Two Peds in a Pod®

Avoiding “TV Heads”: how to limit your child’s TV and video game time

“Mom, can we do screen?”

My kids ask me this question when they are bored. Never mind the basement full of toys and games, the outdoor sports equipment, or the numerous books on our shelves. They’d watch any screen whether television, hand-held video game, or computer for hours if I let them. But I notice that on days I give in, my children bicker more and engage in less creative play than on days that I don’t allow some screen time.

Babies who watch television develop language slower than their screen-free counterparts (despite what the makers of “educational videos” claim) and children who log in more screen time are prone to obesity, insomnia, and behavior difficulties. The American Academy of Pediatrics recommends no more than two hours of television watching a day for kids over the age of two years, and NO television for those younger than two.

Over the years, parents have given me tips on how they limit screen time. Here are some ideas for cutting back:

Have children who play a musical instrument earn screen time by practicing music. Have children who play a sport earn screen time by practicing their sport.
Turn off the screen during the week. Limit screen to weekends or one day per week.
Set a predetermined time limit on screen time, such as 30 minutes or one hour per day. If your child chooses, she can skip a day to accumulate and “save” for a longer movie or longer video game.
Take the TV, personal computer, and video games out of your children’s bedrooms. Be a good role model by taking them out of your own bedroom as well.
Turn off the TV during meals.
Turn off the TV as background noise. Turn on music instead.
Have books available to read in relaxing places in the house (near couches, beds, etc.). When kids flop on the couch they will pick up a book to relax instead of reaching for the remote control.
Give kids a weekly “TV/screen allowance” with parameters such as no screen before homework is done, no screen right before bed, etc. Let the kids decide how to “spend” their allowance.

Not that I am averse to “family movie night,” and I understand the value of plunking an ill child in front of a video in order to take his mind off his ailment. In fact, Dr. Lai lives in a house with three iPod Touches, two iPhones, a Nintendo DS and three computers. But I do find it frightening to watch my otherwise very animated children lose all facial expression as they tune in to a television show.

For more information about how screen time affects children, see the American Academy of Pediatrics web site (www.aap.org) and put in “television” in the search box.

Let us know how you dissuade your children from the allure of the screen.

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

May 28, 2010 by twopedsinapod

What’s the big deal about Fifth Disease?

Eeek, you say to yourself when you see your child’s bright red cheeks. I forgot to apply enough sunscreen. Other than the splash of color, however, your kid is acting fine and does not say his face hurts. You are perplexed…and it has been raining most of this week.

Another reason for stomach acid-churning parental guilt?

A day or two later, your child breaks out in a lacy, light pink rash mainly on his upper arms, thighs and chest. So it’s NOT sunburn. It’s the common childhood illness Fifth’s disease. This illness, your child’s doctor tells you, was the fifth childhood rash to be classified. Also called Parvovirus, it won’t impact him very much. Occasionally there are mild cold symptoms, headache, or fever before the rash and the rash is not particularly itchy. Within a week the rash fades, but it can come and go for a few weeks. Sun, exercise and heat can bring out the rash. As a bonus, your child now has life-long immunity (protection) to the disease. You only get it once.

Pictured is the characteristic facial rash often described as “slapped cheeks.” Also pictured is the “lacy” rash on a child’s arm.

If the symptoms are mild, then why do we care about diagnosing Fifth’s disease? If your child has certain types of chronic anemia, parvovirus can make the anemia much worse. But for most families, the impact of the disease is not on the child who catches it but on the child’s contacts. If a pregnant woman contracts the disease, the disease can be lethal to the fetus. Luckily, most women already contracted the disease in childhood and have immunity against the germ. In adults who did not have the disease as a child, parvovirus can cause achy joints in the hands and feet.

The tricky thing about preventing spread of fifth disease is that children are NO LONGER CONTAGEOUS once they have the rash. They expose others before parents realize their children are sick. The virus is spread through respiratory secretions and saliva-another reason to teach your children to wash their hands.

Again, if your child comes down with Fifth’s disease, remember to tell any pregnant contacts (teachers, friends’ moms, etc) so that they can let their obstetricians know about their exposure.

As a precaution when I was pregnant, my obstetrician checked my parvovirus immunity. “Wow,” he said, “those are some of the highest levels of immunity I have seen.” When it comes to parvovirus, I suppose a history of being around sick kids can be good for you.

Naline Lai, MD with Julie Kardos, MD

May 24, 2010 by twopedsinapod

That’s using your head! Or, how to assess your child’s knock on the noggin.

