A picture is worth a thousand words: Dr. Lai joins Dr. Kardos in practice at The Children’s Hospital of Philadelphia Care Network- Newtown, Pennsylvania
It’s a heat wave and in extreme temperatures, kids, like adults, find it tough to go outside for physical activity. We find it perfect timing for the release of Dr. Pat Cantrell’s new kid fitness video (demo below). The video, made in conjunction with kids fitness expert Anna Renderer, gives follow-along exercises along with health advice tailored to kids. We asked Dr. Pat to expand on one piece of advice she gives in the video: eat five servings of fruits and vegetables a day. For many parents, even one serving can be tough to get into a child. Many a parent has asked himself, “Does one bite of zucchini spit back onto the table count as a serving?” If this is you, then you’ll appreciate Dr. Pat Cantrell’s guest blog post.
– Dr. Lai and Dr. Kardos
Not eating enough fruits and vegetables is one of the biggest concerns that parents have regarding their children’s diet. The US department of agriculture recommends that children get at least five servings of fruits and/or vegetables in their diet every day. But most kids aren’t getting that amount. Below are 5 tips that can help children get their 5 a day.
- Cut it! Kids love when food is cut into pieces that they can pick up. An apple or orange might sit on the counter in the fruit bowl. But, cut it up and all of a sudden it is much more appealing. Even the fast food restaurants have figured this out and instead of just handing a child an apple or orange with their kid’s meal, they get apple or mandarin slices.
- Dip it! Some vegetables can be bitter to a child’s immature taste buds. Offering a yogurt or ranch dip can add the flavor they like and helps mellow out the taste of the vegetable.
- Hide it! What they don’t know won’t hurt them! By disguising fruits and vegetables, kids will get the nutrients they need. Plus, without knowing it, kids will learn to develop the taste for the vegetables or fruits and their taste buds will be more accepting of the fruit or vegetable in the future. Smoothies are a perfect way to blend in a few servings of fruits and/or vegetables. You can also puree vegetables like carrots or spinach and add that to a pasta sauce! For more ideas, check out Jessica Seinfeld’s cookbook “Deceptively Delicious”.
- Grow it! Gardens are a great way to get kids to eat more fruits and veggies! I took my sons (7 and 9) to their grandmother’s house and they ate just-picked sugar snap peas. I was shocked! First of all, they tried it without whining and second, they liked it and asked for more! Since the fruits and vegetables can be picked when they are ripe, they often taste better than the store bought version. Kids love to see the food grow and helping them be a part of the process encourages healthy eating.
- Make it fun! Put cream cheese on celery and add raisins on top and you have Ants on a Log. Use cookie cutters to cut watermelon or cucumbers into fun shapes. The more appealing it looks, the more kids want to try it. For some fun ideas, check out http://familyfun.go.com/recipes/cooking-with-kids/.
Be creative and persistent and try to offer at least one or two servings of fruits and/or vegetables at each meal.
Pat Cantrell, MD, FAAP
Dr. Pat Cantrell, mother of two young boys (who can be picky eaters at times!), is a board certified pediatrician who has been practicing pediatrics at Southern California Permanente Medical Group for over 14 years. She has a special interest in pediatric obesity and is the President of KFIT Health, LLC (www.kidfitnessandhealth.com) which creates fitness and nutrition DVDs and products for children. A board member of the San Diego Childhood Obesity Initiative, Dr. Cantrell is also the Pediatric Obesity Champion for her medical group. Additionally she serves as Secretary of the San Diego Chapter of the American Academy of Pediatrics.
©2012 Two Peds in a Pod®
Two Peds in a Pod® turns three years old! In honor of our third birthday, we bring you our top ten parental experiences through the years list:
- “Helping” your child manage his ice-cream cone (especially when he orders the soft chocolate kind with the chocolate sprinkles)
- Coaching a sport you have not played in twenty years.
