“Now what kind of soup did the doctor recommend? Was that tomato soup? Mushroom Barley?”

Headlines remind us daily that the US is officially in the midst of flu season. We are also in the midst of a really yucky cold season. We have seen numerous kids in our offices with bad colds and others with flu.

Parents ask us every day how they can tell if their child has a cold or the flu. While no method is fool proof, here are some typical differences:

The flu, caused by influenza virus, comes on suddenly and makes you feel as if you’ve been hit by a truck.

Flu almost always causes fever of 101°F or higher and some respiratory symptoms such as runny nose, cough, or sore throat (many times, all three). Children, more often than adults, sometimes will vomit and have diarrhea along with their respiratory symptoms, but contrary to popular belief, there is no such thing as “stomach flu.” In addition to the usual respiratory symptoms, the flu causes body aches, headaches, and often the sensation of your eyes burning. The fever usually lasts 5-7 days. All symptoms come on at once; there is nothing gradual about coming down with the flu.

Colds, even really yucky ones, start out gradually.

Think back to your last cold: first your throat felt scratchy or sore, then the next day your nose got stuffy or then started running profusely, then you developed a cough. Sometimes during a cold you get a fever for a few days. Sometimes you get hoarse and lose your voice. The same gradual progression of symptoms occurs in kids. In addition, kids often feel tired because of interrupted sleep from cough or nasal congestion. This tiredness leads to extra crankiness.

Usually kids still feel well enough to play and attend school with colds.

The average length of a cold is 7-10 days although sometimes it takes two weeks or more for all coughing and nasal congestion to resolve.

Important news flash about mucus:

The mucus from a cold can be thick, thin, clear, yellow, green, or white, and can change from one to the other, all in the same cold. The color of mucus does NOT tell you if your child needs an antibiotic and will not help you differentiate between a cold and the flu. Here’s a post on sinus infections vs. a cold.

Remember: colds = gradual and annoying. Flu = sudden and miserable.

If your child has a runny nose and cough, but is drinking well, playing well, sleeping well and does not have a fever and the symptoms have been around for a few days, the illness is unlikely to “turn into the flu.”

Fortunately, a vaccine against the flu is available for all kids over 6 months old

This flu vaccine can prevent the misery of the flu. In addition, vaccines against influenza save lives by preventing flu-related complications such as pneumonia, encephalitis (brain infection), and severe dehydration. Even though we are starting to see a lot of flu, it is not too late to get the flu vaccine for your child. Please schedule a flu vaccine ASAP if your child has not yet received one for this season. Parents and caregivers should also immunize themselves. We all know how well a household functions when Mom or Dad have the flu… not very well! Sadly there have been 20 children so far this flu season who died from the flu. In past years many flu deaths were in kids who did not receive the flu vaccine, so please vaccinate your children against the flu if you have not already. Unfortunately, the vaccine isn’t effective in babies younger than 6 months, so it is important to vaccinate everyone who lives or cares for a baby this young.

Be sure to read our article on ways to prevent colds and flu. As pediatricians, we remind you to WASH HANDS, make sure your child eats healthy, gets enough sleep, and avoid crowds, when possible. As moms, we add that you might want to cook up a pot of good old-fashioned chicken soup to have on hand in case illness strikes your family.

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

We wonder: do elephants get big ear infections?

“An ear infection,” we often hear parents say, “how can that be? I am so careful not to get water into her ear.”

Let us reassure you: parents do not cause ear infections. Germs cause infections. So please: no parent guilt!

When we doctors say “ear infections,” we usually refer to middle ear infections. Where exactly is the middle ear? When we look into the ear we peer down a tunnel called the ear canal. This part of the ear is considered the outer ear. At the end of the tunnel is a sealed door called the “ear drum” The medical term for ear drum is “tympanic membrane.” We’ll stick with “ear drum.” Behind the ear drum is the middle ear. As long as the ear drum (the door) leading into the middle ear is closed, water cannot enter the middle ear. Only if a child has ear tubes, or if the ear drum is ruptured, can water from a pool or bath enter the middle ear.

Now picture yourself opening the door and walking through to the middle ear. When you stand in the middle ear you will see tiny bones which help with hearing. The middle ear is the space that fills with fluid and gives you the uncomfortable sensation of pressure when you have a cold. It is the same space that gives you discomfort when you are descending in an airplane.

