Two Peds in a Pod®

More Warm Weather Tidbits: sunscreen, swimming, bug bites, and bike helmets

Here’s a quick blast of more summer hints.

Sunscreen: Apply SPF (Sun Protection Factor) of at least 15, and use more than you think is necessary. SPF gives you an idea of how long it may take you to burn. SPF of 15 means you will take 15 times longer to burn…if you burn in one minute, that’s only 15 minutes of protection! So apply, reapply and reapply. Sunscreen is fine for even young babies. For a baby’s first application of sunscreen, test the sunscreen by rubbing a small amount (size of a quarter) on the inner forearm and watch for a reaction. Clothing and shade work best to protect the skin, but not all clothing is protective. Depending on the weave and the fabric, protection fluctuates with each piece of clothing. Look for UPF (ultraviolet protection factor) ratings. A UPF rating measures the amount of UV light that reaches your skin. Higher numbers are better. For example, a rating of 100 means 1/100 or one percent of all rays will reach the skin.

Swimming: Lessons are fun and safe for all ages (including young toddlers). Studies have shown that children who drown are more likely to NOT have had swimming lessons compared to same age children who have not drowned. Even if he graduated from swimming lessons, attend to your child around water, whether it is a swimming pool, lake, puddle or bath. Lessons are not a substitute for adult supervision. Also, do not submerge your baby underwater. Contrary to media hype, your baby will NOT automatically hold his breath.

Patients frequently ask me when pool water is safe for a baby’s skin. Frankly, I worry more about sunburn from sunlight reflecting off the water than damage from contact with pool water. Just wash her with soap and water after she is done swimming for the day. If the chlorine in a pool seems to dry your baby’s skin, apply moisturizer after her bath.

Mosquito Bites: Initially wash with soap and water. For the itch: apply hydrocortisone 1% cream or ointment up to 4 times daily. Give oral diphenhydramine (brand name Benadryl) before bedtime to prevent your child from scratching in his sleep. Signs of an infected bite include new or worsening pain, increasing redness, any pus-filled area, or red streaks extending from the bite. Swelling, itchiness, and some redness at the site of the bite are signs of local irritation but not necessarily infection.

Bike helmets: Insist on the use of bike helmets. Head trauma from falling off bikes, roller blades, scooters, and skateboards often happen in the summer when kids say they are “too hot” to wear their helmet.

I would write more, but I have to go adjust a bike helmet on my sun-screened son who is scratching his bug bite as he is getting ready to bike to a neighbor’s pool to swim, under adult supervision.

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod℠

July 9, 2010 by twopedsinapod

The latest friend torture game: cracking knuckles

Okay ready? Put your palms together. Fold your pinkie and ring fingers down. Tuck in your middle and pointer fingers. Cross your thumbs. Allow your BFF to lean over and suddenly push your knuckles together: c-r-a-c-k ! She cracks your knuckles.

It’s one in a long line of mildly torturous friendship games children play. Remember building a “rose garden” on your friend’s arm by pinching his forearm until it turned beet red?

As I watch my kids play the “knuckle cracking game,” I am reminded of a question parents often ask: “He is always cracking his knuckes! Won’t that cause early arthritis?”

When I look over at the object of the parent’s complaint in the office, the child usually gives me a big grin, and c-r-a-c-k, happily demonstrates to me the reason for the parent’s question. To the parent’s dismay, I tell the family knuckle cracking will not lead to early arthritis. However, I always laugh and warn the kid that harm from cracking knuckles comes not from the action of cracking knuckles but rather from an irritated parent’s wrath.

What’s the consequence of allowing a friend to crack your knuckles? That I do not know… although I have a suspicion the parental consequence is similar to when you crack your own.

Naline Lai, MD with Julie Kardos, MD
©2010 Two Peds in a Pod℠

July 5, 2010 by

How will my own childhood impact how I raise my children?

Earlier in the month I attended a developmental pediatrics conference in Philadelphia. The keynote speaker, Barry Zuckerman MD, professor and chairman of pediatrics at Boston University, raised a set of thoughtful questions. Parents can use the answers as a starting point for understanding how they were raised. Here are some of the questions with modifications:

-What was it like growing up? Who was in your family? Who raised you?

-Do you plan to raise your child like your parents raised you?

-How did your relationship with your family evolve throughout your youth?

–How did your relationship with your caregivers (mother/father/aunt/grandparent/etc) differ from each other? What did you like or not like about each relationship?