- Playing hours of Mario Cart or Just Dance on the Wii (and losing every time)
- Building snowmen
- Coloring with brand new crayons (and the aroma of opening that new box of Crayolas!)
- If you are a mom, discovering your teen daughter is the same shoe size and you can borrow her hip shoes
- Experiencing your child’s first bike ride without training wheels
- Getting to be the Tooth Fairy (shhh… don’t tell!)
- Re-reading your favorite kid books (Dr. Seuss really was a genius)
- Realizing your child honestly believes that you have a really good singing voice
We hope to celebrate many more birthdays with you. Please continue to send us your ideas at twopedsinapod@gmail.com, comment on our posts and tell your friends about us.
Happy,
Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®
Vacation! As I watched my kids scamper across the beach today, I remembered a conversation I had with a family recently. “My kid sometimes coughs up sand,” the mom said to me. “Little hard specks sometimes come out of her mouth. ”
“Hmmm, bring me a speck of the ‘sand’ the next time he spits one out,” I said.
A few days later, rattling inside a small plastic container on my desk, I found a tawny-hued speck which resembled a chip of rock. The mom had kept her promise and now I was the owner of a tonsillolith. Pictured here next to a paperclip, this and other tonsilloliths are harmless hardened pieces of debris which lodge in crevices (crypts) of tonsils. No one is exactly sure why tonsilloliths form, but they do seem to run in families. A combination of the right type of saliva, food, and deep tonsillar crevices produce these white or tan specks which occasionally become the size of a small pebble. In fact, they are also known as tonsil stones. Most people consider tonsilloliths a nuisance, but sometimes they are associated with bad breath. Warm salt water gargles after meals (one teaspoon of salt per 8 ounces of warm water) is usually enough to dislodge the tonsilloliths and prevent new ones from sticking. People have been known to overcome gag reflexes and flick them out with their nails. Addressing any tonsillar irritation such as Strep throat infections (see our previous posts: part one and two) or post-nasal drip from allergies may also be helpful. For those having continual tonsillolith-induced bad breath, removal of the tonsils is the definitive answer.
Some people dream of getting away to Sannibel Island’s shell covered beaches, others to Bermuda’s wispy pink speckled beaches and still others to the jagged rock-strewn beaches of Maine. Do otolaryngologists (ENTs) dream of tonsillolith-covered shores?
Naline Lai, MD with Julie Kardos, MD
©2012 Two Peds in a Pod®
Let’s think about universal parental admonishments:
“Hold on tight.”
“Be careful.”
“Look out!”
“Don’t let go.”
Now let’s think about the universal goal of parenting: to create children who grow up to become independent.
That means that at some point, after your child learns to hold tight, be careful, and look out, your child will need to let go.
This inevitable march toward independence does not begin when your child turns eighteen, but rather years before. Kids learn independence in small steps starting when they are still babies in our eyes.
For instance, take feeding. First you breastfeed or bottle feed. Eventually you encourage your young child to drink out of her own cup as SHE holds it. When she’s able to pick up lint from the floor and stuff it into her mouth, you know she’ll be able to feed herself finger foods from the family dinner table. At 18 months, children are capable of wielding their OWN spoons and fork—so let her do so, no matter the mess. By constantly challenging her with self feeding, your toddler becomes the preschooler who eats lunch with her friends at “lunch bunch” and the college student who chooses to eat salad at the cafeteria.
How does a child learn to maneuver stairs? If you always carry her, she will never learn. Older siblings often teach the younger ones how to crawl backwards to the top of the steps and then go down safely buttocks first. I have fond memories of my son crawling backwards like a dump truck nearly the entire length of the hallway before reaching the steps. I would imagine a high pitched beeping sound as he inched backwards. As walking becomes steadier, your kid will learn to hold onto the banister as she goes up and down. Fast-forward and someday she will be the dexterous mom who carries her coffee in one hand, the laundry basket in the other and her phone between her ear and shoulder as she heads downstairs.
