Two Peds in a Pod®

Spring Break Surprises: preparing for illness

As spring break approaches, here are some ways to handle sickness while traveling with your children when you are far away from your children’s primary care provider.

If your child has a health condition that is intermittent, such as asthma, bring his inhaler, spacer, or any other medication. Even if he hasn’t had a flair up for months, it is much safer to travel prepared. Don’t forget your child’s epi-pen if she has a history of food allergies. If your child’s healthcare provider holds a United States license and you are not in the United States, your healthcare provider can not call in routine medications.
If your child has a complicated health history, bring a typed summary of his health history including current medications.
Decide beforehand where you will seek medical help if your child becomes ill . Maybe it is a pediatric or family medicine office that accepts new patients, a walk-in clinic, or an emergency room that sees children. Your child’s health care provider’s ability to diagnosis and treat your child is limited over the phone. Kids are much safer diagnosed in person with the benefit of a thorough physical exam.
Travel with the basics: 1) pain reducer such as ibuprofen or acetaminophen for headaches, minor injuries, or aches associated with fever, 2) a quick acting allergy medicine such as diphenhydramine (brand name Benedryl) in case of an allergic reaction such as hives, 3) anti-itch cream such as hydrocortisone in case of annoying bug bites or contact rashes such as poison ivy, 4) a topical over the counter antibiotic in case of skin scrapes, and 5) band aids. Remember to first wash any break in skin with soap and water.
Bring your child care provider’s telephone number. Even if she cannot provide a final diagnosis, she can provide advice and guidance as to whether or not you need to take your child to a local health care provider.
Make sure your child is fully vaccinated. You can’t vouch for the health of other people you encounter on your travels. It is much easier to prevent illness than chase it after it strikes. Likewise, practice good hand washing hygiene.
Travel outside of the United States may require specific vaccinations or preventative medications. Call a local travel clinic or check www.cdc.gov for advice on specific countries.

Kids have a knack for knowing just which week of the year their family will travel and then get sick during that one planned-for week. I remember the spring vacation that our twins awoke with fevers on our first day away from home. Fortunately, my children travel with their pediatrician. Families who leave their pediatrician behind when they go on vacation can empower themselves with the knowledge of how to handle illness away from their medical home.

Or, there’s the option of inviting the pediatrician along… especially if you’re headed somewhere warm…

Julie Kardos, MD with Naline Lai, MD

Three’s the magic number: Understanding three-year-old development

Recently I had the pleasure of taking a three-year-old neighbor out to dinner. My own kids and I greatly enjoyed our three-year-old friend’s conversation and antics so afterwards I decided to write about three-year-olds.

THEY HAVE GREAT IMAGINATIONS. My three-year-old friend was playing “Tinkerbell” and I was Tinkerbell’s mom. “So who are the boys (my kids)?” I asked her. “Are they Peter Pan and the Lost Boys?”

“NO,” she explained, “we are NOT playing Boys right now, we are playing Tinkerbell. I live on Pixie Lane.”

Three-year-olds are great at pretending. The problem/charm is that they also often believe what they pretend. So to them, they really saw an elephant on the way to preschool that morning. They really “go to preschool” even if in reality they merely PLAY “preschool” at home. When three-year-olds tell “tall tales,” they believe what they are saying.

This same belief in the pretend world also makes them easily frightened. Refrain from watching any potentially scary show, including the weather channel, in their presence; a three-year-old may be afraid of a tornado that touches down half way across the country. They also can be very concerned about body integrity. A small paper cut might signal that their finger will fall off and may necessitate ten band-aids. Not surprisingly, nightmares are common in three-year-olds.

They are easy to teach because of their natural curiosity and their willingness to try what others are trying. In the deli, my three-year-old guest happily tried pickles because my kids were eating them. Three-year-olds behave better than two-year-olds because they follow rules more consistently as long as they feel somewhat in control. She chose which of my boys’ hand to hold when we walked across the parking lot because she was told to hold a big person’s hand. She handed her butter knife to me because “The waitress must think that I am BIG but really I am little. She didn’t know that!” She sat nicely in the booth and talked to us because my kids were doing just that.