In the floor you will see a drain. This drain, called the Eustachian tube, helps drain fluid out of the middle ear. “Popping” your ears by swallowing opens this drain when you are descending on a flight. If fluid (usually from congestion from a cold or from allergies) sits long enough in the middle ear, it can become infected and the resulting pus causes pressure and pain. Sometimes the pressure becomes so great that it causes the ear drum to rupture and the painful infection will then drain out of the ear. Parents are often surprised to learn that this rupturing can occur both in untreated AND treated ear infections.

Beyond the middle ear is the inner ear, which houses nerves needed for hearing. Because children do not tend to get infections here, you may never hear about this part of the ear from your pediatrician (pun absolutely intended).

So, why do people talk about preventing ear infections by preventing water from getting into the ear? There is a type of ear infection called “swimmer’s ear,” formally known as “otitis externa,” which occurs in the outer ear. Swimmer’s ear usually results from a bacteria which grows in a damp environment. The water that causes this damp environment typically comes from a swimming pool, but can also come from lake, ocean, or even bath water. Swimmer’s ear can also be a result of anything that causes ear canal irritation such as eczema, hearing aids, or even beach sand. You can read more about this malady and it’s treatment and prevention here.

To summarize:

Ear infection = middle ear infection
Swimmer’s ear = outer ear infection
Cause of ear infections = germs

So, are you to blame for either type of ear infection? No, but there are associated factors which you can modify.

Wash hands to decrease spread of cold viruses.
Limit exposure to second hand smoke.
Give all vaccines on time – pneumococcal bacteria and the flu virus can cause ear infections–we have vaccines against these germs.
If your child suffers from allergies, talk to your child’s doctor about decreasing triggers in the environment and/or taking medications which might prevent middle ear fluid build-up from allergies.

Some kids who contract a lot of ear infection need help to stop further infections. Ear tubes, or “myringotomy” tubes,  promote middle ear fluid drainage before an infection occurs. Ear, nose, throat doctors (also known as ENTs or otolaryngologists) poke a hole in the ear drum leading to the middle ear and place a small tube in the hole. Through the myringotomy tubes, or “ear tubes,” fluid runs from the middle ear out into the outer ear canal before the fluid becomes infected. This drainage prevents middle ear infections from occurring.

To prevent swimmer’s ear, dry your children’s ears with a towel or blow gently with a hairdryer on cool setting after they are done swimming for the day.

We wrote this post because of the many questions we often hear about ear infections and ear anatomy. Hope the information wasn’t too eerie. Or is that EARie?

Naline Lai, MD and Julie Kardos, MD
©2018 Two Peds in a Pod®, updated from 2013

“When can I have her ears pierced?” is a question I hear fairly often in the office. Usually, I hear this question from parents of young girls, so for this post the operative pronoun will be “she.”

There really isn’t one correct medical answer to this question. I have heard pediatricians tell patients to wait until after their babies receive their first tetanus vaccine (at two months of age) but I have never heard of a case of tetanus from ear piercing, at least not in the United States. But, I wouldn’t take a younger-than-two-month-old to the mall where strangers could infect her with germs.

And yes, the mall is where I send my patients for ear piercing. If I pierced 100 ears per day, than I would feel comfortable performing this procedure. If I pierce a set of ears once a month, I am hardly an expert. Just as I would refer your child to an Ear, Nose and Throat specialist for too many ear infections for further evaluation, I refer all ear piercing families to the mall where the experts use sterile technique many times daily and are in fact qualified experts.

That said, some pediatricians do pierce ears and pride themselves on delivering the art, as well as the science, of medicine. If your pediatrician likes to perform ear piercing in the office, then consider it a convenience as well as a safe practice.

So when is the best time to pierce ears? I suggest to parents that they may wish to wait until their daughter is old enough to decide for herself if she wants her ears pierced. Some parents want to pierce earlier. Either way, here are some tips and points to consider:

• • Piercing hurts. Take it from this pediatrician who was twenty-three (in medical school, after a really difficult neuroanatomy exam) when she had her ears pierced. It is fine to pre-medicate with ibuprofen (brand names Advil, Motrin) or acetaminophen (Tylenol). She will still feel the sting of piercing but the pain medicine may help prevent some of the throbbing which occurs afterwards.
  • Some of the same techniques used to help ameliorate the sting of vaccines can also help ameliorate the sting of ear piercing. Keep in mind, after the pain of piercing with the first ear, your child may balk at piercing the second.
  • Follow the instructions for ear cleaning. It takes around 6 weeks for the wounds to heal completely.
  • Avoid dangling earrings. They can get caught on clothing or bedding and also are a choking hazard because babies/toddlers can more easily pull out the earrings and then put them into their mouths. At recess a hoop earring can snag as a child runs.
  • Some kids are allergic to gold as well as nickel. If you notice the skin around the hole becoming red, itchy, or scaly, or swollen, your child is probably having an allergic reaction to metal. The only cure is to remove the earrings.
  • Avoid piercing the cartilage of an ear. Infections occurring in the cartilage tend to be more serious than in the lobe of the ear.