–Did you ever feel rejected or threatened by your parents? What sort of influence do they now have on your life?

–Did anyone significant die during your youth? What was your earliest separation from your parents like? Were there any prolonged separations?

–If there were difficult times during your childhood, were there positive role models in or outside your home that you could depend on?

Some of these questions may be tougher than others to answer. Ultimately you are not your parents (although you may feel otherwise when you hear a familiar phrase escape your own lips), and likewise your children are not you. Parenting techniques that worked, or did not work, for your parents will not necessarily work, or not work, for you. However, stopping to reflect on your own youth will help you understand why you parent the way that you do.

Naline Lai, MD with Julie Kardos, MD

June 28, 2010 by twopedsinapod

When potty training gets hard: constipation

help your child with constipation - count squares while she sits on the toilet Unfortunately, constipation and potty training go together.

This should come as no surprise. Let’s consider the two favorite words of two and three-year-olds:
“Mine,” and “No.”

Now think of how these words apply to a toddler who is starting to understand the purpose of the potty. The well meaning parent says, “Honey, we want you to put your poop to the potty.”

For many toddlers, the answer is… “NO! MINE!”

The problem begins when the toddler is determined NOT to give up her own poop. The longer your child holds in the poop, the harder and more difficult it will be to pass the poop. Thus, a vicious cycle begins. Your child finds pooping painful and scary. This cycle must be interrupted. Here are some tips:

Stop potty training and go back to diapers.

Before you groan at this suggestion, hear this story: The parents of one 2 ½-year-old were pleased that all “pee pee” was making it into the potty, but dismayed that she demanded a Pull-Up for poop. I suggested that she should wear diapers full time, and when pee AND poop go in the potty, then the princess underwear would come back. The child responded to me, “That isn’t very nice!” But guess what? That night, she pooped in the potty. Of course, her baby sibling is due in a few weeks, so we’ll see if success continues… but regression with new babies is a topic for another blog post.

Make the poop easy to pass.
Use natural interventions: increase water throughout the day and give undiluted juice such as prune, pear, apple, or pineapple (the other juices don’t hurt but do not actually help the cause) once a day. Offer fresh fruits, fresh vegetables, and high fiber cereals (just read the labels, try for more than 3 grams per serving). Encourage exercise.

Practice regular potty/toilet sitting.

Catch the poop when it’s naturally likely to come. The most likely time a toddler will poop is just after eating because of the gastrocolic reflex, a reflex which causes the bowels to move after eating. After every meal, have your potty trainer sit for 2-5 minutes. Treat this as a house rule. Read a book on the potty or tell stories to help pass the time.

Teach your child to prioritize pooping over playing.
If kids “really have to go” but they are busy playing, they will hold in the poop to avoid interruption. Watch for signs of a need to defecate such as squirming (better known as the potty dance) or hiding. To avoid a power struggle, say something like, “The poop wants to come out, let’s go,” rather than, “Do you want to go to the potty now?” and reward the child for sitting, not for producing.

Some over-the-counter products can help. You should discuss dosing, timing, risks, and benefits of each with your child’s health care provider before choosing. Medicines include:

Mineral oil: mix with something that tastes good such as juice or chocolate milk. The brand Kondremul tastes sweet and is hidden easily in milk because it’s white. Mineral Oil makes poop so slippery that even a determined toddler will not “hold it.”
Polyethyleneglycol (PEG) 3350 (Miralax): with a prescribed amount of liquid, it has no taste and pulls extra water into the bowels so that the poop stays soft.
Glycerin suppositories: can be the “quick fix” step before you have to resort to enemas, which are more traumatic.
Children’s laxatives such as Milk of Magnesia.
Senna-containing products – in the past there were concerns of bowel dependency with long-term use. This concern has been questioned by specialists. Ask your doctor about the products.

At one potty training child’s three year birthday party, the poor birthday boy spent half his party trying to pass a large hard poop, the result of several days of withholding. After one small glycerin suppository and a large amount of anxiety, he rejoined his friends; leaving his parents feeling guilty that they had not paid attention to his pooping frequency prior to the party. While the goal is for our children to be completely independent potty users, we have to help our potty trainers by keeping track of the frequency and consistency of their poop in order to prevent a withholding/painful pooping/constipation cycle from starting.