Three-year-olds get the hang of waiting, taking turns, and sharing MUCH better than they do as two-year-olds. They start to play simple games with rules. But they are also very literal and it’s easy to forget what they do not know. I recall my twins’ hysterical laughter when they were three and I referred to their “bare feet.” They insisted that they had “BOY feet, not BEAR feet, Mommy!” When we asked for a doggie bag after dinner at the deli, my three-year-old neighbor laughed hysterically over the image of a bag that looked like a dog, then at the thought of her dog getting the dinner remains. We explained that even though the family dog could eat the food from the doggie bag, she also could eat the leftovers the next day for lunch. This concept cracked her up, which in turn cracked US up.

I like to point out features of three-year-olds in my office to parents and caregivers. Yes, they can still be irrational, yes they can still have temper tantrums, yes, they can “get stuck” in an undesirable behavior pattern such as always crying at school drop-off (yet they have a wonderful day that starts after the parent’s car pulls away) or refusing to poop on the potty. Because three-year-olds have no sense of time, they don’t understand schedules and feel no sense of urgency to get to a birthday party before it’s over. They can develop irrational fears at the drop of a hat. They vacillate between wanting to be “big” and wanting to crawl back into the womb. But I encourage parents to take the time to enjoy their three-year-old’s charms and antics.

I still remember the “let’s pretend” game I played with my first born who would spend hours playing “explore outer space” where we would build a pretend spaceship out of sofa pillows, make maps to chart our journey, and go to Mars “to visit the Marshmallows.” Never again will (or should) your children hope to marry you. Enjoy their antics now… four and fourteen-year-olds are just around the corner.

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

Social media: the stats, risks and benefits

The American Academy of Pediatrics issued a clinical report today on the impact of social media on our children and teens. Ironically, Dr. Lai heard about it first on her Facebook.

Julie Kardos, MD with Naline Lai, MD

©2011Two Peds in a Pod®

Stay aware of spring break activities

Spring break has arrived for many college students. While students certainly deserve a vacation from the stress of school, parents should stay aware of their children’s spring break plans. Unfortunately, students who spend spring break with friends, rather than family, are much more likely to engage in binge drinking and suffer associated consequences such as injury, unprotected sex, and assault.

Before the spring breaks end, we encourage parents to review earlier posts about binge drinking and how to broach the subject of alcohol and drugs.

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

Car safety update

The American Academy of Pediatrics issued an updated policy on car child restraints earlier this week.

The highlights:

– babies/toddlers ride backwards in a rearfacing carseat until two years old

– kids ride in booster seats until the car’s seat belt fits correctly- usually at 4’9″ and between ages 8-12 years of age

– kids ride in the backseat until at least 13 years of age

Please see the complete policy and the reasons behind it on the AAP website.

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

Ear tubes: who needs ’em?

Remember that funny Sesame Street sketch when Ernie has a banana in his ear and his buddy Bert keeps asking Ernie why he has a banana in his ear? Ernie answers, “I can’t hear you Bert, I have a banana in my ear!” Ernie’s hearing loss was easily remedied by removing the banana. Temporary hearing loss produced by infection and fluid in the middle ear is remedied by removing the infection and fluid. Ear tubes (myringotomy or tympanostomy tubes) inserted into the eardrum will allow clearing.

Back when we were in training (sixteen years ago, but who’s counting?), Dr. Lai and I were taught any child with persistent fluid in her ears for three months, three ear infections in six months or four ear infections in one year was a candidate for ear tubes by an Otolaryngologist (Ear, Nose Throat Doctor).

Now the recommendations for ear tubes have been modified. One large study from 2007 showed toddlers who have ear tubes placed early because of persistent fluid in their middle ears fared the same developmentally as kids who delayed receiving ear tubes, eleven years later. So how do we decide who needs tubes and who doesn’t?