Warning: Pediatricians remove embedded earring backs on an all too frequent basis. Even years after a piercing, the skin on the back of an ear may overgrow.   This malady tends to occur in kids around eight years old or older when parents are no longer taking earrings out for their children. Check your child’s ears frequently to make sure the holes are clean and the earring parts are where they should be:  in the hole in the ear, not embedded in an earlobe. Watch out, an earring can look fine from the front and you may even be able to twirl it around, but the earring back may be burying itself into the skin.

Ear piercing for some families is cultural; for others, cosmetic. Piercing your child’s ears as a baby may lead to some interesting debates later about piercing other body parts. But that’s a topic for another post.

Julie Kardos, MD and Naline Lai, MD
©2018 Two Peds in a Pod®, updated from our prior post.

Earring embedded in the back of an earlobe.

A lot of life’s issues boil down to the essentials…eat, sleep, drink, pee, poop, love and learn… for your child and yourself.  We are here to help you to carry out your parenting New Year’s resolutions in all of these areas.

1- Eat  Resolve to help your picky eater become less picky. Become more patient and creative in helping your children eat new foods.

2- Sleep Resolve to fix your child’s sleep problems. Help create a reasonable bedtime routine for your baby and end night time wakenings, and help your tired teen get better sleep.

3- Drink This year resolve to wean your toddler from the bottle/breast to a cup.

3- Pee Resolve to help your child avoid urine accidents and gain a better understanding of bed-wetting.

4- Poop For parents of newborns: resolve to help your gassy baby. For parents of toddlers: resolve to end the battle of the potty and encourage your child to potty train in a peaceful, non punitive and non-controlling way.  Help solve your child’s tendency to hold onto poop, which leads to constipation.

5- Love and Learn to understand your child’s developmental abilities in order to discipline appropriately and have reasonable expectations. Learn how and when to use “time out.”For your teen, learn how to talk with them. Help your child learn to “go it alone,” and calm test/school work anxiety.

As for us, we resolve to continue to be your source of dependable pediatric advice. We resolve to keep current with pediatric advances, remain honest, and treat your family with respect and care as we help you grow your children into confident, independent adults.

Wishing you health and peace in the New Year,
Drs. Kardos and Lai

©2018 Two Peds in a Pod®

Still looking for that gift that does not involve screen time? We’re reposting our back-to-basics gift ideas post:

0-3 months: Babies this age have perfect hearing and enjoy looking at faces and objects with contrasting colors. Music, mobiles, and bright posters are some age appropriate gift ideas. Infants self-soothe themselves through sucking- if you can figure out what your nephew’s favorite type of binkie is, wrap up a bunch-they are expensive and often mysteriously disappear.

3-6 months: Babies start to reach and grab at objects. They enjoy things big enough to hold onto and safe enough to put in their mouths- try bright colored teething rings and large plastic “keys.” We often see Sophie the Giraffe accompanying babies for their office visits. New cloth and vinyl books will likewise be appreciated; gnawed books don’t make great hand-me-downs.

6-12 months: Around six months, babies begin to sit up. Intellectually, they begin to understand “cause and effect.” Good choices of gifts include toys with large buttons that make things happen with light pressure. Toys which make sounds, play music, or cause Elmo to pop up will be a hit. For a nine-month-old old just starting to pull herself up to a standing position, a water or sand table will provide hours of entertainment in the upcoming year. Right now you can bring winter inside if you fill the water table with a mound of snow. Buy some inexpensive measuring cups and later in the summer a toddler will enjoy standing outside splashing in the water.

12-18 months: This is the age kids learn to stand and walk. They enjoy things they can push while walking such as shopping carts or plastic lawn mowers. Include gifts which promote joint attention. Joint attention is the kind of attention a child shares with people during moments of mutual discovery. Joint attention starts at two months of age when a parent smiles at their baby and their baby smiles back. Later, around 18 months, if a parent points at a dog in a book, she will look at the dog then look back at the parent and smile. A child not only shows interest in the same object, but will acknowledge that both she and the parent are interested. Joint attention is thought to be important for social and emotional growth.