Be alert to potential medical causes of constipation (as opposed to behavioral or situational) and consult your child’s health care provider if you can’t seem to remedy the problem.

In the world of young potty trainers, try to avoid power struggles, “keep things moving,” make things soft and easy, and remember that this too shall pass.

Julie Kardos, MD with Naline Lai, MD
© 2010 Two Peds in a Pod®
updated 2017

June 23, 2010 by twopedsinapod

Can’t you just call in an antibiotic for me?

Our guest blogger today is Dr. Jason Komasz. Practicing pediatrics in Pennsylvania for nearly a decade, he is the father of two and a respected colleague.

“Can’t you just call in an antibiotic for me?”
As doctors we hear this question a lot. Parents are often disappointed and upset when we answer that question with a “No.” Your child is sick, you missed the Saturday office hours, and now you can’t schedule an appointment until Monday morning. There are reasons why doctors usually do, and should, answer “no” to this question.

Not every illness requires an antibiotic. Only bacterial illnesses respond to antibiotics and many illnesses are viral. In fact, misuse of antibiotics can lead to antibiotic resistance in our population.

The physical exam is very important in the evaluation of a patient. The exam helps doctors determine if a patient needs antibiotics, and if so, what type. If we do not see a patient, we are “flying blind.” This puts the patient as risk for misdiagnosis and incorrect treatment.

Antibiotic use before a patient is evaluated can affect laboratory results. For example, after starting antibiotics, Strep Throat and urinary tract infection tests may be inaccurate and therefore obligate the patient to an unnecessary course of antibiotics.

All but the most severely ill patients can usually be managed at home with pain/fever control and symptomatic care (fluids, etc) until they can be evaluated by a doctor.

If your child is ill enough to require an antibiotic, he is sick enough to need an evaluation by a physician. It is better to wait in an ER and receive proper care than to just treat without proper evaluation.

As always, your physician is trying to do what is best for your child. Your doctor should always be able to offer an explanation for why he or she is choosing a particular course of action for your child’s illness. We do not want them to suffer, just as you don’t. Just remember, the antibiotic is not always the answer.

Jason M. Komasz, M.D., F.A.A.P.
© 2010 Two Peds in a Pod®

June 17, 2010 by twopedsinapod

Top Ten Skills You Acquire as a Father

In honor of Father’s Day, we bring you our second “Top Ten” list.

Top ten skills you acquire as a father:

10. The ability to attract swarms of women if you walk in the park or the grocery store with your infant.

9. Tolerance of temperature extremes at the skating rink or on the ball field.

8. Not being completely grossed out by spit up on your nicely pressed shirt.

7. The ability to sit patiently through a 3 hour ballet recital, school music concert or graduation.

6. The ability to sit patiently through an endless one hour television show featuring some sort of dancing and singing animal and then to stand in an hour long line to buy the stuffed toy version of the animal.

5. The skill to coach teams for which you last played the sport twenty years ago.

4. The ability to swing a child, “again!”, “again!”, and “again!”

3. The ability not only to get through a day after one (or many) completely interrupted night’s sleep, but to wake up in the morning having forgotten about the interruptions.

2. An ability to seize the moment and create great memories for your child: you ignore the dishes, the garbage, and the dirty bathrooms in lieu of an impromptu wrestling match.

1. Ability to love more than you ever thought possible, and the ability (finally) to understand just how much your father loves you.

Happy Father’s Day from Two Peds in a Pod!

Julie Kardos, MD and Naline Lai, MD

June 15, 2010 by twopedsinapod

I Need a Nap!

“I need a nap!”—recognize this tired parent?

OKAY, let’s take a quick survey: how many of you have ever put your over-tired young child into the car, then driven on a bumpy road on a route known for its paucity of traffic lights, looking in the rearview mirror hoping to see a sleeping child?

How many of you have ever rocked your young child until you BOTH have fallen asleep in the chair?

How many of you have purposefully keep your child AWAKE in the car in order to get home before nap time, doing anything to keep her awake? Otherwise, you predict, if your child falls asleep on the five minute car ride home, she will wake up when you try to transfer her to the crib. If that occurs you will lose the nap for the rest of the day and she will be MISERABLE (and, hence, so will you).

How precious is nap time? All parents know the answer to this question: VERY VERY PRECIOUS! Parents spend the time during a baby or toddler’s nap to pay bills, do laundry, prepare a meal, clean the house, spend time with an older sibling, and perhaps most importantly, TO TAKE A NAP OURSELVES.

