Two Peds in a Pod®

It’s a gas! your young infant’s burps and farts

Gas is another topic most people don’t think much about until they have a newborn. Then suddenly gas becomes a huge source of parental distress, even though parents are not the ones with the gas. It’s the poor newborn baby who suffers, and as all parents know, our children’s suffering becomes OUR suffering.

So what to do?

First, I reassure you that ALL young babies are gassy. Yes, all. But some newborns are not merely fussy because of their gas. Some become fussy, ball up, grunt, turn red, wake up from a sound sleep, and scream because of their gas. In other words, some babies really CARE about their gas.

Remember, newborns spend nine months as a fetus developing in fluid, and have no experience with air until they take their first breath. Then they cry and swallow some air. Then they feed and swallow some air. Then they cry and swallow some more air. Eventually, some of the air comes up as a burp. To summarize: Living in Air=Gas Production.

Gas expelled from below comes from a different source. As babies drink formula or breast milk, some liquid in the intestines remains undigested, and the normal gut bacteria “eat” the food. The bacteria produce gas as a byproduct of their eating. Thus: a fart is produced.

The gas wants to escape, but young babies are not very good at getting out the gas. Newborns produce thunderous burps and expulsions out the other end. I still remember my bleary-eyed husband and I sitting on the couch with our firstborn. On hearing a loud eruption, we looked at each other and asked simultaneously, “Was that YOU?” Then looked at our son and asked “Was that HIM?”

Gas is a part of life. If your infant is feeding well, gaining weight adequately, passing soft mushy stools that are green, yellow, or brown but NOT bloody, white, or black (for more about poop, see our post The Scoop on Poop), then the grunting, straining, turning red, and crying with gas is harmless and does not imply that your baby has a belly problem or a formula intolerance. However, it’s hard to see your infant uncomfortable.

Here’s what to do if your young baby is bothered by gas:

Start feedings before your infant cries a long time from hunger. When infants cry from hunger, they swallow air. When a frantically hungry baby starts to feed, they will gulp quickly and swallow more air than usual. If your infant is wide awake crying and it’s been at least one or two hours from the last feeding, try to quickly start another feeding.
Burp frequently. If you are breastfeeding, watch the clock, breastfeed for five minutes, change to the other breast. As you change positions, hold her upright in attempt to elicit a burp, then feed for five more minutes on the second breast. Then hold your baby upright and try for a slightly longer burping session, and go return her to the first breast for at least five minutes, then back to the second breast if she still appears hungry. Now if she falls asleep nursing, she has had more milk from both breasts and some opportunities to burp before falling asleep.
If you are bottle feeding, experiment with different nipples and bottle shapes (different ones work better for different babies) to see which one allows your infant to feed without gulping too quickly and without sputtering. Try to feed your baby as upright as possible.
Hold your infant upright for a few minutes after feedings to allow for extra burps. If a burp seems stuck, lay her back down on her back for a minute and then bring her upright and try again.
To help expel gas from below, lay her on her back and pedal her legs with your hands. Give her tummy time when awake. Unlike you, a baby can not change position easily and may need a little help moving the gas out of their system.
If your infant is AWAKE after a feeding, place her prone (on her belly) after a feeding. Babies can burp AND pass gas easier in this position. PUT HER ONTO HER BACK if she starts to fall asleep or if you are walking away from her because she might fall asleep before you return to her. Remember, all infants should SLEEP ON THEIR BACKS unless your infant has a specific medical condition that causes your pediatrician to advise a different sleep position.
Parents often ask if changing the breast feeding mother’s diet or trying formula changes will help decrease the baby’s discomfort from gas. There is not absolute correlation between a certain food in the maternal diet and the production of gas in a baby. However, a nursing mom may find a particular food “gas inducing.” Remember that a nursing mom needs nutrients from a variety of foods to make healthy breast milk so be careful how much you restrict. Try any formula change for a week at a time and if there is no effect on gas, just go back to the original formula.
Do gas drops help? For flatulence, if you find that the standard, FDA approved simethecone drops (e.g. Mylicon Drops) help, then you can use them as the label specifies. If they do not help, then stop using them.

The good news? The discomfort from gas will pass. Gas discomfort typically peaks at six weeks and improves immensely by three months. At that point, even the fussiest babies tend to mellow. The next time your child’s gas will cause you distress won’t be until he becomes a preschooler and tells “fart jokes” at the dinner table in front of Grandma. Now THAT is a gas.