Your son’s baseball league has just upped the ante, moving from “coach pitch” to “kids pitch.” The good news is that your budding major league pitcher gets some practice. The bad news is that the pitches can be wild. Thank goodness for batting helmets!

So what if the unthinkable happens? You are cheering your child on, when suddenly the wild pitch (or the hit ball, or the wild throw to first base) wacks into your child’s head. He is knocked down and you go running.

First evaluate if your child is conscious. Passing out even momentarily is a reason to seek medical attention right away. Most likely he will not have passed out and will want to return to play. However, the safest bet is to have your child sit out the rest of the game.

Next determine if your child is bleeding inside his head. You may see a growing lump on his head which looks gruesome. However, we pediatricians are less concerned about bleeding or bruising that occurs on the outside of his skull than about possible bleeding inside his skull.

How can you tell where the bleeding is? Again, a loss of consciousness, or passing out, is a worrisome event that may signal bleeding on the inside. In addition, watch for blurry or double vision (“I see two mommies!”), inability to speak clearly or rationally, difficulty walking or loss of balance, vomiting more than once (some kids vomit once when they are scared or in pain), or headache so severe that it is not relieved by acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). Not all symptoms appear immediately.

So now your child has cheered the team on to victory, enjoyed the after-game snack, has forgotten about the trauma, and is nodding off in the back seat of your car. As you drive him home you remember some vague advice about not letting your child fall asleep after a head injury. Now what?

Go ahead and let your child sleep for a couple of hours, he probably is tired both from the game and from the injury. You have the rest of the day to observe him.

Sometimes, injuries are not conveniently timed. If a head injury occurs right before bedtime, you will not be able to watch for signs of internal head bleeding because your child will be sleeping. The best way to assess him is to wake him briefly every 2-3 hours throughout the night.

If your child makes it to 24 hours without symptoms, it is unlikely your child is bleeding inside his head. However, if your child still seems “off” he needs medical attention. Even if he is not bleeding, he may have a concussion (now termed “traumatic brain injury”).

Although it’s never easy to see your child hurt, whether it’s a scrape on the knee or a bump on the head, you can empower yourself by knowing what to watch for. Now that’s using your noggin!

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

May 20, 2010 by twopedsinapod

Hot Summer Tips

Here is a photo of a lovely plant nestled along side the bicycle path my family rode on over the weekend. Recognize it? “Leaves of three, let them be!”- That’s right, it’s either poison oak or poison ivy. In this case my iphone captured poison ivy in its late spring glory. As we rode along I barked at my family to avoid the poison ivy, reminded them about Lyme ticks, rubbed in sunscreen, fitted bike helmets and fretted over everyone’s hydration status. Nothing is more jovial and carefree than a bike ride with your pediatrician mom!

Back by popular demand are the links to summer posts which some of you missed last year when we initially launched Two Peds in a Pod.

Here are hints on bee and wasp stings, hydration ,traveling with children, swimmer”s ear , Lyme disease , and poison ivy .

Yes, you too can start summer by spewing health tips at your children.

Naline Lai, MD with Julie Kardos, MD

May 18, 2010 by twopedsinapod

A Parent’s Field Guide to Field Trips

A parent recently wrote us to about her three and one–half year old child’s scheduled field trip to a nature center. “I really wanted my child to attend,” the parent wrote,” but felt uncomfortable without attending with him. I asked if it would be okay if I went, but was told no because it would be distracting to the children. In addition, I had to sign a release of responsibility… Most of his classmates are attending and the parents don’t seem to be concerned.”

Next week Dr. Kardos’s child will go on a class trip to a farm. Last week one of Dr. Lai’s children went with her class to a colonial plantation. Spring field trips often are the highlight of a child’s school year and take learning to a different level. Sometimes you are asked to chaperone as a parent, but what if you aren’t invited along? Particularly for parents of young children, it can be disconcerting when their children are taken out of a familiar structured class environnment. Here are some steps you can take to insure their safety:

Check adult to child supervisory ratios. Developmentally appropriate ratios should be kept whether in the classroom or on trips. According to Caring for our Children (the national health and safety performance standards for out-of-home child care programs), for three year olds the maximum recommended child: staff ratio is 7:1, for four and five year olds the ratio is 8:1, for 6-8 year olds the ratio is 10:1, and for 9-12 years old 12:1

Ask teachers how they keep track of children. Often groups will have children wear the same brightly colored t-shirt. Usually, children are counted at several points during a visit.

