ready to customize your guided tour to her most wonderful fantasies. Have her close her eyes, start deep breaths and use her imagination to picture herself stepping down a series of 10 steps into the setting as you slowly and in your most soothing voice count. For example:

1. You’re at the top of a set of stairs that go down the dunes to the beach. You see the beautiful beach below you.Imagine what you see. Imagine the colors all around you. (Deep breath)

2. You can see the wonderful beach scene before you,the boats on the water, the few wispy clouds in the beautiful blue sky, the gulls that fly over the water. (Deep breath)

3. You can feel the sun on your skin. It’s deliciously warm. (Deep breath)

4. A cool breeze, just the right temperature is gently blowing through your hair. (Deep breath)

5. You can hear the sound of the waves lapping at the shore. The sun is sparkling off the water. Imagine the other sounds you hear on the beach. (Deep breath)

6. You can smell all those wonderful beach smells, the sunscreen, the wet sand. You can almost taste the salty ocean water droplets as they reach your lips. (Deep breath)

7. You feel your toes in the sand. It is just the right warm temperature, soft and comfortable under your feet. (Deep breath)

8. You are at the water now. Just let your toes wiggle and feel the wonderful temperature of the water. As you wriggle your toes you can see the sea foam and the sand make wonderful patterns between your toes. (Deep breath)

9. All around you are the people you love. (Deep breath)

10. You lie down on the beach feeling so relaxed and comfortable, just resting and enjoying the wonderful sounds, smells, feelings,tastes, views of the beach. You are restful and relaxed. You are breathing deep steady breaths. Enjoy this feeling of relaxation in this safe, warm, wonderful place. In a minute, when you are ready, you can gently open your eyes or allow yourself to drift off to sleep.

The above mentioned guided imagery exercise can become a beloved ritual. My daughter’s favorite involved a meadow with a family of unicorns. Each night, I learned to tap all my creative resources to keep the characters on interesting adventures in the meadow all the while engaging my daughter’s sensory system within her fantastic imagination, as she continued to deep breathe and leave the stressors of her day behind.

Invite your kids to share when they’ve used their stress busters during the day. Model for them how to take a “mini” to manage some aggravation that comes your way. With just a little bit of practice, your child can start to use these stress-busting strategies, when challenged, to reestablish a sense of calm. It’s truly a gift that keeps on giving over and over again.

Sandy Barbo, Ph.D.

Dr. Barbo is a licensed psychologist and the mom of two college-aged daughters. She has been working with children, parents and families for over 20 years. In addition to providing psychotherapy for anxiety, depression, trauma, Dr. Barbo has developed sub-specialties in infertility, pre and post-adoption, and ADHD. Contact her at: drsandybarbo@comcast.net or P.O. Box 196, New Hope, PA 18938 telephone (215)297-5092

Managing Munchies: More healthy weight ideas

Most of us, including me, are not always health food angels. However, a family who is a regular customer at a fast food restaurant may simply not know how to break the habit. For those who still need to get those healthy eating New Year’s resolutions rolling, our February podcast, “Helping the Overweight Child,” gave the 5-4-3-2-1-0 rules for healthy eating. This post gives more hints:

BMI, or Body Mass Index (weight in kg divided by height in meters squared) is a number which indicates whether your child’s weight is normal for his or her height and age. Normal weight school aged kids DO look a bit scrawny.Children’s bellies should NOT hang over their pants. On the other hand, normal weight toddlers do look a bit pudgy. The Centers for Disease Control and Prevention has a nice BMI calculator.

Snacks aren’t needed at sports games which last only an hour. Supply water bottles and forget the snack.

Don’t feed your younger child snacks to keep him occupied during an older sibling’s event. Bring books, paper and crayons, a doll, or a matchbox car instead.

Make a stack of peanut butter and jelly or cheese sandwiches and keep them wrapped, ready to go, in the fridge. Keep some washed apple slices or carrot sticks along side the sandwiches and this stash can be your “fast food” at those times you need to feed your family “on the run”.

Don’t give your children a junky snack in order to carry them over until dinner. If your kids come home from school STARVING!!, give them a REAL dinner, and then give them a fruit or vegetable when the entire family later sits down.

holiday is one day, Halloween is October 31^st. ^.Why eat the candy for days and weeks afterwards?