Julie Kardos, MD with Naline Lai, MD

That bites: recognizing spider bites

Wondering what crawled into your child’s room and bit her in the middle of the night? If you see two little pinpricks side by side, it’s probably a spider. Spider fangs make two little bite marks. Unfortunately, by the time you examine it in the morning, the bite may be so puffy and red that the two marks are no longer visible. With the exception of the Black widow spider and the Brown recluse spider, most spider bites are harmless and cause only a little bit of irritation. Over-the-counter hydrocortisone 1% ointment, ice, and an analgesic such as acetaminophen or ibuprofen can take the edge off of the itch and/or pain.

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

Some advice for Back-to-School 2011

Happy Start of School Year 2011! In case you missed these school related posts earlier, here are guides to packing a healthy school lunch, backpack weight guidelines, and deciding when to keep your children home for medical reasons.

We wish your children a rewarding, educational, and healthy year.

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

When it’s not comfort food

The preschool class was going on a field trip to a park. It was a breezy spring day and the four-year-old boy with the closely cropped hair was thrilled. Even though he didn’t usually attend school on Fridays, his mom brought him to meet up with his classmates at the park. The four-year-old’s eyes lit up as the yellow school buses rolled into the park just in time for lunch. Out tumbled the children, loud with excitement. In a flash, teachers spread brightly colored floral bed sheets on picnic tables, transforming the park into a little cafeteria. Twenty kids squashed together at the tables and forty sets of hands plunged into brown paper lunch bags. Holding onto his mother with one hand and holding his lunch bag in the other, the four-year-old boy shyly approached the crowd.

Upon spotting the boy, a little girl with a Scooby Doo shirt ran up and jumped up and down in delight.

“You’re here, you’re here!” she squealed.

The boy went happily with his mother to find a seat. But something was wrong. The boy and his mom went from table to table in a futile attempt to find a spot. But each table was the same: every child had a field-trip-friendly peanut butter sandwich in his hand. Peanut butter was everywhere. Some had it on white doughy bread, some had it on crackers. Another had a bag of peanuts mixed in with chocolate chips. The mom recoiled with horror and tightened her grip on the boy’s hand. Allergic to peanuts, the boy stood hesitantly at the edge of the crowd. As a baby, the boy had broken out in hives after his sister touched him with her hands sticky from her own peanut butter and jelly sandwich.

Imagine having to scrutinize the ingredients of all your food. Imagine being wary of a basic necessity that brings not only nutrition, but also feelings of warmth and comfort. Most children with food allergies have a reaction only when they ingest the offending substance, but the allergenic ingredients can pop up in unlikely dishes. The hyper vigilance of families with food allergies can be wearing. Studies on the psychological impact of food allergies show that families with children with food allergies have an overall lower quality of life than families without food allergies. In fact, although not obvious, families with food allergies rate their own lifestyle quality similar to families who have a child with diabetes or even a child who is respirator dependent.

For a moment a sense of isolation overwhelmed the mom. But just as quickly as it came, the feeling dissipated. In the future, the danger would become just a routine part of life, something to add to the long list of items to teach the boy to watch for. Just as the mom would teach the boy to watch out for cars as he crossed the street, she would teach him to watch for nuts in his food. Perhaps his quality of life would be compromised, but as she watched him laugh with his friends, it didn’t matter, he did not perceive it that way. Well loved, his quality of life index was still sky high.

Finally, the mom found a child who had finished eating his sandwich and had cleaned his hands. Half in jest, she fondly called her son “ostracized one” and placed her allergic boy next to the one who was done. There he perched, surrounded by messy children, with their messy peanut butter covered hands. Thankfully, the boy was happy and too busy chatting with his friends to worry. To him, waiting for a lunch spot was a mere nuisance. The potential danger next to him was just an accepted part of his everyday life.

This scenario actually occurred. The little boy was my son. And the mom was me.

Naline Lai, MD

As the beginning of school approaches, Drs. Lai and Kardos remind parents of children with food allergies to check the dates on their Epi-Pens or Twin Jets to make sure they have not expired. Practice discharging expired pens into a grapefruit. Now is the time to update your “allergy action plan” from your child’s health care provider for your child’s teachers and school nurses.