Ask if previous class trips to the same place have gone smoothly. Chances are, the supervisory teacher has been to the site so many times that she knows every nook and cranny.

Check how the children will be transported. Ideally, they are transported with age appropriate restraints. If they will be traveling in the traditional school bus, review bus safety with your child including sitting down and facing forward during the ride.

Be comfortable with the school’s emergency procedures and notifications.

Remind your child to continue his good health habits even if you are not present. For instance, wash hands prior to eating and after going to the potty.

Get to know the adult supervisors. Connecting with the adult to whom you are entrusting your child will make you feel more comfortable when your child leaves school grounds.

Go ahead and visit the field trip site ahead of time if you need to visualize your child at his field trip. Who knows, you may emerge with plans to go again for a future birthday party.

Remember your goal is to grow a confident kid. Send the signals to your child that he will have a fun time- not that you will be watching the clock every second he is gone. Otherwise, he may approach the trip, and later other new situations, with trepidation rather than anticipation.

If there are medical or behavioral concerns, discuss them with your pediatrician and the adult supervisors before the trip. Since my own children have food allergies, I call teachers in advance to make sure there is an adult who is,if needed, comfortable administering an emergency shot of epinephrine. If you know your child has ADHD and needs constant redirection, perhaps additional adult supervision (not necessarily yourself) can be arranged.

Remember too that the reason parents need to sign permission slips before their children attend field trips is that parents have a choice. If you are not convinced about the value of a particular trip, by all means do not send your child.

Like many steps toward independence, a field trip can be a growing experience for a child but nerve wracking for a parent. Reassure yourself that you are not sending your child off to an unsafe environment and then take pride when she returns confident, safe, and sound, and asking when she can go on another field trip.

Naline Lai, MD

May 14, 2010 by twopedsinapod

Managing Munchkin Manicures: How to cut your baby and toddler’s finger and toe nails

One parental job you probably did not anticipate is the upkeep of rapidly growing finger and toe nails. Questions first time parents often ask me include: Should I use clippers or scissors? How do I avoid accidently nicking the skin? How often should I trim? The only question I haven’t heard so far is: Should the tips be rounded or squared?

When your newborn fingers her face, even her soft finger nails can cause scratches. Yes, newborns need their first “manicure” within days of birth. Although the nails are long enough to scratch, most of the nail is adherent to the underlying skin. I recommend using an emery board or nail file for the first weeks of nail trimming. This method is unlikely to go awry and is effective. File from the bottom up, not just across the nail, in order to shorten and dull the nail.

Babies gain weight rapidly in the first 3 months at a rate of about one ounce per day and they grow in length at a rate of about an inch per month. Their finger nails grow as rapidly as the rest of the body and therefore need trims as often as twice a week. Toe nails grow quickly as well but because they do not cause self-injury, infants tend to be okay with less frequent trimming.

Once the nails are easy to “grab,” advance to using scissors or clippers. I honestly don’t believe either method is superior to the other. The method I used was to hold my baby on my lap facing out and then gently press the skin down from his nails and clip or cut carefully.

Unfortunately, no matter how careful you are, it is possible to hurt your child while cutting his nails. I remember injuring one of my twins when he was a few months old. Picture a benign tiny paper cut that seems to cause a disproportionate amount of bleeding. He wasn’t even all that upset, but…oh, the guilt I felt! If you accidentally nick your child, wash the cut with soap and running water and apply pressure for a few minutes with a clean washcloth to stop the bleeding. Once the bleeding stops, band aids are not necessary and can actually be a choking hazard in babies who spend most of their waking moments with their fingers in their mouths. Thankfully, rapidly growing kids heal wounds rapidly.

I think it is a good idea to trim nails while babies are awake so that they get used to the feeling of a “home manicure.” This practice can prevent the later toddler meltdowns over nail trimming. However, some kids are just adverse to nail trimming, or have sensitive, ticklish feet and balk at trims. Yet trim we must! Try clipping an uncooperative toddler’s nails while she is sleeping. If your toddler sleeps lightly, then you may have to time your manicure/pedicure for when another adult caregiver is home with you. One adult holds the hand/foot or distracts the toddler with singing, book reading, or watching a soothing video together (Elmo to the rescue once again!). The other trims the nails.

So, now with the birth of your child you have added a new title – “Master Manicurist” of your home. This job does become more glamorous when your child is old enough to ask for nail polish. Until then, happy nail trimming!

