Two Peds in a Pod®

Are my teen’s vaccines up to date? Maybe not—HPV, pertussis, meningococcal meningitis and flu

Today we bring you more advice from the Atlantic Regional Osteopathic Convention 2012 Adolescent session, where Dr. Amanda Manning updated us about adolescent vaccines. As always, be sure to review with your child’s doctor any contraindications as well as reasons to vaccinate early with all of these immunizations.

Tdap : This vaccine, which prevents pertussus (whooping cough), tetanus and diphtheria, is given to 11- 12 year olds. But since the pertussis component of the Tdap vaccine was not recommended until six years ago, your teen may have received the formulation without pertussis protection (dT). If so, he should now get a dose which contains pertussis. Recent evidence shows teens and adults lose their immunity to whooping cough and can spread disease to vulnerable infants and young children.

The meningitis vaccine, or “quadrivalent meningoccal conjugate vaccine”: Pediatricians routinely give this vaccine to tweens. New recommendations add a booster dose at age sixteen years. If the first dose was not given until age sixteen, a booster dose is not needed. Read our earlier post for more information about this vaccine and the disease it prevents.

HPV vaccine: This vaccine protects against Human Papillomavirus (HPV), which causes cancer of the cervix, vagina, penis, and throat. HPV also causes genital warts. Most people who are infected pick up the virus unknowingly during their first two years of sexual activity. In fact, eighty percent of women by age 50 are infected with some form of HPV. Luckily, the majority of infected women do not develop illness. The Pap tests that women receive at their yearly gynecology visits screen for cervical cancer caused by this virus. Here are common questions parents ask about the HPV vaccine:

Is this vaccine safe for my kids?- it’s too new

No more need to “watch and wait” for more safety data before giving it to your teen. Health care workers have given over 40 million doses of HPV vaccine worldwide so far with no serious adverse events. The vaccine has a good track record of safety, despite what some internet sources as well as politicians would have you believe. The side effects of local soreness and mild fever are the same as those seen in all other vaccines.

Should both girls and boys be vaccinated?

Yes, but only the brand Gardasil is approved for use in males.

Isn’t giving the vaccine at 11 or 12 years old “too young”? My kid is not sexually active.

Younger teens make better antibodies from this vaccine than older teens. The vaccine is most effective before the onset of sexual activity, before kids could be exposed to the virus.

If my teen forgets a dose, does she need to restart the series?

Three doses complete this vaccine series. Fortunately, if you forget to bring in your teen for the follow up dose, your teen’s doctor can simply continue the series wherever your teen left off and the vaccine will still be effective.

Can my young adult aged children also get the vaccine ?

Yes, but for Gardasil only up through 26 years and for Cervarix through age 25. Cervarix is not approved for males. Last year, the FDA did not find there was enough of a decrease in disease to widen the age range for Gardasil after age 26.

FLU: The guidelines for the flu vaccine are the easiest to remember of all the vaccines. Give a dose of flu vaccine to every teen every year, before the start of flu season. In fact, EVERYONE should get flu vaccine every year, including adults. The mist-in-the-nose form is safe for anyone without asthma or other chronic health conditions, and now, safety data shows most everyone can receive the injectable form, even kids with egg allergy. Please see our earlier post for more information about the flu virus, the flu vaccine, and how to tell if your child has the flu.

Amanda Manning, DO, FAAP, FACOP, is the site supervisor of the pediatric group at Geisinger Medical Group in Bloomsburg, Pennsylvania. She is a graduate of Duke University and The University of Medicine and Dentistry of the New Jersey School of Osteopathic Medicine, and completed her pediatric residency at the Geisenger Medical Center. Dr. Manning has been practicing general pediatrics for fifteen years.

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

Chewing the fat: new cholesterol screening guidelines for all kids

cholesterol cartoon I have a confession to make. Two of my kids still have not had their blood cholesterol checked. You see, according to the National Heart, Lung and Blood Institute (NHLBI), kids with risk factors for heart disease (in my children’s case, a grandfather who had an early heart attack) should have their cholesterol level checked. But I’ll be getting my kids to the lab soon. New research shows that although heart attacks and strokes are rarely seen until adulthood, atherosclerosis (cholesterol plugs) in blood vessels, which is a precursor for heart disease, can be seen as early as during fetal growth. The concern is so great for heart health that guidelines were recently revised: EVERYONE, regardless of risk factors, should be screened twice during childhood.