Dr. Lai serves as an advisor for the FAST (Food Allergy Support Team) of Doylestown, PA, a local support group of the national Food Allergy Anaphylaxis Network.

Bye-bye food pyramid, hello myplate

Teach nutrition with MyPlate We love it! With MyPlate, the United States Department of Agriculture’s new depiction of “a good diet” is easier to understand than the food pyramid. Mentally cut your kid’s plate in half. On one side are fruits and veggies, on the other side are grains and protein. The dairy is represented by a cup. Check out choosemyplate.gov for all sorts of hints including a personal plan which calculates the amount of each food group kids (and adults) above two years old need daily.

We’re wondering when people will start hearing about the “new pyramid”. We think the food pyramid gained prominence partially because of it’s visibility on cereal boxes. After all, we all stare groggily at the back of cereal boxes while eating breakfast. In the food pyramid days, grains were a large part of the pyramid base. Will the cereal companies have as much incentive to post MyPlate if grains have been relegated to a quarter of the plate?

We’ll find out.

Naline Lai, MD and Julie Kardos, MD

French without the fry

I love French fries, I mean really, who doesn’t? They’re probably one of the most delicious treats on the planet, but unfortunately they’re also one of the worst treats when it comes to our health. You’ll likely want to opt for baked “fries.”

It’s about overall diet. Ideally we should enjoy a diet that includes lots of fresh fruits and vegetables, fish, grains, and legumes, and one that is devoid of processed foods and sugary sodas. Even diet sodas may be harmful as they are laden with sweeteners made from chemicals.

Also very important, according to doctors, is maintaining a healthy weight. If you’ve had the pleasure of eating baked “fries,” you know what a tasty option they are; if not, please give the baked variety a chance.

You can cut some russet potatoes a bit thick and coat them and coat them with a little extra-virgin olive oil, some rosemary, a little salt and pepper and bake them until golden at 350 degrees, usually between 30-35 minutes. You can do the same with sweet potatoes, but use a little cracked black pepper instead of the rosemary. I normally boil my sweet potatoes first for about 15 minutes. They are a lot easier to peel that way. The recipe is in my book, My Italian Kitchen on amazon.com.

There is no reason to give up the foods you love, just find healthier ways to make them. This way of thinking has become my mantra. It could well become yours too, if it isn’t already.

Buona Salute! To Your Health~

Janet

Returning guest blogger Janet Zappala is a certified nutritional consultant and author of My Italian Kitchen — Home-Style Recipes Made Lighter & Healthier. She is also a six-time emmy award winning television journalist and the host of Wealth of Health at www.janetzappala.tv. Janet is a busy mom as well and is always creating ways to offer up delicious, nutritious foods that are quick and easy to make.

A pain in the knee: Osgood Schlatter disease

Medical mystery: What is that lump?
Hint: Your basketball star now is taller than you and works out daily.
Hint: He talks about pain at this spot.
Answer: Your kid’s tibial tuberosity when affected by Osgood Schlatter disease

First, some knee anatomy. The knee cap (patella) is anchored into place by tendons and ligaments. One called the patellar tendon attaches to the shin bone (tibia) below the knee at a point called the tibial tuberosity .

Repetitive bending movements of the knee, such as running and jumping, cause the patella tendon to pull on the bone where it attaches at the tibial tuberosity. Strain can result in a large tender lump which forms as the body tries to repair this area. This condition called Osgood Schlatter disease is associated with puberty, so most kids eventually “grow out of it.”

Ice, rest, and ibuprofen will alleviate pain. Your child’s health care provider may recommend gentle stretching of the quadriceps muscles or a knee brace. Beware of increased pain because rarely the muscle tears away from the bone and causes stress fractures.

Never know when you will “kneed” this information.

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

Parents of newborns: get your Zzzzzs back

Recently I’ve seen some very tired parents of newborns in my office.

Sleep deprivation, while common, leaves you prone to emotional distress and more susceptible to illness. Driving sleep deprived is as dangerous as driving drunk. Lack of sleep can even cause brain wave patterns similar to those seen in people with seizures.

