Swimmer’s Ear

Dozens of kids are pouring into our offices or calling from the shore because of swimmers ear. Time to bring up from the archives info about swimmer’s ear and ways you can prevent reoccurrence.

No set of blog posts about summer time plagues would be complete without a discussion on swimmer’s ear (Otitis Externa).

Ear infections are divided into two main types: swimmer’s ear (otitis externa) and middle ear infections (otitis media).

An understanding of the anatomy of the ear is important to understanding the differences between the two types of infection. Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. The tunnel is called the external ear canal and the door is called the ear drum.

Swimmer’s ear occurs in the ear canal. Dampness from water, and it can be water from any source- not just the pool, sits in the ear canal and promotes bacterial infection.

Next, open the door. You will find yourself in a room with a set of three bones. Another closed door lies at the far end. Look down. In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a middle ear infection, fluid, such as during a cold, can collect in the room and promote bacterial infection. Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe called the eustachian tube, drains the fluid. But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected.

Because a swimmer’s ear infection occurs in the external canal, the hallmark symptom of swimmer’s ear is pain produced by pulling the outside of the ear. Since middle ear infections occur farther down in the ear, pain is not reproduced by pulling on the outer ear.

Swimmer’s ear is treated topically by your doctor with antibiotic drops. To avoid dizziness and discomfort when putting drops in, first bring the ear drop medicine up to body temp by holding the bottle in your hand.

Home remedies to prevent swimmer’s ear:

· After immersion in the water, tilt your child’s head to the side and towel dry what leaks out.

· Mix rubbing alcohol and vinegar in equal parts. After swimming, place a couple drops in the ear. Do not put these drops in if there is a hole in your child’s eardrum.

· Prior to swimming put a drop of mineral oil or olive oil in each ear. This serves as a barrier protection against the water. Do not put in if there is a hole in your child’s eardrum

Although it’s tough to remind children to dry their ears well, take heart. I once spent two hours trying to get a cockroach out of a child’s ear canal. I suspect those parents would have been happier if instead, water had gotten into their child’s ear.

Naline Lai, MD and Julie Kardos, MD
originally posted August 9, 2009
©2011 Two Peds in a Pod®

June 26, 2011 by twopedsinapod

Hand-foot-mouth disease

WE HAVE UPDATED THIS POST and added photos- please read it here.

We’re seeing a lot of this stuff around the office. It’s hand-foot-mouth disease, a common, self-limited illness caused by the Coxsackie virus most often in the spring and summer. Named for rashes which can affect the hands, feet or mouth, this illness can cause fever for the first few days as well as some loose stools.

If you look carefully at the photos above, you will see faint red bumps on this child’s feet. The rash may also look like tiny blisters and will always blanch (if you press on it and lift up your finger, the redness will briefly disappear- just as if you pressed on a sunburn). The same rash may appear on the hands and is not itchy. The child’s throat above is red in the back and has several ulcers, or canker sores. The hands, feet and mouth are not always simultaneously affected, and although we don’t call the illness Hand-foot-mouth-tush disease, sometimes kids also get a red bumpy rash on their buttocks.

The throat ulcers can be quite painful and the rash on the feet may be slightly tender. Usually the rash on the hands is not felt by the child. You can alleviate your child’s throat pain with acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil or Motrin). For toddlers and older, Magic mouthwash, a mix of 1/4 tsp diphenhydramine (plain liquid Benadryl) and 1/4 tsp Maalox (the regular adult stuff) squirted over mouth ulcers prior to eating a meal (three times a day) is an age old way to sooth sores.

Because this virus is contagious through saliva, prevent kids from sharing cups, eating utensils, and tooth brushes and clean up toddler drool. This vigilance can prevent the virus from spreading to family members and friends. Children with this virus can still attend daycare as long as they are not feeling ill. Typically after the first few days of illness, fever and pain subside. Most commonly the rash and mouth ulcers last about a week or two.

Unfortunately there is no treatment for hand-foot-mouth disease, but fortunately your child’s body is fully capable of fighting off the virus. Your role is to help soothe pain. Otherwise, kids may refuse to drink and end up dehydrated. When my son had this illness at age two, he liked sucking on a washcloth soaked in very cold water. I also gave him lots of sherbet, ice cream, milk shakes, and noodles. These foods were easier for him to swallow while his throat was sore.

