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Last week a nurse in my office rushed a one year old girl back to one of my exam rooms. She was sitting in her mom’s lap, anxious and breathing hard. Her nostrils flared with every breath she took, and when I had her mom pull up the child’s shirt, I could see her ribs every time she inhaled because she was using extra muscles in her chest to breathe.  Her belly was moving in and out as well. Her breathing had just become labored an hour before the office visit.  The child had similar experiences in the past and now carries the diagnosis of asthma.

Asthma. Parents initially cringe at the diagnosis. But what is it? Most children with asthma never show up in the office with an attack as severe as the child I described above.

Asthma is a condition where the millions of airway tubes (called bronchioles) throughout the lungs get clogged with mucus (inflammation) and also get narrower (constrict) and thus become harder to breathe through. Medicine reverses the effects of asthma. Think of asthma as sensitive airways.  A nasty cold virus or the billowing dust cloud from cleaning the garage makes everyone’s airway spasm. In kids with asthma, the spasm may be more severe, resulting in more cough or airway tightening.

Asthma is the most common on-going illness in children. Many babies and toddlers who have asthma have a good likelihood of outgrowing it by age three. Another subset of children, again especially below age three, have ONE episode that looks for all the world like asthma, but then they never have another episode.  Other kids have asthma that stays and these kids and their families must proactively manage their asthma long term.

Asthma symptoms can start at any point, from infancy through the teen years. Adults can be diagnosed with asthma for the first time at age fifty.  Dr. Lai has had symptoms of asthma since childhood but Dr. Kardos first had symptoms of asthma when she turned thirty.

The tendency to develop asthma is genetic, but there are environmental triggers in kids who carry the asthma gene. The most common triggers of asthma flares are cold viruses, cigarette smoke, and environmental allergies (animals, pollen, etc). Also, air pollution, exercise, and very strong scents (new house paint or perfume, for example) can trigger an asthma attack. It is also common for someone with asthma to have allergies and/or eczema (excessively dry, irritated skin).

How do you know your child has asthma? No one test can definitively identify asthma.  Chest x-rays cannot show asthma. Sometimes Pulmonary Function Testing  in older children helps doctors diagnose asthma, but younger kids often have a hard time performing the test.

Pediatricians diagnose asthma by studying the past experiences of the child.  Not every child is out of breath like the patient I saw in the office. The most common symptom of asthma is cough.  Watch for the following symptoms:

1. Night time cough most nights of the week, usually starting somewhere after midnight. The child may or may not wake up because of the cough.
2. Cough that shows up with exercise, usually after several minutes of running, swimming, jumping, even laughing.
3. Cough with a common cold virus that lasts much longer than what is typical—longer than two weeks after the onset of a cold when most other kids or siblings with the same cold are better.
4. Cough that is accompanied by increased work of breathing. Your child’s nostrils may flare in and out with each breath, or her ribs might stick out with each breath, or her breathing rate is much higher than baseline as if she were just running hard even when she is just resting. She might not be able to talk in complete sentences, drink, or eat because she is too short of breath.
5. A wheeze— a high pitched sound heard during exhalation. The sound is not the strange, hoarse sound heard during inhalation (e.g. in a child with croup) nor is it the mucus/rumble you hear from the back of the throat of most kids with a cold.
6. Cough triggered by cold: eating an ice pop or breathing cold, winter air, for example.

Don’t worry about labeling your child with the diagnosis of asthma.  Gone is the stereotype of a child with asthma as a sickly kid who sits in the corner and is told not to participate in sports.  A large percentage of Olympic athletes have asthma.  The diagnosis of asthma will open up a world of medication and lifestyles which can soothe your child’s irritated airways.

Stay tuned for Understanding Asthma, part 2: the treatment of asthma.

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

Panic.

Off to the mall today with my children. Everyone was strapped in the minivan ready to go.  But where were the gift certificates the kids just got for Christmas from the relatives? I was perplexed and scuttled back into the house. Inside, I recreated in my head the scene at grandma and grandpa’s where I had last seen the gift certificates. At their house, after the children had properly said their thank yous, I remembered carefully folding the certificates in tissue paper and tucking them into the sparkly blue gift bag which was to go to my parents on behalf of my in-laws.  As an added guarantee that they would not be forgotten, I deliberately placed the blue bag with the other presents we had received. Where could they be? After all, they were safely in the big black trash bag with all of the other presents.