Yet all children outgrow their need to nap sooner or later (at least, until they become parents themselves). The exact time this dreaded day comes can vary. The range is typically between two and five years of age. And children do not always give up their naps all at once. One day they do not nap, then they nap the rest of the week, then they don’t nap for a few days, then they nap one day, and so forth. Sometimes they fall asleep only if they happen to be in the car. Eventually your child will sleep only overnight and not at all during the day.

Naps are very important for young children. Not only do naps foster better cheer, better learning, and better behavior, but also good naps actually help improve night time sleep. Any parent can attest that an overtired toddler has a WORSE night sleep than a toddler who goes into bedtime well-rested. This is one of the great paradoxes of childhood. I like to explain to my patients: “Good sleep begets good sleep.”

Just as you invest your time and effort in taking good care of baby teeth only to have them all fall out later, you should invest your time and effort in establishing good nap habits for your young child, even though your child eventually gives up her nap. Start by making sure she can fall asleep on her own during her NIGHT bedtime routine (see our podcast on this subject) . If she can fall asleep on her own at night, she will be more apt to fall asleep in the day. Darken the room and give her other signals associated with sleep such as her favorite stuffed animal or lullaby. Have a short “nap time routine” just as you have a night time routine. Save the serious sleep training for night time- you do not have the luxury of hours to train in the day. If she does not fall asleep within half an hour, get her up and struggle through the rest of the day, or try again later.

If she still will not nap after several days of trying, go ahead and do whatever it takes to have a happy kid by dinner. Take that car ride, rock her to sleep… understand that the “fix” is temporary. Either she will give up the “nap rebellion” or she will give up the nap entirely. Continue to put your non-napper in bed at night earlier to make up for her lack of daytime sleep. When your child is mostly cheerful, not throwing an unusual number of toddler tantrums, and is at least two years old, then likely she has truly outgrown her need to nap.

In the meantime, go grab some Zzzzzs. I know some of you only have time to read this post because your child is napping. So go follow suit!!

Julie Kardos, MD with Naline Lai, MD
© 2010 Two Peds in a Pod℠

June 12, 2010 by twopedsinapod

A “New” Old Vaccine: Prevnar 13

Ten years ago I watched a very sick, feverish toddler arch his back on my exam table while a high pitched screech weakly escaped his mouth as I tried to examine him. Attempts by his mother to cradle him in her arms only resulted in more pain.

The diagnosis –– bacterial meningitis, puss in the spinal cord and around the brain.

The culprit ––a potentially deadly germ called Streptococcus pneumonia.

A few months after I saw that toddler with meningitis, a vaccine against Strep pneumonia, under the brand name Prevnar-7, entered the market. I often wonder how outcomes would have differed for that toddler if the vaccine had been released earlier.

In addition to causing bacterial meningitis in children, this pneumococcal germ is also responsible for other forms of invasive disease such as pneumonia and overwhelming infection in the blood (sepsis). After Prevnar-7 entered the market in 2000, the number of children contracting invasive pneumococcal disease dropped by 76 percent. This decrease was seen in children under age five years, the most common age group for contracting pneumococcal disease. Vaccines at work!

The original Prevnar-7 offered protection against 7 types of the pneumococcal germ. But other types which weren’t targeted by Prevnar continued to cause infections. A new vaccine called Prevnar-13 offers protection against six additional types.

How does the release of the new Prevnar-13 affect your child? Recently, the American Academy of Pediatrics released its immunization recommendations:

–If your child has never been immunized against Pneumococcus, he will receive Prevnar-13 instead of Prevnar-7 on the same schedule as in the past. The series of four doses total are given at two months of age, four months, six months, and lastly a booster dose at 12-15 months of age.
–If your child is under five years old but has completed the full Prevnar-7 schedule, he will need at least one dose of Prevnar-13 to be fully protected.
–If your child is in the middle of the Prevnar series, he will likely complete the series with Prevnar-13.
–Children from 6 years to 18 years of age who are at very high risk for complications (e.g., children with sickle cell anemia and cochlear implants) may consider at least one dose of Prevnar-13 along with their usual “high risk” pneumovax 23 vaccine.

At this point there aren’t any recommendations to immunize non-high-risk children after five years of age because for most children, the risk of contracting life-threatening illness from this germ dramatically decreases after age five.

There’s more protection out there against more streptococcal pneumonia. Go get it!