What does “be careful” mean? I find that kids often have no frame of reference for “careful” So be specific with your advice. When my kids were toddlers and carried cups of milk to the table, instead of only saying “be careful” I would remind them to “walk slowly.” If they (gasp) cut paper with scissors, I would say, “watch where your fingers are.”
For kids, personal safety is often not enough of a motivation to listen to advice. When my twins were almost two years old, I realized that I belted them in their double stroller so often in public, they did not have an opportunity to learn how to stay with me. So, one day I had them hold my hands as we crossed the parking lot at their older brother’s school. They immediately tried to escape and run in opposite directions. I instructed them to “hold tight to my hands” or “Mommy will have to carry you like a baby.” The thought of walking into their older brother’s school like “big boys,” kept them holding on.
Sometimes we need to allow children to fall, literally and figuratively. If missing the carpeted step that leads to the living room means your toddler falls, then let her learn from her mistake. An older child who insists on leaving his jacket at home will learn from natural consequences if he is too cold outside (remember you can’t catch a cold from the cold, you just feel cold). Remember all those skinned knees you sustained as a child? Yet now you can ride a two wheeler bike and you run faster because you practiced running, even if you fell a few times. If you make your child too afraid of falling, then he will be unable to take the risks involved in learning new skills.
Let your child complete his own homework from a young age. Offer to proofread but don’t nag. Teachers already have consequences in place for children who do not complete homework, or for those who do a sloppy job. Let your middle schooler choose which foreign language or musical instrument or sport he wants to learn without pointing out the practicalities of what you consider the “better” choice.
Of course we need to protect and guide our children. But we need to learn to relinquish control over our children’s actions at the appropriate ages.
As the viral internet sage Eva Witsel says, “I can spend my energy on limiting my child’s world so that he will be safe and happy or I can spend my energy on helping my child learn the skills to navigate our world himself so that he will be safe and happy. I think the latter has a better chance of success in the long term.”
In grade school I remember holding tight to the chains of the playground swing as I swung higher and higher. But I also remember that glorious feeling as I let go, sailed through the air, and landed on my feet.
Don’t deprive your child of that same glorious feeling of letting go.
Julie Kardos, MD with Naline Lai, MD
©2012 Two Peds in a Pod®
Lucky kid! My daughter’s first rock concert, and not only did her girlfriend score tickets to the hot teen band One Direction, but the girls sat in 9th row seats. Despite fears of appearing dorky, my kid took along a box of earplugs. A half-hour into the concert, the mom accompanying the girls texted me. “Earplugs a necessity,” she wrote.
No, it’s not a myth your parents told you as a teen to keep you miserable at home on a Saturday night. Loud music really can cause high frequency hearing loss.
Sound is described by decibels (loudness) and by frequency (pitch). Examples of high frequency noises are the sound of a nail scratching a chalk board or a person whispering. A very high frequency noise is the sound of a dog whistle. By thirty years old, almost everyone experiences some hearing loss at frequencies above 15 hertz – if you are this age, this is why everyone now seems to mumble at parties. A few years ago, teens capitalized on this natural hearing loss phenomenon with “mosquito” ring tones– high frequency cell phone rings heard only by younger ears but not by prying adult ears. For kicks, check out your ability to hear high frequencies at this non-scientific site.
Exposure to loud sounds at high decibels hastens the natural progression of high frequency hearing loss. Damage to the hearing nerve (cochlear nerve) in an ear can occur from a one time exposure or from repetitive exposure over time. Sounds above 85 decibels cause damage. Those below 75 decibels rarely cause problems. The humming of a refrigerator is 40 decibels, ordinary conversations are 60 decibels and city traffic registers at 80 decibels. Lawn mowers and hair dryers are around 90 decibels and firecrackers explode at 120-140 decibels. After two minutes, exposure to rock concerts (which usually register at 110 decibels) may cause damage. For lawn mowing, the permissible exposure time is sometime between 2-4 hours. The site www.dangerousdecibels.com gives maximum recommended lengths of time for exposure to loud sounds.