The trash bag? Oh dear.

Suddenly I remembered arriving home from my in-laws to a family room cluttered with gifts from Santa. I told the kids to clear everything out. When the dust settled I saw a big black trash bag in the center of the room. I grabbed it and threw it in the garage. Then a Christmas miracle happened.  In the midst of holiday hub-bub, my husband remembered that it was trash pickup day and took out the trash.

Gone were the gift certificates. Gone were my in-law’s presents to my parents. Gone was the plug in Star Wars game module. Gone was the “last copy” of a book of Chinese folk tales lovingly picked out for my daughter. And gone was the silly Bop- it game, a crazy game of Simon Says where one of the commands is to “bop” the toy against your tummy.

For a brief moment I contemplated running down to the dump and trolling through the garbage. After all, there were probably only a couple thousand black garbage bags. If I started now, I could be done by next Christmas.

Laughing (what else could I do?), I made my way back to the car where I broke the news to my kids. I too was disappointed, but I couldn’t go back and undo the event.  I had no choice but to laugh.

Together, between the tears, we stepped through lessons learned.

Lesson #1 Be more careful with our things

Lesson #2  Forgiveness is hard but essential for moving forward

Lesson #3 We were happy two days ago and that was before the presents arrived

Lesson #4  Let your kids play with their new toys the moment they get them- you never know when they will disappear

And the most important lesson #5 Use clear trash bags

My oldest smiled slowly and pointed out that I had declared to the kids, “Any presents not cleared out of the family room and put away in your own rooms will be thrown out.” I had unknowingly carried out my threat. Gradually, murmurs of disappointment gave way to laughter as we all imagined a scruffy bearded hobo going through the garbage picking up gift certificates from the girly stores Justice and Abercrombie.  Somewhere there is a stylin’ hobo with a scruffy beard in a fur trimmed hooded puffy coat and tank top, hopping up and down, playing Bop-it.

The minivan shook with laughter.”Oh, mommy, I’m laughing so hard my stomach hurts,” my daughter said. “Mine too,” my other two moaned between giggles.

The cost of “the stuff”:

A lot.

Making kids laugh so hard that their stomachs hurt:

Priceless.

Naline Lai, MD
©Two Peds in a Pod℠

Kids are noisy. A noisy child is usually a healthy child, so we pediatricians welcome noise. Today we give you Top Ten Sounds we are grateful for this Thanksgiving:

10. The sound of a six-month-old baby’s belly laugh.

 9. The sound of a two year old trying to say “gobble, gobble, gobble.”

 8. The sound of a three year old saying “why?” about 100 times a day.

 7. The sound of a chatty first grader who tells you about her favorite part of her day in one gigantic run-on sentence.

 6. The sound of a grade school orchestra concert (as heard through ear plugs).

 5. The sound of a high school orchestra concert played by the same students you remember playing in their grade school concert.

 4. The sound of a teenager confiding something very important during a check up and then answering “yes” to the question “Do your parents know about this?”

 3. The sound of a high school senior saying he got into his first choice college.

 2. The sound of children (and their pets) breathing as they sleep.

 1. The sound of a child’s small voice at Thanksgiving dinner leading her family in thanks.  

Wishing you all a noisy Thanksgiving.

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod℠

Lately my office staff has taken to giving out Sillybandz as rewards for kids who bravely endure the sting of vaccines , cooperate during exams, or just behave well while along for the ride at a sibling’s doctor visit. The kids LOVE them. Better than stickers. Healthier than lollipops.

You poured out all of your two liter soda bottles, replaced all the potato chip snacks with fruit and signed all your children up for winter sports.  Just when you thought your family’s activity and diet balance was perfect, along comes Halloween, that fabulous candy-filled holiday to thwart your efforts. Ways to keep the candy deluge down to a trickle:

-Let your children know Halloween (and most holidays) lasts only one day. Live it up on Halloween then dump the extra sweets into the trashcan the next day.