Don’t keep junk food in your home. This will avoid arguments about what to eat.

Have your children ask you if they can have something to eat, rather than allowing “free access” to your pantry/refrigerator. That allows you decide if it is too close to mealtime to have a snack (remember from the Picky Eaters blog post,“hunger is the best sauce”) and will allow you to choose an appropriate snack and portion size. If kids inherently knew healthy choices and portion sizes, they wouldn’t need parents! Also this allows you to determine if the child is truly hungry, bored, or attention seeking.

Now back to the the fast food establishment I find myself in with my family. “Maybe this restaurant chain should offer a Two Peds in a Pod kid’s lunch box,” I mused as my family finished up their greasy, salty meal. Everyone’s curiosity was piqued. My husband and I began to hypothesize what kind of food would be inside a Two Peds box.

“What do you think?” I asked the kids.

“We’re actually more interested in what kind of prize would you would offer,” they said.

Gotta love my regular customers.

Naline Lai, MD and Julie Kardos, MD

Driving to distraction: cell phones and our teens

Phone Photo One of my office nurses was clearly rattled when she came into work the other day. “I was in the Acme parking lot,” she told me. “The parking was tight. As I was backing out, I saw a woman engrossed in a conversation on her cell phone driving towards me. There was nothing I could do to avoid an accident. If I pulled forward, away from the phone-talking driver, I would have hit an elderly person lugging groceries. If I backed up I would have driven into the car. I pushed against my horn. The woman did not even blink. All I could do is brace for a crash.”

Cell phones. Even for an experienced driver they can be a distraction. You would think that these kind of accidents would deter people from becoming distracted, but apparently not. Yes, they are ubiquitous. What would we do without them? Even now I am typing this post on my iPhone during my kindergardener’s swim lesson.Our teens are equally as glued to their phones. At the New Jersey shore this summer, I noticed teens away from home with no keys, no purses; just a cellphone tucked under a bikini strap. One time during an office visit with a teen,I started to talk to his mother when I noticed that he had his hand in his coat pocket. He was texting with one hand– most likely about the office visit. On week day afternoons, adults drivers know to avoid the local high schools because teens driving cars swarm into the streets, too often with phones glued to their ears. Some even text while driving.

One time I cornered a group of teens in my office.”Adults are concerned that young drivers are texting and driving simultaneously. What can be said to teens in order to make them stop?” I asked. They simply shrugged their shoulders. Nothing short of a law, they told me.

According to the Governor’s Highway Safety Association, 26 states have laws curtailing the use of cell phones (hand held or texting) while driving. In my home state of PA, legislation is currently pending. Despite what those teens in my office said, parents can and should guide their children–even without a law. Here are facts, courtesy of Pennsylvania State Representative Marguerite Quinn, to share with your teen.

Driver inattention is the leading factor in most crashes and near-crashes, according to a 2006 report by the National Highway Traffic Safety Administration and the Virginia Tech Transportation Institute.

According to the National Safety Council, traffic crashes are the leading cause of teen deaths, accounting for 44% of all teen deaths in the United States.

The 100-car Naturalistic Driving study found cell phone use associated with the highest frequency of distraction-related crashes and near-crashes.

As my office nurse found, a cell phone can be more than”just a little” distraction. Hopefully your teen will never find that out the hard way.

Naline Lai, MD

Ankle Strengthening Exercises- what to do after an ankle sprain

Today, our esteemed guest pediatric physical therapist Deborah Stack helps us with therapy for twisted ankles. Dr. Stack has been a physical therapist for over 15 years and heads The Pediatric Therapy Center of Bucks County in Pennsylvania. She holds both masters and doctoral degrees in physical therapy from Thomas Jefferson University.

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As I watched my ten-year-old play basketball today, my first question was “Will my child might finally get the ball into the basket?” My second question was, “Will all the kids make it through the game without spraining an ankle?

Kids are playing competitive sports at younger and younger ages and children are suffering sports injuries earlier as well. Acute ankle trauma is responsible for 10 to 30 percent of sports-related injuries in young athletes.¹With all the rapid starts, stops, and turns on the basketball court some injury is inevitable. But what is an ankle sprain? What can you do to help your child from joining the crutches crew? What do kids need to do to get back to full play after an injury?