To understand the need for tubes, lets first look at anatomy. 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. This door is the ear drum. Next, open the door. You will find yourself in a room with a set of 3 bones. 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 cold, fluid 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. Otolaryngologists give the fluid a different way to escape by placing artificial drainage tubes in the ear drum (the door). The reason young kids get so many ear infections compared to older kids is because the positioning of the eustachian tube in young children does not allow adequate drainage. Also, young children get many more colds —up to 10 per year. Tubes buy time until a child’s anatomy changes with age and a child contracts fewer colds.

An operation to insert ear tubes is very brief, yet still has a baseline small risk of anesthesia. Then the ears must be kept dry because the tubes give the “outside” a direct link to the “inside” of the ear. Kids have to prevent pool water from entering their ears by wearing ear plugs. Many kids don’t like to wear the plugs and it’s difficult to get them to fit properly.

In the past, one way doctors used to stall surgery in kids with reocuring infections was to start daily antibiotics. We gave this antibiotic for several months at a time to lower the ear infection rate. However, with the increased concern about antibiotic resistant “super germs,” this practice is falling out of favor. As for other medications, antihistamines and decongestants have not shown to help treat or prevent ear infections.

So when is it appropriate to try to hold off on surgery, even in the child who has suffered several bouts of ear infections? If a child has normal hearing despite the history of ear infections, and has been developing language normally, then one option is to continue treating the ear infections with antibiotics as they come and make sure ear pain is adequately controlled by using oral or topical medication. The same holds true for children with persistent middle ear fluid.

Current recommendations are for health care providers to check on kids with fluid every 3-4 months for signs of hearing loss or changes in ear anatomy until the fluid subsides. But no longer does the presence of persistent fluid without any hearing loss demand immediate surgical consultation.

Because all children are different, they may need different management even with the same ear infection and fluid history. Start asking your pediatrician about tubes not only if your child has suffered from more than three ear infections within six months, but also if your child shows of hearing difficulty, delayed talking, or any developmental delay (which can be signs of hearing loss). Your child’s health care provider may need the additional input from an audiologist as well as an otolaryngologist.

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

Explaining tragedy to children

When the first news of the earthquake and subsequent tsunami rolled in from Japan last week, my family started to track down news of my cousin who resides in Tokyo with her husband and two sons. We were relieved to hear of shaken china and toppled bookshelves but no injuries. My nephew was on a school field trip that day and the bus was delayed, but he got home safely the next day. They were physically safe, but mentally shaken.

Even though the event may be half a world away, explaining a large scale tragedy such as what happened in Japan to children is tough; especially in this case when the uncertainty of a nuclear meltdown still looms and images of a struggling Haiti still fill the newsfeeds.

Understand that kids sense your emotions even if you don’t tell them. Not telling them about an event may make them concerned that they are the cause for your worried hushed conversations. Break away from your discussion with adults to say, “ Do you know what we are talking about? We are not talking about you.”

Tell the facts in a straight forward, age appropriate manner. Answer questions and don’t be afraid to answer with an “I don’t know.” Preschoolers are concrete in their thinking—dragons are real and live under their bed, so don’t put any there that do not exist. For a preschooler a simple “Mom is sad because a lot of people got hurt,” will suffice. Young school age kids will want to know more details. And be prepared to grapple with more high level questions from teens.

If the kids ask,” Will that happen here?” or “Why did that happen?” Again, reassure in a simple straight forward manner. For instance you can say, “Many people are working hard to prevent something like that here.” Consider answering the question with a question. Asking “What do you think?” will give you an idea of exactly what your child fears. You can also reach out to other family supports for help with answers. Say to your child, ”I wonder what our minister or school counselor has to say about this, let’s ask.”

Routine is reassuring to children, so turn off the background 24 hour television coverage and make dinner, take them to sports activities, and get the homework done.