For those WITHOUT risk factors, your child’s doctor can order NON-fasting total and high-density lipoprotein-HDL (aka “total cholesterol” and “good cholesterol”) levels for initial screening. Routine screening should occur sometime between 9-11 years and again between 17-21 years.

For kids WITH heart disease risk factors like mine, the American Academy of Pediatrics recommends a nine to twelve hour fasting “lipid panel.” Lipid panels usually measure low density lipoprotein (LDL) “bad cholesterol” and triglycerides in addition to total and HDL cholesterol. For kids with risk factors, screening should occur when the risks are discovered.

Pediatricians start asking for a family history of risk factors by three years old. Risk factors include: a parent, grandparent, aunt/uncle, or sibling with a heart attack or evidence of heart blood vessel damage less than 55 years in males or less than 65 years in females, or a parent with high cholesterol or triglycerides. Other risk factors for your child include having medical conditions such as diabetes, high blood pressure, obesity (Body Mass Index/BMI ≥95th percentile) and smoking cigarettes. Ask your child’s doctor for a full list of qualifying conditions.

The easiest way to time a “fasting” blood draw is to give your child dinner at his regular time, send him off to bed, and go to the lab first thing in the morning. Bring a snack with you so you can feed your child immediately after his blood is taken.

Because drinking water will not affect the lab results, have your child drink plenty of water before-hand and throw a sweater on him. The extra fluid will plump up the veins and the warmth from the sweater will dilate blood vessels, making it easier for the lab technician to draw blood.

Worried about calming down your kids’ nerves before a blood draw? Use techniques discussed in How to take the sting out of injectible vaccines.

For the full NHLBI report check out http://www.nhlbi.nih.gov/guidelines/cvd_ped/index.htm . For guideline analysis look at this link from the American Academy of Pediatrics.

Naline Lai, MD with Julie Kardos, MD

The Jersey Shore: pediatric style

We’re back from a Jersey Shore medical conference where we moderated the adolescent session of the Atlantic Regional Osteopathic Convention. In the next few weeks, we’ll be posting you advice gleaned from talks on teen depression, vaccine updates, fatigue in adolescents and worrisome teen drug use trends.

Today we start with advice based on Dr. Melisa Lai Becker’s talk, Trendy Tox Teen Behaviors:

How do I know if my kid is high? Your tween or teen wanders in late on a Saturday night and acts like he is in slow motion. “I’m just tired,” he claims. Is he high, you wonder? To answer the question, have him look you straight in the eye as you talk to him. Even if he is lying, the truth will be in his eyes. More specifically, it’s in the size of his pupils (the black part of his eyes). Too big (nearly covers the colored part of his eyes) or too little (like pinpoints) is a sign he is currently high.

Alcohol: Parents, beware. The type of alcohol in your beer, ethanol, is the same type of alcohol in your morning mouth wash and perhaps in your medicine cabinet. The difference is that mouthwash contains more alcohol than beer. Beer typically contains up to 5 percent ethanol, wine up to 14 percent ethanol, and liquors usually up to 40 percent ethanol. Compare this to Original Listerine with 27 percent ethanol and Nyquil Nighttime Cold/Cough with 25 percent ethanol (and you wonder why it helps you fall asleep?!).

How can you tell if your kid is drunk? Again, look at his eyes- if he is drunk you may see pupils dancing in small circles. The dancing eyes give the sensation of “dizziness” to drunk individuals.

Pharming: We teach our children that medicine is not candy, and yet Pharming—consuming prescription substances to get a high—is a big problem among teens. Since 2003, according to the Centers for Disease Control, more overdose deaths have involved painkillers like Vicodin and Percocet than heroin and cocaine combined. Among teens, medications prescribed for Attention Deficit Hyperactivity Disorder are the most popular pharmed drugs. Don’t unwittingly contribute to a pharming party where kids raid medicine cabinets, deposit pills into big bowls and randomly ingest them. This upcoming week, April 28, is National Prescription Drug Take-Back Day . Make it a spring cleaning priority.

The most important phone number parents (and doctors) can know:

poison control: 1-800-222-1222

Melisa Lai Becker, MD, is chief of Emergency Medicine at the Cambridge Health Alliance at Whidden Memorial Hospital campus in Everett, Massachusetts. She also serves as Director of Medical Toxicology of the Cambridge Health Alliance and as a Harvard Medical School instructor.

Naline Lai, MD and Julie Kardos, MD
©2012 Two Peds in a Pod®

It’s Tummy Time! Taming tummy time torture

My oldest child hated tummy time. Miserable, she would flail on the floor and wail like a marooned walrus. Although she eventually learned to tolerate it for periods of time, she disliked time on her belly so much, she skipped the developmental milestone of flipping over from her back to her belly and went straight to sitting upright.