For the full AAP recommendations see the online version of the AAP Policy Statement May 24, 1010 at www.pediatrics.org.

See also: Center for Disease Control March 12, 2010 Mobidity and Mortality Weekly Report for information about the impact of Prevnar on invasive pneumococcal disease.

Naline Lai, MD with Julie Kardos, MD

June 7, 2010 by twopedsinapod

Childhood and Teen Depression: know the signs

It’s June, a time of hellos and goodbyes.

Change in routine can be tough. For some children and teens the transition from school year to summer unmasks depression.

The signs of depression in younger children can look different than depression in teens and young adults. Younger children are less likely to tell you that they feel sad- often because they can not pinpoint what is wrong. Of course everyone is allowed periodic “bad days”, but when there are more “bad days” than “good days” action must be taken. Below are some warning signs that your child may be depressed:

Feels down or sad much of the time

Acts angry much of the time

Acts “out of control” or has new behavior problems that seem resistant to your usual discipline measures.

Loses interest in activities which normally bring pleasure, withdraws from friends

Exhibits changes in sleep patterns-difficulty falling asleep, numerous awakenings, or excess sleeping

Has feelings of worthlessness (feelings she let a family member or teacher down, etc.)

Finds it difficult to concentrate

Performs worse in school, grades slip, or tries to avoid going to school

Shows low energy or fatigue or conversely seems restless or “hyper”

Alcohol or drug use (attempts at “self-medicating”)

Expresses thoughts of being better off dead or desires to hurt himself.

If you suspect your child is depressed, ask him the hard questions. Ask him if he is thinking of hurting himself or others. Ask if he wants to commit suicide. You will not be “planting an idea.” Asking will allow you to find the medical help he needs immediately. Not asking may lead to death. We always tell patients and their parents not to hesitate to call “911” or go to the emergency room if the patient is suicidal. After all, it is an emergency– a life is at stake.

Sometimes it’s not your child who is depressed.Your child’s friend may confide that he or she is extremely sad and may tell your child to keep the information a secret. Let your child know that her friend is giving a “cry for help” and that it is appropriate to share information with adults.

Children and teens can have “real” depression just like adults and they need treatment from an experienced health care professional just like adults do. Consequences of untreated depression, just like adults, can include loss of enjoyment in life, estrangement from friends, school or job failure, and untimely death from suicide.

Naline Lai, MD and Julie Kardos, MD

June 3, 2010 by twopedsinapod

In the Blink of an Eye: corneal abrasions

Sand and specks of dried seaweed fly into the air. Your kids are on the beach shoveling their way to China. “Watch out!” you yell. “Watch those shovels! The ocean is big. The beach is big. You don’t need to be right on top of each other. There is plenty of sand for everyone.”

You sigh and go back to counting snacks and unearthing buried flip-flops. You look back at the kids. Aw, you think to your self, they look so cute. Just as you reach for the camera, the idyllic moment is shattered. Your youngest is holding his eye and everyone, even the kid who threw sand into the injured child’s face, is crying.

Quickly you grab a water bottle and flush the irritating granules out of his eye. Satisfied nothing is left, you ask, “Does that feel better?” Your child ruefully nods, and resumes holding his eye. An hour later his eye is still watering. What next?

With any eye injury, pain, watery eyes or visual changes are all reasons to seek medical care. In this case, the sand or a little wood chip probably caused a scratch on the outer layer of the eye. This layer, called the cornea, heals very quickly. But like a scratch on any part of the body, the major potential complication is infection.

The most common way for health care providers to find a scratch on the cornea is to place a dye (fluorescine) into the injured eye. This dye glows under black light. The dye pools wherever there is a depression or scratch on the eye. Pictured here is a photo of a child I saw in the office the other day. The scratch is marked with an arrow. If an abrasion is found, your child’s doctor will prescribe antibiotic eye drops to prevent infection. Placing a patch over the eye has not been shown to hasten healing. However, for comfort, some children prefer putting on an eye patch for a day.

It’s a good thing our eyes are set back in our skulls, otherwise, we’d constantly have scratches on our eyes. Despite any precautions you may take, accidents still happen. Years ago a nurse I knew accidentally rolled over in bed and scratched her spouse’s eye with her diamond engagement ring. Imagine explaining that to the in-laws.

Naline Lai, MD with Julie Kardos, MD

June 1, 2010 by twopedsinapod

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