-Buy back the candy with toys or money.  Alternatively, have the sweet tooth fairy come overnight, pick up the candy and leave a present behind.

-If you decide to keep a small bag of candy around, watch out, your children will be tempted to eat some daily. Candy becomes an ongoing “must have.” Instead, designate a day to eat candy during the week such as Sweet Saturday or Candy Friday. If the kids whine for candy on any other day of the week, you can say, ”Sorry, it’s not Sweet Saturday.”

-One parent told me she discourages her kids from eating Halloween candy by making their dental appointments on November 1—the day after Halloween.

According to an article published in the New England Journal of Medicine in 2000, the average American adult gains about a pound over the winter holidays. Unfortunately, the weight is not shed during the rest of the year.  

Hope your kids don’t grow into that kind of adult. Now, that’s a scary Halloween thought.

Naline Lai, MD with Julie Kardos, MD

©2010 Two Peds in a Pod

Parents can become frustrated when searching for effective therapeutic treatment for childhood anxiety. Parents want to know what works and what their child will experience. Cognitive behavioral therapy is one type of therapy for children which directly addresses the behaviors kids exhibit. When anxiety starts, CBT gives kids concrete strategies to employ. Today psychologist and mom, Dr. Leah Murphy gives us an example of cognitive behavioral therapy treatment and how it involves the patient’s family and community.

Naline Lai, MD and Julie Kardos, MD

We all experience anxiety at times; anxiety can help us get things done (e.g., study for a test, finish a project, complete things in time for deadlines) and inform us that something is wrong. However, frequent, moderate to high levels of childhood anxiety both prevent, and interfere with, enjoyment and success in the school, home, and social arenas, resulting in a poorer quality of life. Wanting to improve your child’s anxiety and stress without “pushing them” much? You could have a look about at what summer activities for kids might be able to help manage their anxieties.

The experience of Connor, an 11 year-old boy, is a good example of how children can experience and show social and separation anxiety, as well as of how psychologists help children with anxiety.

Connor constantly worried. When he came to school Connor clung to his mother. At bedtime, Connor was unable to fall asleep without a parent staying with him, and he would often wake up and go into his parents’ room in the middle of the night. He even felt uncomfortable talking to other children. He constantly worried that kids would not like him and that he would “do something” that would cause the other children to tease him. He would avoid other children, and as a result, he had very few friends. He felt sad and lonely. Connor’s social and separation anxiety also manifested in physical symptoms. He felt nauseous, tired, suffered headaches and stomach aches, and experienced panic attacks in social situations. At school, Connor failed to concentrate on his work. Anger ensued when he felt pressure to perform anxiety provoking acts.

To help Conner, his pediatrician determined Conner had anxiety but no other medical condition and referred Conner to us for therapy. Our initial therapy sessions focused on teaching him how to to identify and express his feelings. During these sessions he created a feelings dictionary book and a feelings collage.

During the next set of sessions, Connor learned relaxation skills (deep breathing and muscle relaxation), positive coping thinking (“I can do this, the chance of something bad happening is very small, the chance of something good happening is very big”), and problem solving skills to help him to identify and implement solutions to the problems that made him nervous. Most sessions were conducted individually, but his parents participated in these sessions at times to learn the skills and to establish a plan for practicing and using these skills outside of our sessions. Also, I conducted parent-only and family meetings helped his parents cope with their own stress and anxiety about Connor’s difficulties.

During the last part of the skills based therapy, Connor used his skills in the situations which made him anxious. Starting with the least anxiety provoking situations, he gradually worked into more anxiety provoking situations. He practiced asking a teacher for a pencil, asking a waiter for a napkin/straw, introducing himself to a new peer, giving answers in class, asking a teacher for help, and going to swim lessons/baseball. We made a list of coping strategies (think positive, deep breathing, muscle relaxation, use problem solving steps, ask an adult for support/help) that he could use when overcoming anxiety provoking situations. He hung this list in his room and sometimes took it with him in his pocket or backpack. Apparently it was a lot of help to him.