18-24 months: Although kids this age cannot pedal yet, they enjoy riding on toys such as “big wheels” “Fred Flintstone” style. Dexterous enough to drink out of a cup and use a spoon and fork, toddlers can always use another place setting. Toddlers are also able to manipulate shape sorters and toys where they put a plastic ball into the top and the ball goes down a short maze/slide. They also love containers to collect things, dump out, then collect again.

Yes, older toddlers are also dexterous enough to swipe an ipad, but be aware, electronics can be a double edged sword— the same device which plays karaoke music for your daddy-toddler sing-along can be transformed into a substitute parent. The other day, a toddler was frightened of my stethoscope in the office. Instead of smiling and demonstrating to her toddler how a stethoscope does not hurt, the mother repeatedly tried to give her toddler her phone and told the child to watch a video. Fast forward a few years, and the mother will wonder why her kid fixates on her phone and does not look up at the family at the dinner table. Don’t train an addiction. A device can be entertainment, learning, and communication but it is NOT a source of comfort.

2-3 years: To encourage motor skills, offer tricycles, balls, bubbles, and boxes to crawl into and out of. Choose crayons over markers because crayons require a child to exert pressure and therefore develop hand strength. Dolls, cars, and sand boxes all foster imagination. Don’t forget those indestructible board books so kids can “read” to themselves. By now, the plastic squirting fish bath toys you bought your nephew when he was one are probably squirting out black specks of mold instead of water- get him a new set. Looking ahead, in the spring a three- year-old may start participating in team sports (although they often go the wrong way down the field) or in other classes such as dance or swimming lessons. Give your relatives the gift of a shin guards and soccer ball with a shirt. Offer to pay for swim lessons and package a gift certificate with a pair of goggles.

3-4 years: Now kids engage in elaborate imaginary play. They enjoy “dress up” clothes to create characters- super heroes, dancers, wizards, princesses, kings, queens, animals. Kids also enjoy props for their pretend play, such as plastic kitchen gadgets, magic wands, and building blocks. They become adept at pedaling tricycles or even riding small training-wheeled bikes. Other gift ideas include crayons, paint, markers, Play-doh®, or side-walk chalk. Children this age understand rules and turn-taking and can be taught simple card games such as “go fish,” “war,” and “matching.” Three-year-olds recognize colors but can’t read- so they can finally play the classic board game Candyland, and they can rote count in order to play the sequential numbers game Chutes and Ladders. Preschool kids now understand and execute the process of washing their hands independently… one problem… they can’t reach the faucets on the sink. A personalized, sturdy step stool will be appreciated for years.

5-year-olds: Since 5-year-olds can hop on one foot, games like Twister® will be fun. Kids this age start to understand time. In our world of digital clocks, get your nephew an analog clock with numbers and a minute hand… they are hard to come by. Five-year-olds also begin to understand charts— a calendar will also cause delight. They can also work jigsaw puzzles with somewhat large pieces.

8-year-olds: Kids at this point should be able to perform self help skills such as teeth brushing. Help them out with stocking stuffers such as toothbrushes with timers. They also start to understand the value of money so kids will appreciate gifts such as a real wallet or piggy bank. Eight-year-olds engage in rough and tumble play and can play outdoor games with rules. Think balls, balls, balls- soccer balls, kickballs, baseballs, tennis balls, footballs. Basic sports equipment of any sort will be a hit. Label makers will also appeal to this age group since they start to have a greater sense of ownership.

10-year-olds: Fine motor skills are quite developed and intricate arts and crafts such as weaving kits can be manipulated. Give a “cake making set” (no, not the plastic oven with a light bulb) with tubes of frosting and cake mix to bake over the winter break. Kids at this age love doodling on the long rolls of paper on our exam table. Get a kid a few rolls of banner paper to duplicate the fun. Buy two plastic recorders, one for an adult and one for a child, to play duets. The instrument is simple enough for ten-year-olds or forty-year-olds to learn on their own. Ten-year-olds value organization in their world and want to be more independent. Therefore, a watch makes a good gift at this age. And don’t forget about books: reading skills are more advanced at this age. They can read chapter books or books about subjects of interest to them. In particular, kids at this age love a good joke or riddle book.

Tweens: Your child now has a longer attention span (30-40 minutes) so building projects such as K’nex models will be of interest to her. She can now also understand directions for performing magic tricks or making animal balloons. This is a time when group identity becomes more important. Sleepovers and scouting trips are common at this age so sleeping bags and camping tents make great gifts. Tweens value their privacy – consider a present of a journal with a lock or a doorbell for her room. It’s already time to think about summer camps. Maybe you can convince the grandparents to purchase a week for your child at robotics camp or gymnastics camp this year.