Kids can get this virus more than once, and many strains of this virus circulate. Even parents are not always immune. So now add Coxsackie virus, or hand-foot-mouth disease, to your Dr. Mom and Dr. Dad list of manageable diseases. Knowledge is power. However, if your child’s fever lasts more than three days, he does not drink enough to urinate his baseline amount, he is unconsolable or seems disoriented or if your parent gut-instinct tells you something more might be wrong, do get your child to medical attention.

Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®

June 24, 2011 by twopedsinapod

Happy Father’s Day 2011

In honor of Father’s Day, Two Peds in a Pod sends out a salute to dads.

We salute the dads sent to the grocery store at midnight after the little kids are in bed.

We salute the dads who show up in our offices first thing Saturday morning with a feverish child while birthday party/holiday dinner/ grandparent anniversary celebration preparations go on at home.

We salute the dads who run the weekend errands while their partners go for a long run.

We salute the dads who, when called, immediately drive the teens home from a party- no questions asked.

We salute the dads who make the elaborate chocolate chip pancake and waffle extravaganzas after a sleep over party.

We salute the dads who don’t pay to “opt out” of volunteer duties on a sports team and grab their wheel barrows to prepare muddy fields for play.

We salute the dads who help build the larger-than-life school project and then drive it to school in the pouring rain.

We salute the dads who carry their kids (no matter how old) when they are too tired to walk.

Happy Father’s Day!

Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®

June 17, 2011 by twopedsinapod

What’s for dinner? ideas from our kitchen tables

After we complete a Two Peds in a Pod planning or edit session, our conversation inevitably turns to the question, “What are you cooking for dinner tonight?”

We know parents are always searching for simple ways to move beyond macaroni and cheese suppers. Here are two chicken dishes Dr. Kardos’s kids love and one tofu dish Dr. Lai’s children enjoy. For picky eaters, please note each item is well demarcated- no food has to “run into” or “touch” the other items. All can be eaten with a fork or with fingers for younger toddlers. They have flavors that adults like but are not too strongly flavored to turn a kid off. Best of all, they are easy to prepare.

Gram mom’s Chicken-in-a-Pot

Need: One 5-8 lb oven stuffer roaster chicken, carrots, onions, spices, cast-iron pot/dutch oven

Rinse off chicken and discard innards/gizzards. Pat dry. Sprinkle with spices that are kid friendly (no hot pepper unless your child really likes it). I use garlic powder, onion powder, salt, and tarragon. Place chicken into a cast-iron pot/Dutch oven. Add cut up carrots or “baby” carrots and either frozen pearl onions or a fresh onion chopped up. Other vegetables that will not fall apart/become mush would work as well. DO NOT ADD WATER.

Cover the pot, place on stove on low heat, and cook for 2-3 hours, until chicken is tender. It makes its own juices as it cooks so you never need to add water. When done, the chicken falls off the bones with minimal prompting. Carefully discard bones.

Result: easy to chew, pleasantly but not strongly flavored chicken, and cooked carrots. Dr. Kardos’s kids love to eat this with applesauce (two like to dip the chicken), raw carrots (only one of her kids likes cooked carrots), rice or noodles (juices from chicken taste great on either one) and fresh strawberries or other kid-pleasing fruit.

A ma’s (Taiwanese for gram mom) easy Tofu

Need: extra firm or firm tofu, rice, soy sauce, sesame oil, dried basil (Mrs. Dash has a tomato-basil-garlic spice mixture which is great, but tough to find)

Cut a block of tofu into one-third inch thick square pieces (approximately one and one half inch by one and one half inch). Liberally coat the bottom of a frying pan with sesame oil, add tofu and soy sauce, sprinkle dried dried basil over pieces. Cover and cook on high heat until starting to brown, then flip pieces over and cook on medium heat until other side starts to brown. For the picky kid, mush with a fork into rice and serve in a big bowl with fruit and vegetables on a separate plate. For everyone else, consider adding pepper and serve over steamed white or brown rice.

Mom mom’s baked chicken

Need: Boneless/skinless thicker cut chicken breasts, herb or Italian flavored breadcrumbs, grated parmesan cheese, butter (or Smart Balance).

Melt butter in one bowl. In another bowl, mix equal parts breadcrumbs and parmesan cheese.

Rinse chicken, pat dry. Dip the chicken first into the melted butter, then into the breadcrumb mixture until well coated, then place onto baking pan. Drizzle any remaining melted butter onto the chicken. Bake at 350° for 25-30 minutes (until chicken is cooked through).

Serve with rice, noodles, couscous, or bulgur wheat, salad or frozen mixed vegetables that steam right in the bag, and fresh pineapple or other kid-pleasing fruit.