Connor’s parents and school/camp staff prompted and reinforced his use of these skills in anxiety provoking situations. Connor had a point chart in which he earned points for using his skills and doing anxiety provoking activities. When he earned a sufficient number of points, he would pick a privilege from the privilege list that he created with his parents. Parent-only meetings during this time further assisted his parents cope with the discomfort and distress that they experienced when Connor began engaging in situations that caused him anxiety.

Additionally, Connor participated in a social skills group for children experiencing anxiety. Therapy groups are a great way for children to practice social skills while in a small group setting under supervision. The group practiced relaxation skills, as well as introduction/greeting and conversation skills. The group also learned skills to make friends.

In response to the therapy, all of Connor’s anxiety symptoms stopped over the course of 9-12 months, and his mood changed from anxious and fearful to calm and happy much of the time. He successfully attended school, participated in camp and after school programs, participated in social and recreational activities with children, and established friendships.

Sometimes, other strategies are needed to alleviate anxiety, including medication. Your pediatrician is able to provide information about medication options.

Leah Murphy, Psy.D.

Center for Psychology and Counseling www.psychologyandcounseling.com

© 2010 Two Peds in a Pod

(introduction modified 10:48a.m. October 13, 2010)

She’s eyeing your lip gloss and won’t wear clothes with animals or hearts on them anymore. She’s begging you for a Facebook account, but still talks to her dolls and holds her dad’s hand in public. Yes, your daughter is on the edge of puberty and you’ve been talking to her about her upcoming body changes and getting her period. But your own memory of early adolescence from a couple of decades ago is a little fuzzy. Beyond the basic anatomical changes, did you cover everything?  Here is a smattering of questions about menstruation which may not have occurred to you, but we hear in the office:

From the girls: Does a period hurt just like when I cut myself?

In a kid’s experience, blood is associated with an injury and therefore pain. Reassure your daughter that bleeding during a period is not like the bleeding of a cut. Yes, you can mention that she may feel cramps, but usually not initially.

From the moms: When can she wear a tampon?

At any point. Several manufacturers make tampons especially designed for teens. Do not worry; even for a virgin, a tampon will not cause any injury. Just like you’ve taught her everything, you may need to teach her how to insert and take out a tampon.Warning—do not teach her five minutes before she leaves for the beach during her period. For some girls, removing the tampon is more difficult than inserting it. Teach her/ talk it through when she is not menstruating. Remind her to change tampons frequently- young girls in particular are more vulnerable to Toxic Shock Syndrome.

From both: It’s been months, how long until her period is regular?

It can take around two years for periods to come regularly. Once they are regular, the average frequency is every 28 days, but can vary from 21 to 36 days.

From the girls: Will I know when I get my period?

Let your girls know that when they see their first period it may not be a bright red blotch of blood on their underpants. Explain that dried blood looks like brownish streaks; they may confuse it with stool.

From both: In this age of skinny jeans and jeggings, where to hide a pad or tampon during school?

If she doesn’t carry a purse, then have your daughter try inside the cuff of a sock or tucked in the waistband of pants. I have seen a thin pad hidden under the tongue of a sneaker.

From the girls: Do I go to the nurse’s office if I get my period for the first time during school?

Not necessarily, unless you are looking for pads. This is not an illness.

Remind your tween to let you know when she starts getting her period and that you will keep it private. One girl told me she did not tell her mother for months. The reason? Her neighbor’s mother had given her neighbor a “Red” party in honor of her neighbor’s first period. Everyone wore red to the party and there was even a red cake. My patient was appalled at the attention and avoided telling her own mother until well after her menstrual cycle was well established.

Also, you can help your tween track how heavy her flow is by checking her supply of pads and tampons. Excessively heavy periods cause anemia from blood loss and young girls can be unaware how much blood loss is normal. Remind her that if she has to change a pad once an hour, or if her period drags on over a week (average is three to seven days) she needs to tell you about it. Even without excessive blood loss, make sure she eats iron containing foods (eg. spinach, lean red meats) to help prevent anemia.

If you get overwhelmed by all the facts about menstruation which need to be explained, keep in mind this conversation I once had during a check-up. During the visit I gave a young teen a moment alone to ask questions privately. As the door closed behind her mother, I asked the girl if she had any questions about adolescence.