Teens: If you look at factors which build a teen into a resilient adult, you will see that adult involvement in a child’s life is important. We know parents who jokingly say they renamed their teens “Door 1” and “Door 2,” since they spend more time talking to their kids’ bedroom doors than their kids. Create opportunities for one-on-one interaction by giving gifts such as a day of shopping with her aunt, tickets to a show with her uncle, or two hours at the rock climbing gym with dad.

Encourage physical activity. Sports equipment is always pricey for a teen to purchase- give the fancy sports bag he’s been eying or give a gym membership. Cool techy trackers like Fitbit will always appreciated or treat your teen to moisture wicking work-out clothes.

Sleep! Who doesn’t need it, and teens often short change themselves on sleep and fall into poor sleep habits. Help a teen enjoy a comfortable night of rest and buy luxurious high thread count pillow cases, foam memory pillows, or even a new mattress. After all, it been nearly 20 years since you bought your teen a mattress and he probably wasn’t old enough at the time to tell you if he was comfortable. Since a teen often goes to bed later than you do, a remote light control will be appreciated by all.

Adolescence is the age of abstract thinking and self awareness— Google “wall decals” and find a plethora of inexpensive ways to jazz up his or her room with inspiring quotes.

Enjoy your holiday shopping.

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

A family asked, “My toddler figured out how to climb out of the crib! How do I transition him into a bed?”

Some kids never climb out of their cribs, but sometimes families need the crib for a new sibling. If this is the case, consider if you really need the crib right away. Using a bassinet for the new baby allows the big brother/sister to get used to having a baby around. Many older siblings regress after the birth of a sibling and it can be useful to keep the older one in a crib for just a little bit longer, then use the new bed as a reward for “helping” or as a token of increased status.

The scariest part of putting your child into a bed is that your child now has access to his bedroom. So if your child is NOT yet climbing out of the crib, do not rush to transition him out. You first need to childproof the bedroom. Crawl on your hands and knees to see what you can reach. See our post on childproofing. For his safety, gate him into his room or keep the door closed. You may also need to gate the steps or gate a hallway to prevent him from wandering into more dangerous rooms, such as the kitchen, in the middle of the night. We know one family who found their child crawling around on the kitchen counters one morning.  Know that open or closed bedroom doors likely do not impact potential fire safety. It is far more important make sure your smoke detectors work.

If you have no reason to break down the crib and your child goes to sleep easily in it, there is no harm in keeping him in his crib. However, once a child is able to climb out, a child is able to fall out. So….time to get out. For many toddlers, the ability to throw a leg over the side of the crib occurs around two years of age or when the toddler reaches three feet tall. If your child is potty trained at this point, he will have easier access to the bathroom at night if he is in a bed rather than a crib, so that is another reason to move to a bed. On the other hand, many kids who are fully potty trained during the day continue to wet the bed for years, so don’t wait for dry overnight diapers to put your child into a bed. Just protect the bed mattress with a water-proof liner until your child masters night time dryness.

How to start the transition? You can talk up sleeping in a big boy/big girl bed “just like Mommy and Daddy.” Let your toddler pick out sheets or buy him ones you know he will love. For example, choose sheets in a  favorite color, or with favorite characters. Supply a pillow and blanket, but if he is used to a crib without bedding, expect the blanket or pillow to end up off the bed. You might want to continue warm pajamas until a blanket stays on. Sometimes kids want a small “kid’s sized” blanket, but sometimes a larger blanket is more apt to stay on the bed.

While kids are often excited by their new bed, remember that toddlers are creatures of habit. Their excitement might lead them to nap enthusiastically in the bed but then they may want their crib at night. Or they might fight their naps now- remember that many children give up napping between the ages of 2-5 years. If space allows, consider leaving the crib set up for the first week of sleeping in the new bed, then break down the crib once you have several successful naps and overnights in the bed.

Some kids may invite a “friend” or two into his bed: stuffed animals, pacifier, or in the case of one of Dr. Kardos’s kids, a soft Philadelphia Eagles football. Many kids fall asleep with toy cars clutched in their hands. If these friends help your child sleep better, then allow the slumber party.

Falling out of bed is common. For his first week in a bed, Dr Kardos’s first son was always found sleeping peacefully in the middle of his room on the carpet after they tucked him into his bed for the night. You can place a carpet or pillow next to the bed so when the inevitable falling overboard occurs, your child has a softer landing.

You could shorten the distance to the ground by placing a mattress, or a mattress plus the box spring, directly on the floor. Then when your child has gone for a few weeks without falling off the mattress,  “build up the bed” onto the standard bedframe.