Bon Appetite,

Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®

June 12, 2011 by twopedsinapod

Thrush: out of the mouth of babes

Cottage cheese like curds coat the inside of your baby’s tongue and inner cheeks. What is this white stuff that won’t wipe off? Not breast milk, not formula, it’s thrush.

Thrush, fancy medical name Oral Candidiasis, is caused by an overgrowth of yeast, called Candida. Although not painful, it may cause discomfort akin to having a film of cotton coating the inside of the mouth.

We all have Candida on our bodies. Usually we have enough bacteria on our bodies to suppress the growth of Candida, but in cases when there is less than usual bacteria such as in young babies or for kids who are on antibiotics, Candida can emerge. For older kids on inhaled steroids for asthma, failure to rinse out the mouth after medication use also promotes an environment conducive to thrush.

To treat thrush, we usually prescribe Nystatin, an anti-fungal/anti-yeast medication, which works topically. Parents apply the medicine to the inside of the baby’s mouth after feedings four times per day. Use Nystatin until thrush is no longer visible for 48 hours. A course takes one to two weeks to complete. An oral medication called fluconazole (brand name Diflucan) may also be prescribed.

Watch out. Thrush may be thriving on mom’s breasts or on pacifiers or bottle nipples. Mothers can apply the same medicine to their breasts after breast feeding. Scrub pacifiers, bottle nipples, and any other object that goes in to a baby’s mouth extra well with hot water and soap or use the dishwasher.

Thrush that persists despite proper treatment can signal an immune system problem. So if your child’s thrush is not resolving in the expected time, let your child’s health care provider know.

A newborn’s tongue may always look slightly white. This “coated tongue” in young babies could be residual breast milk or formula and does not need treatment. If you are not sure, bring him in to see his health care provider for proper diagnosis.

Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®

June 6, 2011 by twopedsinapod

Art Barn Opening

We’re thrilled to announce the showing of our fabulous photographer Lexi Logan’s work at the Art Barn in Buckingham Pennsylvania. The Art Barn where she collaborates with several other artists, including her renowned sculptor husband Andrew Logan, will be opening to the public for the first time this weekend. Here is the clipping from the May 26 Bucks County Herald:

May 31, 2011 by twopedsinapod

Two Peds goes undercover at your local pharmacy

Picture the Mission Impossible theme song in your head… da da da DUM DUM da da da DUM DUM dadada…dadada…dadada…DA DA! Keep this background music playing as you read.

Recently, Two Peds in a Pod went undercover as two unsuspecting moms surveying the scene on the shelves of a local chain pharmacy, seeking to uncover what medicines, ointments, and therapies avail themselves to the unsuspecting consumer. Today we break open the case.

All medication labels have an “active ingredient” list. This list contains the actual medicine that acts on your child’s body to hide symptoms or cure a condition. Read this list carefully so that you know what you are actually giving your child. For example, Flu-Be-Gone claims it “cures the aches and cough of flu and helps your child sleep better.” In order to know just what is actually in Flu-Be-Gone, you need to read the active ingredients. Included might be acetaminophen (brand name Tylenol), a fever reducer and pain reliever, and diphenhydramine (brand name Benadryl), allergy medicine that has the common side effect of causing drowsiness and has some mild anti-cough properties. Notice neither active ingredient actually kills the flu germ. Additionally, you may already have these two medications in your medicine cabinet, or you might have already given your child diphenhydramine recently and giving Flu-Be-Gone would overdose your child.

Also note, diphenhydramine is everywhere. If you see the word “sleep” or “PM” in the name of a product, you will usually find diphenhydramine in the active ingredient list.

Now, let’s hone in on your choices for the anti-itch therapy, hydrocortisone. When your child’s health care provider advises treating an itchy bug bite, poison ivy, or allergic rash with hydrocortisone, make sure that the ACTIVE INGREDIENT in the product is “hydrocortisone 1%.” Hydrocortisone comes as a cream, ointment, spray, or stick (looks like a glue stick) and can have aloe, menthol, or other ingredients thrown in as well. Don’t bother with anything less than maximum strength. Regular strength is 0.5% and is generally ineffective. Also, keep in mind that while ointment is absorbed a bit better, it is more greasy/messy than cream.

Don’t be fooled into thinking products with the same brand name contain similar active ingredients. Also, do not depend on your doctor to necessarily know the difference between the all the formulations.We noticed that the same brand name pain reliever, such as Midol, can have different active ingredients depending on which one you choose. Midol Teen contains acetaminophen, Midol liquid gels contains ibuprofen, and Midol PM contains acetaminophen and diphenhydramine.