Babies spend a lot of time on their backs when they are young. In accordance with guidelines to prevent Sudden Infant Death Syndrome, babies are put to bed on their backs. But continual pressure on the back of an infant’s head when the baby is also awake leads to head flattening. Thus, current recommendations are to give your baby time on his belly when he is awake. But for some, tummy time is torture time. For those infants, Physical Therapist Deborah Stack gives us ideas on how to make tummy time tolerable.

Dr. Lai with Dr. Kardos

Physical therapists are sometimes enlisted to treat or prevent plagiocephaly (head flattening). Physical therapy for plagiocephaly is a combination of parent teaching, assessment of nursing positions, carseat and feeding seats, handling techniques for promotion of typical movement patterns, and facilitation of motor development. Much teaching revolves around different ways to incorporate tummy time into your family schedule. Remember…it is critical to keep weight off the flattened area for as many hours a day as possible. If needed, babies do best if referred to physical therapy by their doctors at two to four months of age. In fact, a 2008 research study¹ showed a significant improvement in plagiocephaly for children referred to physical therapy versus children whose parents were provided with an instructional pamphlet.

How can you get started? Try these ways to do “tummy time” with your baby.

1. Belly to belly with your baby

Recline back comfortably in a chair with your child on your chest. Try to help your baby keep his forearms supported on your chest. Talk to your baby to encourage him to lift his head to look at your face.

2. Eye level play with your baby

Place your baby on a bed, couch, or other raised large area with her head near the edge of the surface. Get down so you can look your baby in the face and talk, sing, or make funny faces or sounds. Keep one hand on your baby’s buttocks so she does not roll or fall. Siblings love to be the entertainment!

3. Lap play

Place your baby across you lap with his chest on one leg and his thighs on the other. You can raise the leg nearer the baby’s head a bit to make it easier.

4. Airplane carry

Carry your baby face down as you walk. If your child is small enough, place your forearm under her belly with your hand supporting the upper chest. Younger infants will need their heads and chest supported, but as your baby gains strength in the neck and trunk muscles, less support is needed. Most babies really like this!

Progress tummy time as tolerated. Many babies can initially only handle 20 or 30 seconds at a time without becoming distressed. Within a few weeks, many children will be able to be on their tummies for 15 minutes or more.

Remember, babies should be placed on their backs to sleep, but while your infant is asleep, you can still tiptoe in and rotate your baby’s head gently away from the flat side.

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.

Source cited:1 van Vlimmeren LA, van der Graaf Y, Boere-Boonekamp MM, et al. Effect of pediatric physical therapy on deformational plagiocephaly in children with positional preference: a randomized controlled trial. Arch Pediatr Adolesc Med. 2008;162:712-718..

Why is my baby’s head flat? Positional plagiocephaly

Squeezed through the birth canal, many babies are born with pointy, cone-shaped heads. Others, delivered by caesarian section, start off life with round heads. No baby begins with a flat head. But as parents put babies on their backs to sleep in accordance with Sudden Infant Death Syndrome prevention guidelines, babies are developing flat heads.

Called positional plagiocephaly, a young infant’s head flattens when prolonged pressure is placed on one spot. Tricks to prevent positional plagiocephaly all encourage equal pressure over the entire head. Because babies’ heads are malleable, parents can easily prevent and treat the flatness. In fact, the flat shape begins to correct itself after six months of age, when babies spend less time lying down and more time sitting and crawling. Additionally, increased hair growth hides some of the flatness.

To prevent positional plagiocephaly, place your baby prone (belly down) frequently WHILE AWAKE, starting in the newborn period. This tummy time decreases pressure on the back of the head. Some babies are not fond of tummy time and will cry until they are back on their backs. For those kids, in our next post, guest blogger physical therapist Deborah Stack will address ways to make the time tolerable.

Encourage your baby to look to both sides while lying down. Too much time turned to one side will cause flattening on that side. Alternate how you place the baby in crib so that sometimes she turns to the right and other times she turns to the left to face into the room and away from the wall. If your baby seems to prefer looking only to the right or only to the left, place toys or bright objects toward the non-preferred side. If bottle feeding, switch off which arm you use to feed your baby, so that the baby sometimes turns to the right and sometimes to the left . If breastfeeding, start and end on the side that the baby tends to avoid. These actions will help prevent neck muscles from becoming too tight on one side and thus allow your baby to turn easily to both sides.