Julie Kardos, MD
©2010 Two Peds in a Pod

May 12, 2010 by twopedsinapod

The skinny on preventing skin infections: decontaminating scrapes and scratches

I heaved a sigh of relief. My children and their friend greeted my husband and me at the door. The children had just baby-sat themselves. I thought everyone was unscathed until I saw one of my children covered in band aids. Apparently, although I had admonished them not to ride anything with wheels and not to climb on anything above the ground, the child with the band aids had tripped over her own feet during a benign game of four square.

“Did you wash the scrapes?” I asked.

“Yes,” the kids said, proudly nodding. They knew the first line of defense against infection is to wash out a wound. But as it turns out, they had only dabbed the cuts with wet paper towels. Aghast, I propelled the injured child off to the bathroom and hosed down the cuts. Too many times I have seen a minor scrape turn into a major skin infection.

When a wound is not thoroughly cleansed, the bacteria which normally live on skin (Staphylococcus or Streptococcus) find an opportunity to enter the body. Even a mosquito bite can turn into a raging puss filled mess if scratched often and not cleansed enough. These days, some children carry on their skin a type of Staphylococcus called MRSA (Methicillin resistant Staphylococcus aureus), since this germ can be tough to treat, a deep cleansing is more important than ever.
While infection is rarely introduced from whatever cuts the child, exceptions include cuts caused by animal or human bites (the human mouth is particularly filthy) or cuts caused by old, dirty or rusty metal. Tetanus lives in non-oxygenated places such as soil. So for deep or very dirty wounds, make sure your child’s tetanus vaccine is up to date.

Despite what many believe, wiping the surface of a cut with a wipe is not adequate to cleanse a wound. “Irrigate, irrigate, irrigate,” a wise Emergency Department physician explained to me when I was a resident in training. “I have never had someone return with a wound infection,” she said proudly. In the emergency room, saline is usually used, but at home soap and running water are effective. Stay away from hydrogen peroxide because it can irritate rather than help the skin. Stay away from rubbing alcohol because it hurts and is not necessary if soap and water are used.

So, even if your child just took a shower, wash him again if he scrapes himself. The sooner you irrigate even the tiniest of wounds, the better. An ounce of prevention is worth a pound of antibiotics.

Naline Lai, MD and Julie Kardos, MD

May 9, 2010 by twopedsinapod

Top Ten Skills You Acquire as a Mother

As Mother’s Day approaches, we give you our first Two Peds in a Pod “Top Ten List.”

Top Ten Skills You Acquire as a Mother

10) Not being completely grossed out by another person’s poop.

9) Ability to sense the “moment before the vomit” and to hustle your child to the nearest garbage can or toilet before it’s too late.

8) Ability to lick your own finger and then use it to clean a smudge completely off your child’s face.

7) Ability to get through a day (after day after day) after one (or many) completely interrupted night’s sleep.

6) Willingness to show up at work or just go out in public with dried spit-up on your shoulder.

5) Ability to use your “momometer” by touching or kissing your child’s forehead to tell if he has a fever (with fair degree of accuracy!).

4) Ability to see through walls in order to tell that your child did not wash his hands after using the bathroom.

3) Ability to see directly behind you to know that your child is getting into trouble.

2) Ability to wield the Magic Kiss that can make any and all boo-boos better.

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

Rejoice in your abilities!

Happy Mother’s Day from Two Peds in a Pod.

May 2, 2010 by twopedsinapod

Books for Helping Children Through Bereavement

Our guest blogger today is Mrs. Beverly Keegan, Librarian at Millcreek Elementry School, Bucks County Pennsylvania . A teacher for over thirteen years and a school librarian for the past nine years, Mrs. Keegan suggests books which may help a grieving child. She writes:

The loss of a loved one is difficult for anyone, but it can be especially confusing for young people. There are many ways to help children better understand death, but perhaps the least threatening approach is to expose them to a character feeling their same emotions in a fictional book. Reading a book either independently or together can be a good way to start a conversation about tough feelings. Below, I have created a list of books that might be helpful for various types of grief. I tried to choose more titles that would be most likely found in a school or library setting.

Loss of a Pet:
Cat Heaven or Dog Heaven by Cynthia Rylant (all ages): Beautiful verse and vibrant illustrations highlight the possible afterlife of both of our most beloved animal friends.

I’ll Always Love You by Hans Wilhelm (grades K-2): A boy loses his longtime companion in this beautiful picture book.

The 10^th Good Thing About Barney by Judith Viorst (all ages): A tender picture book that deals with the loss of the main character’s cat.