Ask for help. If you live near family, take them up on offers to cook a meal or come hold the baby while you take a nap during the day. If you don’t have friends or family to provide free help, look for local teens trying to earn some community service hours or volunteer seniors from your local house of worship or YMCA. For a relatively small expense you could probably pay a money-starved teen to complete some household chores or to babysit in your home while you, the parents, grab some much needed sleep. Remember, too, that this is the time to get to know the baby as a family member, not to entertain others. If the people standing in your kitchen are not willing to do the dishes, then point them to the door.

For a larger expense but sanity-saving measure, pay someone to help out overnight a few times a week, or ask a kind relative to sleep over. My husband and I still credit our neighbor, who helped us out some nights after our twins were born, for saving our marriage (sleep deprivation does not enhance a spousal relationship). Even breastfeeding moms can make this work. The helper should wake mom to breastfeed, then take the baby away so the mom can go immediately back to sleep. Meanwhile the helper burps, changes, soothes, and settles the infant.

Even if you never took naps before, you will learn to extract super-human refreshment from a series of short naps throughout the day and night. Remember that the frequent awakenings are temporary because newborns only have newborn sleep patterns for as long as they are, well, newborns. Although this time FEELS like centuries while you are living it, in reality it lasts at most for about three months. After that, babies naturally lengthen time between feeds because their growth rate slows and thus they are able to stay asleep for longer periods of time. Sleep when the baby sleeps. Do not try to do anything “productive.”

Other tricks to fend off the effects of sleep deprivation, I learned as a pediatric resident. In those days I worked 36 hour shifts every fourth day for three years. I found seeing sunlight and smelling coffee helps ameliorate sleepiness. A shower FEELS like about two hours of sleep.

New parents need to force themselves to nap and put the rest of their household on hold. Hire a cleaning service if you can afford it, order take-out or eat breakfast cereal for dinner, and don’t worry about keeping up with laundry.

Sleep is an essential of life, just like food and water. If this post put you to sleep, then you are not getting enough. Sleep, that is. Hey, did you just see a sheep? Count it!

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

Nipping conflicts between dogs and kids

Many of our patients have dogs in their homes, and many choose to add a dog to their family during summer. Unfortunately, dog bite rates are also highest in summer, and occur most often in five to nine year olds, according to the Centers for Disease Control. Our guest expert today, veterinarian Dr. Sharin Skolnik, provides tips on how to introduce a dog into a home with children and how to best avoid dog bites. Interestingly, we noticed similar behavioral management strategies work for dogs and kids.

–Julie Kardos, MD and Naline Lai, MD

Two Peds: Are some breeds of dogs better for children?

Dr. Skolnik: Breed recommendations are tough, because there are such different personalities within every breed. Breeds bred to protect will tend to guard their family, but may not be friendly with other kids. I have had to euthanize golden retrievers and labs for severe aggression, and know some truly stellar pit bulls. I would like every family bringing a dog into their home to think about how much time and energy they can devote to the following: exercise/walks/play dates/ mental stimulation, grooming, feeding, veterinary care and arranging travel concerns/contingency plans. If I had to pick a good family breed, I would suggest a Cavalier King Charles spaniel, but only if you forced me to pick one!

Two Peds: Any suggestions for screening a dog before bringing it into the family?

Dr. Skolnik: Many rescue groups use experienced foster homes to really get an idea of where a dog is at before placement, which is wonderful. Look for a puppy or dog that is not too hyper or timid, unless you have the time and energy to devote to modifying these behaviors. An inquisitive but not pushy dog is ideal. Having said that, dogs are incredibly trainable in the right hands. Use care when bathing, feeding, or taking things away from a newly adopted dog. Trust is a two-way deal, and positive and gentle first interactions will set the stage for the relationship.

Two Peds: Why are young kids prone to dog bites by the family dog?

Dr. Skolnik: Many factors: kids are usually very bad at reading dog body language. For that matter, many adults I meet think that a wagging tail indicates a friendly dog, when in fact it means the dog is willing to interact, positively or negatively. Kids are usually loud and move unpredictably and quickly. Never leave kids and dogs unsupervised, because the kids may not understand how to be gentle and respectful of the dog. It is important to set clear and consistent expectations for both kids and dogs on what counts as acceptable behavior

Two Peds: What should parents teach their children about approaching a dog?

Dr. Skolnik: Teach them to always ask an owner’s permission with unknown dogs. Look for “soft” features like relaxed ears, floppy wagging tail, wiggling body. Tense body, rigid tail (wagging or not), backing up, dilated pupils– leave that dog alone. Supervision by responsible adults is key.