Amongst teens, high frequency hearing loss is on the rise. The exact cause is unclear, but doctors suspect that the loss is secondary to constant exposure to loud sounds. Limit your child’s exposure to high decibel activities. Give your teen earplugs as she mows the lawn this summer and uses the leaf blower this fall. Because of differences in ear buds and how music is recorded, there is no uniform way to regulate volume produced by MP3 players. However, as a general rule of thumb, if you hear your teen’s music playing when he has ear buds in, it’s too loud. Kids should be able to hear normal conversations even when their devices are on.
So don’t fret if your teenager gets a mosquito ring for his cell. The ringing in the ears after a loud concert or a day of weed-wacking is the “sound” of hearing loss occurring— THAT’s the ring to avoid.
Thanks to Educational Audiologist Kristin Peppiatt, Au.D., CCC-A, the expert advisor who provided information for this post. An Audiologist for Bucks County Schools Intermediate Unit #22 in Pennsylvania, Dr. Peppiatt received her Bachelor’s of Communication Disorders and Masters of Audiology degrees from Penn State University and her Doctorate of Audiology from A.T. Stills University. She holds her Certificate of Clinical Competency from the American Speech, Language and Hearing Association and is a fellow in the American Academy of Audiology.
Naline Lai, MD with Julie Kardos, MD
©2012 Two Peds in a Pod®
“Chloe” is a two month old baby who cries. Often. Loudly. Although most of the wailing occurs in the late afternoon and early evening, she also cries other times. She eats great and in fact, seems very happy while she feeds. She smiles at her parents mainly in the morning. She also smiles at her ceiling fan and the desk lamp. Movement calms her and her parents worry that she spends excessive time rocking in their arms or in her swing. Her cries pierce through walls and make her parents feel helpless. She often spits up during crying jags, and erupts with gas. She gained weight well since her last visit. Here’s the lesson: All babies cry. All babies pee and poop. All babies sleep (at times). AND: all babies spit up. The muscle in the lower esophagus that keeps our food and drink down in our stomachs and prevents it from sloshing upwards, called the “lower esophageal sphincter,” is loose in all babies. The muscle naturally tightens up and becomes more effective over the first year of life, which is why younger babies tend to spit up more than older babies. Max has GER (gastroesophageal reflux) , Chloe has GER/ colic and Mona has GERD (gastroesophageal reflux disease). Max and Chloe have physiologic, or normal, reflux. Mona has reflux that interferes with her mood, her feedings, and her growth. GER, GERD and colic (excessive crying in an otherwise healthy baby, see our post on this topic) improve by three to four months of age. If your baby cries often (enough to make you cry as well) then you should see your baby’s pediatrician to help determine the cause. It helps, before your visit, to think about when the crying occurs (with feedings? At certain times of the day?), what soothes the crying (feeding? walking/rocking?) and other symptoms that accompany the crying such as spitting up, fever, or coughing. Keeping a three day diary for trends can help pinpoint a diagnosis. We worry a lot when the babies are not “spitting up” but are actually “vomiting.” Spit blobs onto the ground. Vomit shoots to the ground. Vomit which is yellow, is accompanied by a hard stomach, is painful, is forceful (think Exorcist), or enough to cause dehydration, all may be signs of blockage in the belly such as pyloric stenosis or vovulus. Seek medical attention immediately. The treatment for Max, the happy spitter with GER? Lots of bibs for baby and extra shirts for his parents. The treatment for Mona, the baby with GERD? Small, frequent feedings to prevent overload of her stomach, adding cereal to the any bottle feed to help thicken them and weigh down the liquid, thus preventing some of the spit up (ask your doctor if this is appropriate for your baby), holding her upright after feeds for 15-20 minutes, and inclining her crib by putting a thick book under each of 2 crib legs to help her upper body stay higher than her feet which helps her stomach to empty sooner. To prevent Sudden Infant death Syndrome, she should still be placed on her back to sleep. Sometimes, pediatricians prescribe medication that decreases the acid content of the stomach to help relieve the pain of stomach contents refluxing into the esophagus. Treatment for Chloe, the crier? Patience and tincture of time. You can’t spoil a young baby, so hold, rock and sway with her to keep her calm. Enlist a baby sitter or grandparents to help. Treatment for parents? Knowing that someday your baby will grow up, no longer need a bib, and probably have a baby who spits up too. ©2012 Two Peds in a Pod® 
In my office, two-month-old Max smiles ear to ear, naked except for a diaper and a bib. His worried mom asks me about the large amounts of spit up Max spews forth daily. “He spits up after every feeding. It seems like everything he eats just comes back up. It even comes out of his nose!” she says. Max gained an expected amount of weight, an average of one ounce per day, since his one-month check-up. He breastfeeds well and accepts an occasional bottle from his dad. Even after spitting up and drenching his bib and everything around him, he remains comfortable and cheerful. He is well hydrated, urinates often, and poops normally.