Alternatively, your child can sleep in a bed with side rails. Note that portable side rails are made for use only on adult beds,  NOT for toddler beds or bunk beds. Guidelines for preventing injury from side rails are found here. Rails are are designed for children aged two to five years who are capable of getting in and out of an adult bed by themselves. According to safety guidelines published by Consumer Reports in 2010, “Be sure they (the rails) fit tightly with no gaps between the mattress and the rail, so that your child can’t get stuck. Leave at least 9 inches between the bed rail and the footboard and headboard of the bed.” The wall is not a bed rail substitute because a child can get trapped between the wall and the mattress.

Decide if you will teach your child to call out to you or to teach him to come into your bedroom if he needs you in the middle of the night. For everyone’s safety, be sure no clothes or clutter between his bed and yours can cause tripping in the dark. A night light in the bathroom helps as well.

As for the beginning of the night, if your child pops out of bed immediately after tucking him in, it’s not too late to teach him how to self-calm  and fall asleep in his own bed. This teaching might involve repeated walking him back to bed in a caring manner with minimal conversation besides: “I love you, good night.”

Now your child’s bedtime story will really include a bed! (For instance click here)

Julie Kardos, MD and Naline Lai, MD
Ⓒ2017 Two Peds in a PodⓇ

You don’t appreciate how much your baby has grown until you attempt a diaper change on a plane. For families, any holiday can become stressful when traveling with young children is involved. Often families travel great distances to be together and attend parties that run later than their children’s usual bedtimes. Fancy food and fancy dress are common. Well-meaning relatives who see your children once a year can be too quick to hug and kiss, sending even not-so-shy kids running. Here are some tips for safer and smoother holiday travel:

If you are flying, refrain from offering Benadryl (diphenhydramine) as a way of “insuring” sleep during a flight. Kids can have paradoxical reactions and become hyper instead of sleepy, and even if they do become sleepy, the added stimulation of flying can combine to produce an ornery, sleepy, tantrum-prone kid. Usually the drone of the plane is enough to sooth kids into slumber.

Know also that not all kids develop ear pain on planes as they descend- some sleep right through landing. However, if needed you can offer pacifiers, bottles, drinks, or healthy snacks during take-off and landing because swallowing may help prevent pressure buildup and thus discomfort in the ears. And yes, it is okay to fly with an ear infection.

Before you travel, identify the nearest children’s hospital, urgent care center, or pediatrician who is willing to see out-of-town new patients, so that if your child becomes ill enough to need medical care while you are away from home, you will already know where to go.

Traveling 400 miles away from home to spend a few days with close family and/or friends is not the time to solve your child’s chronic problems. Let’s say you have a child who is a poor sleeper and climbs into your bed every night at home. Knowing that even the best of sleepers often have difficulty sleeping in a new environment, just take your “bad sleeper” into your bed at bedtime and avoid your usual home routine of waking up every hour to walk her back into her room. Similarly, if you have a picky eater, pack her favorite portable meal as a backup for fancy dinners. One exception about problem solving to consider is when you are trying to say bye-bye to the binkie or pacifier.

Supervise your child’s eating and do not allow your child to overeat while you catch up with a distant relative or friend. Ginger-bread house vomit is DISGUSTING, as Dr. Kardos found out first-hand when one of her children ate too much of the beautiful and generously-sized ginger bread house for dessert.

Speaking of food, a good idea is to give your children a wholesome, healthy meal at home, or at your “home base,” before going to a holiday party that will be filled with food that will be foreign to your children. Hunger fuels tantrums so make sure his appetite needs are met. Then, you also won’t feel guilty letting him eat sweets at a party because he already ate healthy foods earlier in the day.

If you have a young baby, take care to avoid losing control of your ability to protect your baby from germs. Well-meaning family members love passing infants from person to person, smothering them with kisses along the way. Unfortunately, nose-to-nose kisses may spread cold and flu viruses along with holiday cheer.

On the flip side, there are some family events, such as having your 95-year-old great-grandfather meet your baby for the first time, that are once-in-a-lifetime. So while you should be cautious on behalf of your child, ultimately, heed your heart. At six weeks old, Dr. Lai’s baby traveled several hours to see her grandfather in a hospital after he had a heart attack. Dr. Lai likes to think it made her father-in-law’s recovery go more smoothly.

