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

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

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

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

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

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

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

Naline Lai, MD with Julie Kardos, MD

©2010 Two Peds in a Pod℠

Ah…you’ve tucked in your tired kids, now kick back and take out your Kleenex while you read Dr. Lai’s personal letter to her own child as she started school. The post is meant for all parents with a child who is approaching a major milestone. Then, come back to reality and read Dr. Kardos’s post on how to help kids get back to a healthy school year sleep pattern.

Best wishes for a smooth transition to school.

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

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

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

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

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

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

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

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

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

© 2010 Roxanne B. Sukol, MD, MS

TeachMed, LLC

http://yourhealthisonyourplate.com

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

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

Julie Kardos, MD and Naline Lai, MD

Just in time for the fall sales,  physical therapist Dr. Deborah Stack returns to give us the low-down on backpacks.

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Believe it or not, there are only a few weeks left before school starts for the fall.  As I look at last year’s first day of school photo, I notice my not-quite-100-pound child bending in half under the weight of a backpack, trombone, lunchbox and art portfolio. This year, I quietly decree, that scenario will not happen again.  To make sure it does not happen at your house either, consider a few tidbits as you plan your back-to-school purchases:

-A traditional backpack with two shoulder straps distributes the weight more evenly than a pack or messenger bag with a single strap.

-Look for wide, padded straps.  Narrow straps can dig in and limit circulation.

-A chest or waist strap can distribute weight more evenly.

-Look for a padded back to protect your child from pointy pencils etc.

-Look for a lightweight pack that does not add much overall weight.

–Multiple compartments can help distribute weight.

–Compression straps on the sides or bottom of a backpack can compress and stabilize the contents.

–Reflective material allows your child to be more visible on those rainy mornings.

–A well fitting backpack should match the size of the child. Shoulder straps should fit comfortably on the shoulder and under the arms, so that the arms can move freely. The bottom of the pack should rest in the contour of the lower back. The pack should “sit” evenly in the middle of the back, not “sag down” toward the buttocks.

How much should your tike tote? Experts, including the American Academy of Pediatrics and the American Physical Therapy Association, recommend kids should not carry backpacks weighing more than 15-20% of the kid’s weight.

Here’s a chart to give you an idea of the absolute maximum a child should carry in a properly worn backpack:

Here are some ideas to help lighten the load, especially for those middle school kids who have a plethora of textbooks:

-Find out if your child’s textbook can be accessed on the internet.  Many schools are purchasing access so the students can log on rather than lug home.

-Consider buying an extra set of books for home.  Used textbooks are available inexpensively online.

-Limit the “extras” in the backpack such as one free reading book instead of five.  I am not exaggerating; one day I found five free reading books in my child’s backpack!

-Encourage your child to use free periods to actually study, and leave the extra books in his locker.

-Remind your child to stop by her locker between classes to switch books rather than carrying them all at once.

-Consider individual folders or pockets for each class rather than a bulky 3-ring notebook that holds every subject.

 

You may need to limit the load even further if your child is still:

-Struggling to get the backpack on by herself

-Complaining of back, neck or shoulder pain

-Leaning forward to carry the backpack

If your child complains of back pain or numbness or weakness in the arms or legs, talk to your doctor or physical therapist.

When used correctly, backpacks are supported by some of the strongest muscles in the body: the back and abdominal muscles. These muscle groups work together to stabilize the trunk and hold the body in proper postural alignment.  However, backpacks that are worn incorrectly or are too heavy can lead to neck, shoulder and back pain as well as postural problems.  So choose wisely and lighten the load.  Happy shopping!

Deborah Stack, PT, DPT, PCS

Dr. Stack has been a physical therapist for over 15 years and heads The Pediatric Therapy Center of Bucks County in Pennsylvania www.buckscountypeds.com. She holds both masters and doctoral degrees in physical therapy from Thomas Jefferson University.

© 2010 Two Peds in a Pod℠

In the wake of liquid Tylenol and Motrin recalls, some parents are facing empty shelves of liquid medications in the stores. Check to see if your child weighs enough to take the dose in pill form. If so, it’s time to learn to swallow pills! Here are some of our favorite helpful ideas:

-Don’t wait until your child is ill. She may not feel up to learning a new skill.

-Practice swallowing peas, tic-tacs or watermelon seeds. You can start with a cake sprinkle and move up to something larger.

-Demonstrate for your child the process of swallowing.

-Thick liquid will carry down a pill better than thin liquid. Try orange juice or milk instead of water.

-Try having your child tilt her head forward as she drinks so that she is “upside down.”