In short, Max is a “happy spitter” Other than creating piles of laundry, he acts like any healthy baby.
Contrast this to two-month-old “Mona.” She also spits up frequently. Sometimes it’s right after a feed and sometimes an hour later. She seems hungry, yet she’ll cry, arch her back, and pull off the nipple while feeding. She cries before and after spitting up. Her weight gain is not so good— she averaged one-half ounce of gain per day since her one-month visit. She seems more comfortable when upright and more cranky lying down.
Mona is not a “happy spitter.”
Last story and then the lesson:
Kinda cute. At least that’s what the medical books lead you to believe. They are described as little pink or flesh-colored dome-shaped harmless bumps with belly buttons. The little rash with the big name, Molluscum Contagiosum, is cute only until you discover the bumps on your child’s skin. Like your neighbor’s cute toddler, the little belly-buttoned rash can overstay its welcome.
Pictured here is the rash of molluscum. The bumps are generally flesh colored, but can be slightly pink. Look carefully at the circled bump— this one has a tiny dimple in the center (the “belly button”). While the rash often appears on areas with irritated skin such as eczema, molluscum can show up on every part of the body. As with any new rash, visit your child’s doctor to confirm the diagnosis.
The best thing about molluscum is that it is not harmful. Children can attend school and camp with it. Yes it looks funny, but like warts, it is a virus that is only skin deep. Also, like warts, it can be very stubborn about going away. Probably because it is so benign, children’s immune systems don’t get excited about an out-cropping of molluscum and do not bother attacking the rash.
The rash is spread by direct skin to skin rubbing (think wrestlers or think kids rolling around in play or think sexual contact—teens can get molluscum in compromising areas) and by towel sharing and very close contact in water—siblings catch molluscum from each other when they bathe together. However, kids do not contract the virus in swimming pools. The rash itself is not particularly itchy. But, because it often appears on itchy patches of skin, kids will scratch areas with molluscum and with each scratch, spread the molluscum over a greater area. One of my patients first developed molluscum on the inner aspect of his arm. During the summer when he went shirtless, the rubbing of his arm against his body caused molluscum to appear on the side of his chest where his arm brushed against his body. Mysteriously, some kids don’t seem prone to picking up the rash. One of my twins had the rash all over his belly for close to a year. Yet my other twin only had one bump on his ankle for a few months.
Treating molluscum is frustrating. Pediatricians and dermatologists have some agents which irritate the molluscum in hopes that the body’s immune system will wake-up and get rid of it. Medications such as cantheridin (extract of blister beetle), Retin A, liquid nitrogen, and others all are used to treat molluscum with varying success rates. Hydrocortisone 1% three times a day for a few days will soothe itchy skin patches of molluscum. Although the medication will not cure the rash, it will help calm the itch and prevent further spread. Rarely, just like any area which is scratched, bacteria from the skin will infect the rash. If a bump is scratched open, put a dab of antibacterial ointment on along with the hydrocortisone. If redness increases and the area becomes progressively tender, seek medical attention. Take heart in the fact that molluscum DOES go away on its own, but can linger for months or even years before finally fading. My husband and I opted not to treat our twins, and waited for the molluscum to leave on its own, which it did. Often, just before spontaneously going away, the bumps become red and irritated for a day or so and then just… go.