If you have a shy child, try to arrive early to the family gathering. This avoids the situation of walking into a house full of unfamiliar relatives or friends who can overwhelm him with their enthusiasm. Together, you and your shy child can explore the house, locate the toys, find the bathrooms, and become familiar with the party hosts. Then your child can become a greeter, or can simply play alone first before you introduce him to guests as they arrive. If possible, spend time in the days before the gathering sharing family photos and stories to familiarize your child with relatives or friends he may not see often.

Sometimes you have to remember that once you have children, their needs come before yours. Although you eagerly anticipated a holiday reunion, your child may be too young to appreciate it for more than a couple of hours . An ill, overtired child makes everyone miserable. If your child has an illness, is tired, won’t use the unfamiliar bathroom, has eaten too many cookies and has a belly ache, or is in general crying, clingy, and miserable despite your best efforts, just leave the party. You can console yourself that when your child is older his actions at that gathering will be the impetus for family legends, or at least will make for a funny story.

Enjoy your CHILD’s perspective of holidays: enjoy his pride in learning new customs, his enthusiasm for opening gifts, his joy in playing with cousins he seldom sees, his excitement in reading holiday books, and his happiness as he spends extra time with you, his parents.

We wish you all the best this holiday season!

Julie Kardos, MD and Naline Lai, MD
©2017 Two Peds in a Pod®
Updated from our 2009, 2014, and 2015 articles on these topics

Bummed about diaper rash? 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. Fortunately there are other ways to combat these 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. Grab a water bottle with a sports top and fill it with warm water to squirt on raw skin. Even better, grab mom’s squirty-bottle that she used right after delivery for cleaning, and use that to avoid rubbing baby’s bottom.

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. Examples are clotrimazole (sold over the counter as Lotrimin in the anti-foot fungus aisle of your pharmacy) and nystatin (prescription). Anytime you use a medicated cream, remember to put a barrier protection on top to prevent contact irritation. Treatment can take as long as 2-3 weeks. Even if the yeast rash disappears within less than two weeks, to insure the yeast stays away, treat for a couple days afterwards.

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 abscess 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. This 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 contagiosum 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
©2017, updated from 2014 Two Peds in a Pod®

Ben’s runny nose, as depicted by Ben

The good news is that there was only a smattering of influenza (flu) cases across the United States over the summer. The great news is that according to the Centers for Disease Control, most of the detected strains are covered in this year’s vaccine.

If you’re still hesitant to vaccinate your family, let’s talk frankly about some myths we sometimes hear about flu vaccines:

If my friend’s child has flu symptoms, I’ll just avoid their house to avoid catching the flu
False. According to the CDC , you are infectious the day before symptoms show up. So it is TOO LATE to avoid only those already sick.

My family never gets the flu so it’s not necessary to get the vaccine.
False and dangerous. Saying “My child and I have never had the flu so we don’t need the flu vaccine” is like saying, “I’ve never a car accident so I won’t wear my seat belt.”

I got the flu shot last year and then I got sick. So the flu shot must have made me sick.
Our condolences. True, you were sick. But this statement is False, because the illness was not caused by the flu vaccine. Vaccines are not real germs, so you can’t “get” a disease from the vaccine. But to your body, vaccine proteins appear very similar to real germs and your immune system will respond by making protection against the fake vaccine germ. When the real germ comes along, pow, your body already has the protection to fend off the real disease.

It is important to realize that the vaccine takes about 2 weeks to take effect in your body. So, if you were unlucky enough to be exposed to someone with the flu and then got the vaccine the next day, you still have a good chance of coming down with the flu. Unfortunately, the vaccine will not have had a chance to work yet.

Please know, however, there is a chance that for a couple days after a vaccine, you will ache and have a mild fever. The reason? Your immune system is simply revving up. But no, the flu vaccine does not give you the flu.

No one dies from the flu anymore, do they? Flu is just not that dangerous, so my child does not need a flu shot. I will just take my chances with flu.                                                                             

False! A total of 107 influenza-associated pediatric deaths were reported for the 2016-2017 season. In past seasons up to 90% of children who died from flu did not receive a flu vaccine. So please, vaccinate yourself and your children.

The vaccine coverage is awful.
Not the case this year. On the other hand, even if coverage was spotty, look at it this way— if half of the flu out there was covered, that’s a lot fewer people that won’t give your kid the flu.

Naline Lai, MD and Julie Kardos, MD

©2017 Two Peds in a Pod®

rev Oct. 10, 2017 see comments

Admit it.

Before you became a parent, you never really gave much thought to other people’s poop.

Now you are captivated and can even discuss it over meal time: your child’s poop with its changing colors and consistency. Your vocabulary for poop has likely also changed. Before your baby’s birth, you probably used some grown-up word like “bowel movement” or “stool” or perhaps some “R” rated term not appropriate to this pediatric site.