“No questions,” she declared.” I wear a bra… I bleed every month. There’s nothing else to know.”

Wish everything about the teenage years could be so simple.

Naline Lai, MD with Julie Kardos, MD

© 2010, revised 2017 Two Peds in a Pod®

Two Peds in a Pod turns today to guest blogger Dr. Alan Woolf, Director of the Pediatric Environmental Health Center at Children’s Hospital Boston and president-elect  of the American Academy of Clinical Toxicology, to tackle the question, “Should you feed your kids organic fruits and vegetables?”

Nutritionists are urging parents to feed kids one and one-half cups of fruit and two and one-half cups of vegetables daily and the American Academy of Pediatrics suggests whole fruit rather than juice to meet most of the daily fruit requirements. 

OK, so that’s fine, but why spend a lot more money to buy those fruits and veggies labed organic? Are they worth it? Will non-organic produce harm your kid? No easy answers here. American consumers demand a bountiful supply of blemish-free, perfect fruits and vegetables. We want unspotted shiny red apples, brightly colored large oranges and arrow-straight asparagus. Farmers want to give us just that. Since pests attack crops causing blemishes, worms, blight, and other forms of costly crop damage, farmers have been using pesticides for years to increase crop yield, profit, and visual marketability. 

The US Dept of Agriculture (USDA) regulates the agricultural procedures and labeling that use the buzz word organic. Obviously every business wants to put that word on their product if it means consumers will run out and buy it. The USDA will certify farms that use organic methods. But even the USDA’s definition of organic allows a percentage of synthetic chemicals to be added to products labeled organic. Also organic does not mean that the food contains increased amounts of essential minerals and vitamins or is more nutritious for you. And remember that organic produce doesn’t necessarily come from small, cuddly, local, family-run farms. Most large, international agribusinesses are touting organic foods for sale these days.

Well over one billion pounds of pesticides, according to the Department of Agriculture, are used on American crops annually. And pesticides tend to be nasty chemicals—otherwise they wouldn’t kill bugs. In large amounts, some types can cause seizures or coma in people. However, all foods , whether organic or non-organic, must contain pesticide residues well below the standard that the government considers safe. Not every piece of non organic fruit even contains a residue; it’s hit and miss.

But what about the long-term safety of pesticides in trace amounts, the amounts barely present as micro-grams or nano-grams? The fact is that no one knows the safety for sure. The science just isn’t there yet. Some dispute the government’s definitions; arguing that children don’t eat the same market basket as adults (they eat more fruit). They reason that using adult pesticide residue standards may not protect children. Recently some scientists did a study where they measured pesticide residue in the urine of school-aged children who were fed regular, market-basket produce, and then measured again after they switched them to organic-only fruits and vegetables. Guess what—kids fed organic foods excreted less pesticide residues in their urine. There’s a powerful argument for organic. 

One thing that everyone agrees with—wash all of your fruits and vegetables after you buy them and before anybody in your family eats them. And that means soap and water, not just a quick rinse. Also keep in mind that infants and children are resilient even in this modern age filled with all sorts of hazards. Kids and adults are armed with marvelous defense mechanisms that prevent chemicals from doing bodily harm. Even if a chemical does cause some injury, the body has remarkable mechanisms that repair the damage in a hurry. No need to be “chemical phobic;” you can’t keep your kids in a bubble.

That being said, you still need to be cautious. In pediatrics we often invoke the “precautionary principle.” The idea is that if you don’t exactly know what a chemical will do to a child’s health because there aren’t enough scientific studies out there, then you assume that what it is capable of is bad and so, if possible, try not to expose them, just as a precaution. 

When you can, buy from local farms or stands where you can ask them their growing practices, or else just grow your own. If you decide to buy organic foods, you should eat them right away. They may not stay edible as long without preservatives. Again, no matter what type of food you buy, wash, wash, wash.

Finally, alternative “greener” farming techniques, integrated pest management (IPM), and more resistant varieties of plants have increased crop yields, in many cases without using as much pesticide. That’s good news for all of us. Breeding of genetically-engineered plants require less use of pesticides, but they may not be acceptable to most consumers. That’s a whole column in itself!