When I diagnose a patient with this condition, the name of this rash always makes me feel like I am casting a Harry Potter spell:
Parent: “Doctor Kardos, what is this rash on my child?”
Dr. Kardos, brandishing a magic wand: “MOLLUSCUM CON-TA-GIOSUM!!!”
The medical literature and 15 years in pediatric practice tell me there are no vitamins or behavior therapies that play any role in banishing this rash. In short, there are no quick fixes.
If only the cure were as easy as waving a wand. We’ll let you know if we hear of any new spells.
Julie Kardos, MD with Naline Lai, MD
©2012 Two Peds in a Pod®
Just in time for Father’s Day— the book Dad to Dad: Parenting Like a Pro. Written by our pediatrician colleague, Dr. David Hill, this North Carolina based Pediatrician brings a humorous, yet practical perspective on fatherhood. His book includes chapters on nontraditional parenting relationships, talking to kids about sexual development and helping your child sleep. Two Peds in a Pod is pleased to give you a sneak peek:
Dads are not good for kids just because we do the same stuff moms do. That’s not to say doing that stuff isn’t important; it’s critical! Mothers and fathers have a similar effect on their children’s moral development, social comptence, school performance, and mental health. There is a reason, after all, it takes 2 parents to make a baby, and not just because it’s more fun that way.
Probably the most accurate generalization about dads versus moms is that fathers play more. In the first 4 years of a child’s life we tend to focus on activities that involve touch and stimulation, like tickling, wrestling, and playing an airplane. It’s our job, in other words, to get kids all wound up so they won’t go to bed, to make them laugh until they pee on themselves. (Note: If this happens, be a good sport and help with the clothing change; after all, it is your fault.) During middle childhood, we’re more likely than mothers to get out and do stuff, like take walks, go fishing, or see a ball game. Are you surprised? No, you are not. You already knew that from watching sitcoms.
……
Some people might still call this a man’s world, but the corners of it devoted to child care can sometimes feel downright unfriendly to fathers. I recall times when, taking my young children to the playground, moms actually got up from a park bench where they had been talking and moved over to the next swing set. It’s possible they were just following the shade, but I couldn’t help looking around to see if my picture was stapled to a nearby utility pole.
As an involved father you might expect everyone you encounter to smile and praise you or tell you how impressed they are at what you’re doing. At times you will get this reaction. Some people seem amazed I can get my kids out of the house wearing 2 matched shoes. In fact, one of my pet peeves is when the children’s clothes clash and someone says, “Daddy must have dressed you today.” I want to look that person dead in the eye and say, “You don’t know me very well, do you? My daughter here left the house in a perfect little outfit, but she threw up on that one, and this is what was in the trunk of the car. Now stand back— she’s looking a little pale.”
David L. Hill, MD, FAAP
excerpted with permission, from Dad to Dad: Parenting like a Pro
Dr. David Hill is a pediatrician, writer and father of 3. He believes humor is essential to surviving parenthood. He has put this theory to the test at various times as a stay-at-home dad, a primary breadwinner, part of a 2-working-parent family, and a single father. He is vice president of Cape Fear Pediatrics. As a writer, Dr. Hill has composed and recorded humorous commentaries for National Public Radio’s All Things Considered and NPR affiliate WHQR. Dad to Dad: Parenting like a Pro is available at bookstores everywhere and through Independent Publishers Group and the American Academy of Pediatrics bookstore.
Welcome to summer! Some seasonal topics to read up on: a germ that lurks in pool water, itchy rashes from poison ivy, painful ears from swimmer’s ear and how to prevent kids from dehydrating.
Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®