We pediatricians have many conversations with new parents, and some not-so-new parents, about poop. Mostly this topic is of great interest to parents with newborns, but this issue come out at other milestones in a child’s life, namely when starting solid foods and during potty training.

Poop comes in three basic colors that are all equal signs of normal health: brown, yellow, and green. Newborn stool, while typically yellow and mustard like, can occasionally come out in the two other colors, even if what goes in, namely breast milk or formula, stays the same. The color change is more a reflection of how long the milk takes to pass through the intestines and how much bile acid gets mixed in with the developing poop.

Bad colors of poop are: red (blood), white (complete absence of color), and tarry black. Only the first stool that babies pass on the first day of life, called meconium, is always tarry black and is normal. At any other time of life, black tarry stools are abnormal and are a sign of potential internal bleeding. You should always discuss with your child’s doctor black poop, blood in poop (this is not normal), and white poop (which could indicate a liver problem).

Normal pooping behavior for a newborn can be grunting, turning red, crying, and generally appearing as if an explosion is about to occur. As long as what comes out after all this effort is a soft (normal poop should always be soft), then this behavior is normal. Other babies poop effortlessly and this, too, is normal.

Besides its color, another topic of intense fascination to many parents is the frequency and consistency of poop. This aspect is often tied in with questions about diarrhea and constipation. Here is the scoop:

It is normal for newborns to poop during or after every feeding, although not all babies go this often. This means that if your baby feeds 8-12 times a day, then she can have 8-12 poops a day. One reason that newborns are seen every few weeks in the pediatric office is to check that they are gaining weight normally. Good weight gain means that calories taken in are enough for growth and are not just being pooped out. While normal poop can be very soft and mushy, diarrhea is watery and prevents normal weight gain.

After the first few weeks of life, a change in pooping frequency can occur. Some formula fed babies will continue their frequent pooping while others decrease to once a day or even once every 2-3 days. Some breastfed babies actually decrease their poop frequency to once a week! These babies’ guts digest breast milk so efficiently that they are left with little waste product.

As long as these less-frequently-pooping babies are feeding well, not vomiting, acting well, have soft bellies rather than hard, distended bellies, and are growing normally, then parents and other caregivers can enjoy the less frequent diaper changes. Urine frequency should remain the same (at least 6 wet diapers every 24 hours, on average) and is a sign that your baby is adequately hydrated. Again, as long as what comes out in the end is soft, then your baby is not “constipated” but rather has “decreased poop frequency.”

True constipation is poop that is hard and comes out as either small hard pellets or a large hard mass. These poops are often painful to pass and can cause small tears in the anus. You should discuss true constipation with your child’s health care provider. A typical remedy, assuming that everything else about your baby is okay, is adding a bit of prune or apple juice, generally ½ to 1 ounce, to the formula bottle once or twice daily. True constipation in general is more common in formula-fed babies than breastfed babies.

Adding solid foods generally causes poop to become more firm or formed, but not always. It DOES always cause more odor and can also add color. Dr. Kardos still remembers her surprise over her eldest’s first “sweet potato poop” as she and her husband asked each other, “Will you look at that? Isn’t this exactly how it looked when he ATE it?” If constipation, meaning hard stools that are painful to pass, occurs during solid food introductions, you can usually help soften up the poop by giving more prunes and oatmeal and less rice and bananas.

Potty training can trigger constipation resulting from poop withholding. This withholding can result in backup in the intestines which leads to pain and poor eating. Children withhold for one of three main reasons:

1. They are afraid of the toilet or potty seat.
2. They had one painful poop and they resolve never to repeat the experience by trying to never go again.
3. They are locked into a control issue with their parents. Recall the truism “You can lead a horse to water but you can’t make him drink.” This applies to potty training as well.

Treatment for stool withholding is to QUIT potty training for at least a few weeks and to ADD as much stool softening foods and drinks as possible. Good-for-poop drinks and foods include prune juice, apple juice, pear juice, water, fiber-rich breads and cereals, beans, fresh fruits and vegetables. Sometimes, under the guidance of your child’s health care provider, children need medical stool softeners or laxatives until they overcome their fear of pooping. For more information about potty training we refer you to our post with podcast on this subject.

Our goal with this blog post was to highlight some frequently-asked-about poop topics and to reassure that most things come out okay in the end. And that’s the real scoop.

Julie Kardos, MD and Naline Lai, MD
©2017 Two Peds in a Pod®