Give your kids something tangible to do to be helpful. Help them set up a coin donation jar at school or put aside part of their allowance for a donation.

If your child seems overly anxious and fearful, and her worries are interfering with her ability to conduct her daily activities, such as performing at school, sleeping, eating, and maintaining strong relationships with family and friends, then seek professional help.

You may not hold the answers to why a large scale tragedy strikes, but you do hold the ability to comfort and reassure your children.

Naline Lai, MD with Julie Kardos, MD

Teaching kids a culture of over eating- parts 2&3 of Pediatric Childhood Obesity

In Part 1 of our talk, we presented the problems with pediatric obesity and provided six seemingly simple rules to follow that can help encourage your kids to become or maintain a healthy weight. But why is it so hard to follow these rules? In Parts two and three of our talk, we play out several common scenarios that illustrate our culture of over eating and suggest ways to change this culture.

As always, we welcome your comments and suggestions.

What to do about childhood obesity-part 1

Worried about your overweight child? Last week we gave a talk in which we outlined six simple rules which you can use as a starting point for getting your child to a healthy weight. We also discussed ways to change our “culture of overeating” which unfortunately teaches our children to eat even if they are not hungry.

While the copy of the video recorded on the auditorium equipment did not turn out, the good news is that the presentation was captured on a different camera. It’s a little blurry, and the recording starts after the introduction slide (pictured here), but the audio is fine… think of it as an augmented pod cast.

We wish to thank our attendees for their many questions and for engaging in thought- provoking dialogue at the end of the session. Stay tuned for part 2.

New recommendation for teen meningococcal booster vaccine

New American Academy of Pediatric recommendations include a booster vaccine against the cause of meningococcal disease (Neisseria meningitidis) for older teens in addition to the one routinely given to tweens. Olga Pasick, mom of a teen who died of meningococcal disease, shares her personal experience and talks about the updated guidelines.

I wish I had known the importance of vaccination for meningococcal disease before it was too late for my son. Back in September of 2004, David was a happy, healthy 13 year old, who came down with flu-like symptoms one evening. He first felt cold, then spiked a high fever, and vomited throughout the night. In the morning we called the pediatrician to have him seen. Everything ached, and he needed help getting dressed. That’s when I noticed purplish spots on his chest and arms. I didn’t know how serious that symptom was. As soon as the doctors saw him, they knew he had meningococcal disease. He was rushed to the ER for a spinal tap and treatment. Unfortunately, the disease spread quickly and his organs failed. David died within 24 hours of first developing those flu-like symptoms from a potentially vaccine-preventable disease. Unbelievable… and heartbreaking.

Meningococcal disease is spread through respiratory droplets, such as coughing or sneezing, or through direct contact with an infected person, such as kissing. About 1 in 10 people are carriers, and don’t even know it. It doesn’t affect everyone. It is difficult to diagnose because symptoms are similar to the flu, and include high fever, headache, stiff neck, nausea, vomiting, exhaustion and a blotchy rash. The disease spreads quickly and within hours can cause organ failure, brain damage, amputations of limbs, and death.

The CDC (Centers for Disease Control and Prevention) and the AAP (American Academy of Pediatrics) recommend meningococcal vaccination for all 11-18 year olds. If vaccinated at age 11-12, a booster at age 16 is recommended. If vaccinated at age 13-15, a booster is recommended at age 16-18. No vaccine is 100% effective, but it is the best preventative measure we can take. Since the vaccine only covers four of the five major strains of the disease, continue to be aware of the symptoms.

Because of my experience, I became a member of the National Meningitis Association’s (NMA) Moms on Meningitis (M.O.M.s) program. We are a coalition of more than 50 mothers from across the country whose children’s lives were drastically affected by this disease, and are dedicated to supporting meningococcal prevention.

Visit the NMA website for more information and to view powerful personal stories of those affected. Talk to your doctor about vaccination. It could save a life. How I wish those recommendations were in place six years ago.

Olga Pasick
Wall, New Jersey