A sprain is stretching and or tearing of ligaments that connect bones to one another. Sprains are graded from one to three with one being the mildest and three being the most severe. In a grade one sprain the ligament simply is overstretched. Grade two sprains involve partial tearing of the ligaments and grade three feature a complete tear. This could happen for a multitude of reasons, from play or even an accident that might not have been their fault, this type of sprain may need attention from a doctor, especially if it is after an accident.

The most common ankle sprain is an inversion sprain where the ankle turns over so the sole of the foot faces inward and damages the ligaments on the outside of the ankle. In younger children, the ligaments tend to be stronger than their bones,so growth plate fractures occur instead of sprains. Therefore, if a child refuses to walk on his leg or seems to be in excessive pain, you should have your pediatrician rule out a fracture.

To help avoid injury, make sure those sneakers are in good condition. Pull laces snug and tie them securely. High top sneakers are recommended for basketball for added protection. Physically three things are needed for a healthy ankle: range of motion, muscular control, and proprioception. Proprioception is the information that comes from your joints and muscles to your brain and lets your brain know what position the ankle is in.

My child turned his ankle. Now what do I do? Remember the acronym RICE: rest, ice, compression, elevation. Rest means to stay off the ankle. For more severe sprains this may mean using crutches for a few days. Ice should be applied (over a thin towel to protect skin) immediately and then for up to 20 minutes every few hours until swelling is minimal. Compression refers to wrapping an elastic bandage over the area. When you use a bandage, it is important to make sure the bandage is not too tight and that any bandage is wrapped at an angle, not straight around the leg, to prevent circulatory problems. The ankle should also be elevated above the level of the heart several times a day while swelling is still present. Recline on the couch while putting ice on for 20 minutes.

How does your future Olympian get back into the game? Range of motion exercises can begin as soon as they can be done without pain, preferably in 48-72 hours. Ankle circles and alphabet letters (below) are two good exercises. These should then be followed by isometric (muscle contraction without movement) and isotonic strengthening exercises (toe and heel raises, see below) such as the ankle heals. Finally, rehab is not complete until the child works to regain proprioception on balance boards, compliant foam etc. One low-tech option is to stand on a firm pillow while watching television. For a bit more excitement, try some Wii balance board games. Remember, full ligaments strength does not return until months after an ankle sprain.²Without full rehabilitation, the ankle is prone to reinjury.

So tell your child to play, but play smart. An ankle sprain is a real injury and needs proper attention before your child returns to the court.

Exercises

Ankle circles³
Sit on the floor with your legs stretched out in front of you. Move your ankle from side to side, up and down and around in circles. Do five to ten circles in each direction at least three times per day.

Alphabet Letters³
Using your big toe as a “pencil,” try to write the letters of the alphabet in the air. Do the entire alphabet two or three times per day.

Toe Raises⁴
Pull your toes back toward you while keeping your knee as straight as you can. Hold for 15 seconds. Do this ten times at least three times per day.

Heel Raises⁴
Point your toes away from you while keeping your knee as straight as you can.Hold for 15 seconds. Do this ten times at least three times per day.

1. Perelman M, Leveille D, DeLeonibus J, Hartman R, Klein J,Handelman R, et al. Inversion lateral ankle trauma: differential diagnosis, review of the literature, and prospective study. J Foot Surg. 1987;26:95–135.

2. Wolfe MW, Uhi T, McCluskey, L.Management of Ankle Sprains. Am Fam Physician 2001;63:93–104.

3. http://www.med.umich.edu/1libr/sma/sma_anksprai_rex.htm

4. http://familydoctor.org/online/famdocen/home/healthy/physical/injuries/010.html

Always something-those rubber bands

The newest trend in kidville- trading rubber bands in various shapes. The kids wear the bands like bracelets and strut around with the colorful bands jutting out in all directions from their arms and wrists. The elementary school crowd is fascinated by them. Teachers, who find them a distraction, are not as enamored. Somewhere there is one teacher today who is particularly appalled. During a check up, a nine year old told me today that a classmate was sent to the nurse’s office- the reason? The bands were on so tight that they were cutting off circulation to the classmate’s arm.