The bottom line: My wife and I will try to buy organic foods when we think of it, but we don’t obsess over it when we forget. 

Alan Woolf, MD, MPH, FAACT, FAAP

Director, Pediatric Environmental Health Center, Children’s Hospital Boston

© 2010 Two Peds in a Pod®

A few days ago, I spoke with the faculty of a local early childhood education center about flu vaccine myths. See how you do on the true and false quiz I gave them:

I can tell when I am getting the flu and will leave work before I infect anyone.

False. According to the CDC (US Center for Disease Control), you are infectious the day before symptoms show up.

I never get the flu so it’s not necessary to get the vaccine. 

False. Saying I’ve never had the flu is like saying, “I’ve never a car accident so I won’t wear my seat belt.”

I hate shots. I hear I can get a flu vaccine in a different form.

True.  One flu vaccine, brand name Flu Mist, provides immunity when squirted in the nose. Non-pregnant, healthy people aged 2-49 years of age qualify for this type of vaccine.

I got the flu shot so I was healthy all year.

False. Perhaps it was the half-hour a day you added to your workout, or the surgical mask you wore to birthday parties, but your entirely healthy winter was not secondary just to the flu vaccine.  The United States flu vaccine protects against several strains of flu predicted to cause illness this winter. This year’s vaccine contain both seasonal and the 2009 H1N1 strains. Your body builds up a defense (immunity) only against the strains covered in the vaccine. Immunity will not be conferred to the thousands of other viruses which exist. On the other hand, the vaccine probably did protect you from some forms of the flu, and two fewer weeks of illness feels great.

My friend got the flu shot last year, therefore, she was sick all winter.

My condolences. True, your friend was sick. But the answer is False, because the illnesses were 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. 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 an illness.

I got the flu vaccine every year for the past decade. I will still need to get one this year.

True. Unfortunately, the flu strains change from year to year. Previous vaccines may not protect you against current germs.

I am a healthy adult and not at high risk for complications from the flu, so I will forgo the flu vaccine this year.

False. The flu vaccine is now recommended for everyone greater than 6 months of age. When supply is limited, targeted groups at risk for flu complications include all children aged 6 months–18 years, all persons aged ≥50 years, and persons with medical conditions that put them at risk for medical complications.   These persons, people living in their home, their close contacts, and their CARETAKERS are the focus of vaccination. 

Even if I get the flu, I’ll just wash my hands a lot to keep the germ from spreading. I have to come back to work because I don’t have much time off.

False, According to the American Academy of Pediatrics Report of the Committee on Infectious Diseases, the influenza virus can spread from an infected person for about a week after infection.

Yes, kids get sick from others kids, but as a parent who comes in contact with two children, an early childhood educator who comes in contact with ten children, an elementary school teacher who comes in contact with twenty children or a high school teacher who comes into contact with one-hundred children daily, you may end up the one who seeds your community with a potentially deadly illness.  Right now, flu vaccine clinics are as plentiful as Starbucks. Hit that CVS or Walgreens on the way home, wander into your doctor’s or grab a shot while you get groceries.  By protecting yourself from the flu, you protect the children you care for.

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠

Move over liveStrong bracelets, move over Silly Bandz. Just when you thought you threw away the your last Oriental Trading Company gadget, here come “I Love Boobies” bracelets.  As I see the newest overpriced piece of fashionable rubber dangle from my daughter’s wrist, I sigh at the cost, but console myself that at least the money goes towards breast cancer research.  Use the bracelets as a reminder to teach your girls to do monthly breast exams. The American Cancer Society recommends monthly self-breast exams starting at age twenty. However, most pediatricians recommend starting exams earlier. Breasts are full of normal lumps and bumps and your teen or young adult should know her baseline. For directions on conducting a breast exam refer to American College of Obstetrics and Gynecology’s online pamphlet . Yes, even a fashion accessory can turn into a parental teaching point. Now what do jeggings teach kids?

Naline Lai, MD with Julie Kardos, MD

©2010 Two Peds in a Pod℠