Some babies wear helmets to correct their abnormal head flattening. Neurosurgeons, who are head and brain specialists, prescribe these helmets for babies who have extreme flattening. Fortunately, the majority of babies with positional plagiocephaly do not need to wear helmets.

You also may have heard of babies who need corrective surgery for an abnormal head shape. This condition, called craniosynostosis, is rare. Pediatricians monitor the size and shape of the head and check the soft spot on the top of the head at every check-up. A baby’s skull develops in pieces as a fetus, and these pieces eventually come together at predictable places called sutures. If the pieces come together too early or the soft spot closes too soon, corrective surgery must be performed.

So, avoid head flatness by rotating your baby’s position frequently (think rotisserie chicken!) and provide plenty of “tummy time” when awake. Start when the baby first comes home.

If you are worried about your baby’s head shape, just head on over to your baby’s pediatrician and bring up your concern. Trust us, your concern will not “fall flat.”

Julie Kardos, MD and Naline Lai, MD

How can I motivate my child in school? — Creating the resilient learner

“What will happen if your grade drops from an “A” to a “C”?” I sometimes ask during a check-up.

Many kids shrug and say, “Try harder next time, I suppose.” Others look shocked and anxious about the possibility and are speechless.

Still others will point at their parents and say,”THEY would kill me.”

Observe a toddler learning a new skill. You will see him repeatedly try to fit a ball into a hole until he is either successful or wanders way. He is not anxious or afraid of failure. He is not “stressed” about trying to learn. Although all children start this way, too often toddlers become big kids who end up in my office discouraged and worried about school performance. Today’s guests Principal Mr. Leonard Schwartz and Vice Principal Michael Testani, based on the work of Dr. Carol Dweck, discuss ways parents can influence their children so that they embrace learning.

– Drs. Lai and Kardos

Researchers under the leadership of Dr. Carol Dweck conducted a survey of parents of school aged children. The majority of parents thought it was necessary to praise their children’s intelligence in order to give them confidence in their abilities and motivate them to succeed. Instead, this approach can lead to fixed mindsets in children. Kids with fixed mindsets believe “my abilities are what they are.”

Instead, the most motivated and resilient students demonstrate a growth mindset. They are the ones who believe their abilities can be developed through their effort and learning. These students are resilient and persevere when tasks become challenging.

A study of students’ brain waves revealed students with a fixed mindset were interested in whether they got an answer right or wrong, but when they were wrong, they paid little attention to the correct answer. Students who were praised for their intelligence later lied about their scores. They felt the errors were so humiliating that they could not own up to them. The students failed to persevere, believing they were no longer “smart,” and therefore unable to meet academic challenges.

Students with a fixed mindset typically think it is best if they:

Don’t make mistakes – “I’m too smart to make mistakes.”
Don’t need to work hard –”I’m smart and learning comes naturally to me.”
Don’t try to repair mistakes- “I was wrong, and that is the end of it.”

Students with a growth mindset generally:

Take on challenges
Work hard
Confront their deficiencies and correct them

How should parents talk to their children in order to develop a growth mindset?

Wow, you got 10 out of 10 right! What strategy did you use to get a perfect score?
What can you learn from this mistake that will help you do better next time?
I am proud of how hard you worked on this project and look at how your hard work paid off!
The strategies you used last time didn’t work. Let’s take a look at them so I can help you figure out better strategies to use next time.
You’re becoming such a good learner!
Smart is not something you are; it’s something you become. Let’s figure out how you can become smart at this assignment.

What is your child’s mindset? Ask yourself, what is your own mindset? Have a conversation with your child as you discuss your child’s report card. Use any upcoming parent teacher conference to examine outlooks, attitudes, and strategies that are or are not supporting your child’s academic progress.

Where applicable, praise your child’s positive skills and attributes. Celebrate instances you observed that contributed to positive indicators.

When necessary, examine areas of poor performance and strategize with your child about how he or she can turn a weakness into a strength. Again, you may revisit situations you observed this past grading period in which your child took shortcuts, provided incomplete work products, or did not do his or her personal best.

Make your expectations very clear in terms of why you value attributes or traits of resiliency, and how they can and will develop into habits that will serve your child well.

Grades are a distant second to the level of effort a child invests in personal learning in any setting.

Leonard H. Schwartz, Principal, Mill Creek Elementary School

Michael R. Testani, Assistant Principal, Mill Creek Elementary School

Mr. Schwartz and Mr. Testani are part of the Central Bucks School System in Pennsylvania. After fourty-three years as an educator in two school districts and five schools, Mr. Schwartz retires this year. This post was published in it’s full original form in the publication Principal’s Prose of Mill Creek Elementary School.