Let’s talk bellyache. Did you know that kids should not take adult pepto bismol because it has a form of aspirin in it? Aspirin may cause Reye’s syndrome, a fatal liver disorder. However, we did see a product called Children’s Pepto Bismol and guess what the active ingredient is? It is calcium carbonate, which is the SAME active ingredient as in Tums, and is safe to give kids. However, watch your wallet: the children’s pepto bismol that we found cost $6.00 for a box of 24 tablets. The TUMS that we found cost $4.50 for a bottle of 150 tablets of the same stuff, just in slightly higher dose. Check with your child’s doctor but in most cases, the kids can take the adult dose.

Also, be aware that cold and cough medicine have not been shown to treat colds successfully or even to actually relieve symptoms in most kids. In fact these medicines have potential for harmful side effects, accidental overdose, or accidental ingestion and are just not worth giving your children. However, we found tons of cold and cough medicines marketed for children. Here are the three most commonly used active ingredients:

If you see “suppressant” you will likely find “dextromethoraphan” in the active ingredient list.
If you see “expectorant” you will likely find “guaifenesin” in the active ingredient list.
If you see “decongestant” you will likely find “phenylephrine” in the active ingredient list.

Many products combine two or all three of the above. We ask, even if these ingredients did work well in kids and were not potentially dangerous, what is the POINT of combining a cough suppressant with an expectorant? Can you really have it both ways?

( Remember, that Mission Impossible theme is still playing in the background.)

A few other tidbits. “Dramamine,” used for motion sickness, gets broken down in the body to diphenhydramine, that allergy medicine that we already talked about. So look at cost differences when choosing a motion sickness medicine. Both have the same side effect: sleepiness.

Many cough drops contain corn syrup and sugar. This is the same stuff lollipops are made of, so just call a candy a candy and keep your child’s throat wet with the cheaper choice, if you choose to do so.

Finally, we found one “natural children’s cough medicine” which claimed that it is superior because of its “all natural ingredients.” The first active ingredient listed? Belladonna. Sure it’s natural because it comes from a plant. So does marijuana. Just because it’s “natural” doesn’t mean it’s safe. Belladonna can cause delirium, hallucinations, and death and in fact has been used in high doses as a poison! Leave the cough medicine on the store shelf, and read our post about other ways to soothe a cough.

Bottom line: remember always to check the “active ingredient” list when buying any over-the-counter medication for your children.

As we were wrapping up our mission, one of the pharmacy employees came over to us, raised an eyebrow at our clipboard, and asked, “Can I help you ladies with anything?” We were tempted to answer “YES, can you help us take notes?” but we just smiled and said “No, we’re fine, thanks. Just checking out what’s available.”

So now, we will don our stethoscopes and come out of hiding, go back into our offices and onto our website. Thanks for tuning in to this episode of Two Peds in a Pod…. Da da da, DUM DUM da da da, DUM DUM dadada…dadada…dadada…DA DA!!!

Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®

May 27, 2011 by

Acetaminophen FYI

All acetaminophen (e.g., Tylenol) will soon be made at the same concentration, the Consumer Healthcare Products Association announced recently. In the past, manufacturers made most infant formulations more concentrated (thicker) than children’s formulations so parents would not need to give as much liquid to babies. However, this difference in concentration was the source of much confusion and accidental overdoses. Now all acetaminophen will be made the same concentration (160mg per 5ml ). Watch for these changes to hit the shelves as early as this summer.

You may also see other changes if the Federal Drug Administration implements the advice received from an advisory panel earlier in the week. Recommendations include adding weight based dosing guidelines for infants six months to two years of age and for medicine to come with measuring devices clearly marked in milliliters in order to ensure more accurate dosing.

Stay tuned.

May 22, 2011 by twopedsinapod

Don’t be rash: tidbits about Lyme disease, poison ivy, and sunburn protection

In today’s podcast we discuss how to spot the rash of lyme disease, what to do about poison ivy, and how to avoid sunburns. Pictured below is a creative way one child found to block the sun effectively. Notice there’s no burn underneath the areas of skin which were once covered by temporary tattoos.

Naline Lai, MD and Julie Kardos, MD

May 17, 2011 by twopedsinapod

Happy Mother’s Day <3!

Happy Mother’s Day to the experts in the field. As Dr. Kardos and Dr. Lai’s mothers always say to them, “Even though you are a pediatrician, I’m still your mom!” Please see our Mother’s Day Top Ten list and enjoy your well deserved day.

May 8, 2011 by twopedsinapod

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