Two Peds: How can a dog be taught to “respect” a child?

Dr. Skolnik: Same way dogs learn to leave people’s houses and other pets alone. “Claim” items as yours, and not the dog’s, while meeting their needs. When I adopt a new dog: Guinea pigs/cats/shoes/etc. are mine. Every time the dog shows an interest in one of these things, he is told firmly “No.” The dog is given plenty of walks through the woods, praise for desired behaviors, some one-on-one time, and a few weeks later and we usually are on the same page. Consistency in training is key. The dog can’t be allowed to chase the cat when you are not home, so keep them separated! Set the dog up for praise, gently but firmly correct missteps, don’t overcorrect or correct after the fact. The latter only increase anxiety and the likelihood of future behavior problems

A common mistake in dog discipline is relying too much on punishment/ negative corrections and ignoring “good” behavior. For example; yelling at the dog for grabbing at the kids’ clothes, hands, whatever and ignoring the dog when it is chewing one of its own toys. Dogs are pack creatures; they rarely will play by themselves. Single-dog homes especially need to budget enough time each day to meet the dog’s mental and physical needs.

Two Peds: Should a dog that bites a kid be given a second chance? Can dogs be rehabilitated?

Dr. Skolnik: Depends on the scenario. A very forward dog with a history of unprovoked aggression towards kids is going to require a huge commitment to prevent injury and likely needs to go where there are no children, or humanely put to sleep. Most vets are pretty intolerant of dog aggression towards children. Now if an adult dog unfamiliar with kids snaps when a kid grabs an ear, or tries to take something away, or if the dog gave some warning that the kid should back off– I would blame the adults that put those two in the situation. Dogs (and people) can be rehabilitated, but there will always be the possibility of relapse. There are no guarantees with behavior modification.

Sharin Skolnik, DVM, holds a Bachelor’s degree from Cornell University School of Agriculture and Life Science and a veterinary degree from University of Pennsylvania School of Veterinary Medicine. She has been practicing veterinary medicine for 17 years and is a member of the AVMA and the NJVMA. She currently works at Chesterfield Veterinary Clinic in Bordentown, New Jersey.

Her “children” include five horses, eight dogs, eight cats, nine guinea pigs, nine hamsters, six sheep, 40 chickens, and 50 rabbits. She is also a long time friend of Dr. Kardos’s. Their children play well together under close supervision.

Two Years Old!

All about Two

Happy Birthday to us: Two Peds in a Pod is two years old today. In honor of this momentous day, we share some of the ups and downs of two-year-olds.

Upside: They can communicate in two word sentences (“more milk!”).
Downside: They can communicate in two word sentences (“no nap!”).

Upside: They start to play “dress up.”
Downside: They nearly strangle themselves with princess necklaces and super hero capes.

Upside: They have long afternoon naps.
Downside: They start to outgrow long afternoon naps.

Upside: Endearing altered sense of reality
Downside: They have no common sense—they would walk off a cliff.

Upside: They love water play.
Downside: They demand “let go!” in a swimming pool.

Upside: They start to show interest in potty training.
Downside: They still occasionally poop in the bathtub.

Upside: They love to give gooey sticky kisses.
Downside: They love to give gooey sticky kisses to runny nosed-friends, the dog, the pet turtle, and the stuffed animal that accidentally spent the night in the backyard.

Upside: They love to explore and use their hands to finger paint and squish play-dough.
Downside: They will find and poke at every piece of already-chewed gum that they find on the sidewalk.

Upside: They are the perfect size to fit in your lap.
Downside: They are the perfect height for cutting their eyebrow on the corner of the kitchen counter as they run by.

Upside: Their determination.
Downside: How long their tantrums can last.

Upside: All the educating we’ve been able to do over the past two years through Two Peds in a Pod. All of our readers’ comments and suggestions. And there’s so much more to write about.
Downside: None!

We are thrilled to have more-than-doubled our daily hits, our email subscribers, and our Facebook friends this past year. We’re now the second entry when you Google the words “Pediatrician Blog.” Please keep the momentum going, continue the dialogue, tell other parents about us and send ideas for blog posts at twopedsinapod@gmail.com.

Enjoy a birthday cupcake on us.

Julie Kardos, MD and Naline Lai, MD