Always something.

Naline Lai, MD

Holes In Your Head: Sinus Infections

You have a hole in your head.

Actually, you have several.

You, your children, and everyone else. These holes are called sinuses.

These dratted air pockets in your skull can fill with puss and cause sinus infections. Scientists hypothesize they once helped us equilibrate water pressure during swimming. Now, sinuses seem only to cause headaches.

Sinuses are wedged in your cheek bones (maxillary sinuses), behind your nose (ethmoid sinuses) and in the bones over your forehead (frontal sinuses). When your child has a cold or allergies, fluid can build up in the sinuses. Normally, the sinuses drain into the back of your nose. If your child’s sinuses don’t drain because of unlucky anatomy, the sludge from her cold may become superinfected with bacteria and becomes too thick to move. Subsequently, pressure builds up in her sinuses and causes pain. A sinus infection of the frontal sinuses manifests itself as pressure over the forehead. The pain is exacerbated when she bends her head forward because the fluid sloshes around in the sinuses. Since frontal sinuses do not fully develop until around ten years old, young children escape frontal sinus infections.

Another sign of infection is the increased urge to brush the top row of teeth because the roots of the teeth protrude near the maxillary sinuses. Bad breath caused by bacterial infested post nasal drip can also be a sign.

The nasal discharge associated with bacterial sinus infections can be green/yellow and gooey. However, nasal drainage from a cold virus is often green/yellow on the third to fourth day. If your child has green boogies on the third or fourth day of a cold, does not have a fever, and is comfortable, have patience. The color should revert to clear. However, if the cold continues past ten days, studies have shown that a large percentage of the nasal secretions have developed into a bacterial sinus infection.

Because toddlers in group childcare often have back-to-back colds, it may seem as if he constantly has a bacterial sinus infection. However, if there is a break in symptoms, even for one day, it is a sign that a cold has ended.

Hydrate your child well when she has a sinus infection. Your child’s body will use the liquid to dilute some of the goo and the thinner goo will be easier for her body to drain. Since sinus infections are caused by bacteria, your pediatrician may recommend an antibiotic. The usual duration of the medicine is ten days, but for chronic sinus infections, two to four weeks may be necessary. Misnamed, “sinus washes” do not penetrate deep into the sinuses; however, they can give relief by mobilizing nasal secretions. When using a wash, ask the pharmacist for one with a low flow. Although the over the counter cold and sinus medicines claim to offer relief, they may have more side effects than good effects. Avoid using them in young children and infants.

Who knows. Someday we’ll discover a purpose to having gooey pockets in our skulls. In the meantime, you can tease your children about the holes in their heads.

Dry winter skin – guidance from a guru

It’s that itchy, scratchy time of year. Today our guest blogger, dermatologist Mary Toporcer MD, gives us hints on how to combat dry skin. For the past 21 years, Dr. Toporcer has practiced general medical dermatology in Doylestown, PA. She did her dermatology training at Hahnemann University and at St Christopher’s Hospital, both in Philadelphia, PA.

Many patients suffer from severe dry skin (xerosis) in the winter when the air is cold and the humidity low. Those who are atopic (have a personal or family history of eczema, allergies, asthma, hayfever or sinus problems) are much more affected by their environment. A few MUST DO’s include:

1. Moisture every day especially after bathing with Cerave Cream or Lotion. It contains ceramides which “waterproofs”the skin and keeps moisture in, but without that greasy feel.

2. Use gentle soaps such as Dove in the shower and keep the shower water luke warm, not hot. Hot water just irritates and ultimately dries the skin even more. It also increases itch.

3. Avoid irritants such as anti-static sheets in the dryer. Even if they say “free”, they still put a coating on your clothing in an effort to prevent it from sticking together. This substance is very irritating to dry, sensitive skin. Liquid, fragrance-free fabric softener is much gentler on skin.

4. Lastly, for those terribly dry, scaly, fissured hands and feet, try vaseline or Aquaphor under the soft stretchy gloves and socks that you can buy at Bath and Body Works…they’re often impregnated with aloe for extra moisture.

Mary Toporcer, MD