Loss of a Mother or Loss of a Teacher:
Remembering Mrs. Rossi by Amy Hest (grades 3-6): Annie deals with the sudden death of her mother, who was also a popular 6^th grade teacher.

Loss of a Parent:

Everett Anderson’s Goodbye (grades K-3) by Lucille Clifton: A boy struggles with the death of his father.

The Memory String (grades 2-4) by Eve Bunting: A girl grieves for her mother while trying to accept a new stepmother. She remembers her mom by counting a string of memory beads.

Loss of a Friend:
If Nathan Were Here (grades 1-3) by Mary Bahr: A young boy deals with the loss of his best friend. It is simple, yet poignant.

Water Bugs and Dragonflies (grades 1-3): a simple animal fable about loss.

Loss of a Sibling:
Kira-Kira (grades 5 and up)—This Newbery Award winner tackles the tough subject of a sister who becomes terminally ill. As her illness worsens, Katie does her best to remember Lynn’s “kira-kira,” which means her bright, shining ways.

Getting Near to Baby (grades 4 and up): In this Newbery medal winner, two sisters move into their aunt’s house. As, the story unfolds, the reader discovers that their infant sister has died. The book deals with the girls’ confusion about their mother’s feelings and their own sense of loss.

Loss of a Relative:
Missing May (grades 4 and up): In this Newbery Award winner, Summer loses her Aunt May. It is a story of how to start to live again after a sharp loss.

Each Little Bird That Sings (grades 4 and up): The main character is used to death, as her family owns the town funeral parlor. However, when her own dear uncle dies, she gets a whole new perspective on sorrow.

For adults and children:
Tear Soup: A parable about a woman who has lost an unnamed loved one. She mixes up a batch of tear soup, made of memories and experiences. This beautiful book could be applied to many different types of grief.

April 29, 2010 by twopedsinapod

The Tall Tales of Teething: What you should know about teething symptoms

This truth we know for certain: teething causes teeth.

We all can picture our babies chewing on their fingers and toys and drooling before getting their first tooth. But what other symptoms do incoming primary teeth cause?

Nearly everything in the past has been blamed on teething, including seizures, meningitis, and tetanus. According to an article in Pediatrics in Review (April 2009), teething was listed as the official cause of death in about five thousand infants in England in the early 1800s. In France from 1600 to 1900, fifty percent of all infant deaths were blamed on teething!

Numerous studies have tried to identify which symptoms coincide with tooth eruption. Two such studies: http://pediatrics.aappublications.org/cgi/content/abstract/106/6/1374 and http://pediatrics.aappublications.org/cgi/content/abstract/105/4/747 involved parents and/or daycare teachers. They kept daily checklists of symptoms such as runny nose, diaper rash, crankiness, diarrhea, and fever. Every day caretakers checked for new teeth. Guess what those researchers found? They found little correlation between any single illness symptom and a new tooth.

Despite scientific evidence to the contrary, people still blame teething for numerous maladies.

Here are symptoms which are NOT caused by teething that parents should be aware of:

· Teething does not cause fever over 101 degrees F. Fever of this height or higher indicates infection somewhere. Maybe a simple viral infection such as a cold, or a more severe infection such as pneumonia, but parents should NOT assume that their baby’s fever over 101 F is caused by teething. These babies could be contagious. Parents should not expose them to others with the false sense of security that they are not spreading germs.

· Teething does not cause diarrhea severe enough to cause dehydration. If a child has severe diarrhea, then he most likely has a severe stomach virus or another medical issue.

· Teething does not cause a cough severe enough to cause increased work of breathing. Babies make more saliva around four months of age and this increased production does result in an occasional cough. But babies never have breathing problems or a severe cough as a result of teething. Instead, suspect a cough virus or other causes of cough such as asthma.

· Teething does not cause pain severe enough to cause a change in mental state.

Some children get crankier as their teeth erupt and cause their gums to swell and redden. But, if parents cannot console their crying/screaming child, the child likely has another, perhaps more serious, cause of pain and needs an evaluation by his or her health care provider.

Just from a logic standpoint, if teething causes symptoms as babies get their primary teeth, shouldn’t incoming permanent teeth cause the same symptoms? Yet I’ve never heard a parent blame teething for a runny nose, rash, cough, fever, or general bad mood in an eight, nine, or ten year old child who is growing permanent teeth.

Maybe these parents are too busy bemoaning the cost of early orthodontal work.

April 25, 2010 by twopedsinapod

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