-Use mind over matter, for a nervous kid, tell him to first take three breaths, sit-down, gulp and quickly swallow.

-Take a pill while simultaneously eating apple sauce, yogurt, or pudding.

-Put a pill in his mouth and have him suck liquid quickly up through a straw. This action will push back the pill before it dissolves in the liquid.

-Remind your child: if you can swallow food, you can swallow a pill.

What if nothing works? Some pills can be chewed, and the contents of some capsules can be sprinkled on food; check with the pharmacist first. Then teach your child the song “I know an old lady who swallowed a fly…”

Naline Lai, MD and Julie Kardos, MD

©2010 Two Peds in a Pod?

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

Drs. Lai and Kardos

_____________________________

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

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

Please.

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

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

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

The Pediatric Insider

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

Why does that big pimple always appear the night before prom, picture day, her sweet sixteenth birthday party or any other important event in your teen’s life?

A rite of passage, acne is caused by a combination of genetics and bad luck. The perception of acne as a problem depends on the eye of the beholder. When I see a teenaged patient in my office for acne, the first question I ask is, “Who is more concerned about the acne? The parent or the patient?” Some kids have very mild acne, yet those kids perceive their pimples are the size of golf balls. Other kids are oblivious, and the parents are more upset than the teen. 

Even if your teen starts to break out with what she perceives are huge blemishes but are really the size of pin pricks, do take her seriously. Many effective, safe products can diminish mild acne and thus greatly help self-esteem in a self conscious teen. Also, make sure to probe to see if a negative perception of her appearance extends to an overall poor body image. Sometimes distress over minimal acne can be an early sign of body image disorders such as anorexia nervosa or bulimia.

The categories of acne medicines are:

-Topical antibiotics such as benzoyl peroxide or clindamycin, applied directly to skin- works to kill the bacteria that lead to acne

-Other topical medications such as tretinoin (Retin A) and adapalene (Differin) stop acne formation mainly by penetrating into the deep layers of the skin to loosen acne causing pores

-Oral antibiotics, such as minocin, clindamycin or erythromycin also kill the bacteria that lead to acne formation

-Accutane, an oral medical reserved for severe, scarring acne. Can cause significant birth defects and so girls who take it must also take birth control pills and have periodic pregnancy tests. Chemical imbalances may occur, so blood work is required for both sexes.

-Hormonal therapy (birth control pills)- works best for females who break out near their periods, smooths out the hormonal fluctuations which fire up acne.

I always remind my patients that most treatments take six weeks to work. For kids who experience dry skin with the topical medications, use noncomedogenic (non acne forming) moisturizer liberally.Dermatologists and pediatricians schedule follow up visits for acne at 4-6 week intervals. If your teen has mild acne but truly doesn’t want to bother with treatment, just encourage washing with a mild cleanser (for example Dove soap) once daily. Tell him also to use a clean washcloth or soft paper towel to dry off after each washing. Applaud his self-confidence and lack of obsession with a skin condition which almost always improves with time.

Myth buster: eating chocolate does not cause acne. The chocoholic in me is greatly relieved by this knowledge.

Truth: arranging hair to hide the face tends to make acne worse. Avoid oily hair gels and sprays. In addition, touching and picking at the skin also causes irritation in an already irritated area.

Finally, what to do on prom night? Cosmetics work wonders, and parental reassurance, even if your teen waves it aside, can take care of the rest.

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

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℠            

Okay ready? Put your palms together. Fold your pinkie and ring fingers down. Tuck in your middle and pointer fingers. Cross your thumbs. Allow your BFF to lean over and suddenly push your knuckles together:  c-r-a-c-k ! She cracks your knuckles.

It’s one in a long line of mildly torturous friendship games children play. Remember building a “rose garden” on your friend’s arm by pinching his forearm until it turned beet red?

As I watch my kids play the “knuckle cracking game,” I am reminded of a question  parents often ask: “He is always cracking his knuckes! Won’t that cause early arthritis?”

When I look over at the object of the parent’s complaint in the office, the child usually gives me a big grin, and c-r-a-c-k, happily demonstrates to me the reason for the parent’s question. To the parent’s dismay, I tell the family knuckle cracking will not lead to early arthritis. However, I always laugh and warn the kid that harm from cracking knuckles comes not from the action of cracking knuckles but rather from an irritated parent’s wrath.

What’s the consequence of allowing a friend to crack your knuckles? That I do not know… although I have a suspicion the parental consequence is similar to when you crack your own.

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

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

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

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

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

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

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

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

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

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

Naline Lai, MD with Julie Kardos, MD

© 2010 Two Peds in a Pod℠