Potty Talk: the “Scoop On Poop” on philly.com

We’re pleased to bring to the Greater Phildaelphia Area our “Scoop on Poop” post which was published in the Healthy Kids blog for Philadelphia Inquirer’s philly.com.

Although many can not talk about the topic without snickering, face it. “Poop” is an essential of life. If pooping gets thrown off, everything gets thrown off. The kid who won’t poop in the potty sets everyone else in the household off kilter, and leads to bribes, threats and chaos. A constipated kid is a grumpy kid. Constipation can lead to tantrums, refusal to eat, and even an inability to fall asleep. If you still have have infant and toddler poop questions, check out our podcast on potty training and our post “When potty training gets hard: constipation.” On a related topic, please also visit our post “It’s a Gas, your young infant’s burps and farts.”

Until you are a parent, you can never fully appreciate the fierce desire for “everything to come out okay in the end.”

Some like it hot: Hot Tub Folliculitis

hot tub rash From the start, a family I know was suspicious of the hot tub sanitation at the resort where they recently stayed. As time went by, even though the water looked clear, the hot tub seemed less chlorinated, and the water more tepid. They dubbed the tub “the scuz tub.” After their return, one of the kids broke out in the rash of hot tub folliculitis pictured to the left. You could say, they figured out just what the “scuz wuz”.

Hot tub folliculitis is a skin rash caused by a bacteria called pseudomonas aeruginosa. The rash appears a day or two after soaking in a hot tub. A light pink bump appears around hair follicles (hence the name). As you can see in this photo, the rash is typically worse on areas of skin where bacteria was trapped under a swimming suit. The rash can cover all body surfaces, including the face, if your child dunked his head under water.

The rash can be slightly itchy but is not usually painful. No other symptoms develop such as fever or sore throat. The rash is not contagious, but often other people who swam in the same hot tub also break out.

Treatment is to wait it out. Typically by one to two weeks, provided your child does not go back into the hot tub, the rash resolves on its own. If your child feels very itchy, you can treat her with oral diphenhydramine (brand name Benedryl). Rarely, just like mosquito bites, the rash can become infected with other bacteria if your child scratches too much.

Pseudomonas thrives in warm wet places. In fact, it’s the same bacteria that causes “swimmer’s ear.” Tight control of chlorine and acid content of the hot tub water limit the growth of the bacteria. Unfortunately, you can not tell the pseudomonas content of water just by eyeing it.

May you bring back a better souvenir than this family did on your next vacation.

Julie Kardos, MD and Naline Lai, MD

Portable Parent: baby advice texted to your cell

“Calling” all moms and dads with cell phones! We discovered a new free service from the US National Healthy Mothers, Healthy Babies Coalition. The service text4baby texts health maintenance tidbits three times a week to your phone during pregnancy and during your baby’s first year of life.

Text BABY or BEBE (to receive messages in Spanish) to 511411, and you will receive three texts a week. This is an example text for expecting parents: “Your baby will be here soon, & it’s time to get a car seat. The hospital won’t let you leave by car or taxi without one.”

Since most cell carriers participate, even people in the United States without a text plan can get messages for free. If you have a text limit per month, text4baby won’t take away from that limit. Look at www.text4baby.org for more information.

Gotta <333 a service like this.

It’s National Sleep Awareness Week: nothing to snooze at

Wake up!

Remember that sleeping, along with eating, peeing and pooping, is an essential of life that helps your child (and you) function well. Inadequate sleep is associated with obesity, learning difficulties, behavior problems, and emotional lability (gotta love the whining of an overtired kid.)

In honor of the National Sleep Foundation’s National Sleep Awareness Week, which ends on March 11when Americans “spring ahead” the clocks and we ironically lose one hour of sleep, please refer to our earlier podcasts and blog posts on sleep. We invite you to learn about how to teach healthy sleep habits to your kids and yourselves (the parents).

The podcasts:
–Sleep Patterns of the Newborn
–Helping your baby to sleep through the night
-“There’s a monster under my bed”: all about nightmares, night terrors, night wandering, and bedwetting
–The tired teen

The blog posts:
-Sleep Safety: How to decrease your baby’s risk of Sudden Infant Death Syndrome (SIDS)

-Parents of newborns: get your Zzzzzs back
–I Need a Nap!
–Wake up, sleepy-head, it’s time for school!

–When your child’s bedtime seems too late, or, will I ever get a late night alone with my spouse again?