Two Peds in a Pod®

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

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

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.

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

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.

Mrs. Keegan has her own blog and website at www1.cbsd.org/schools/millcreek/library
©2010 Two Peds in a Pod

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.

Julie Kardos, MD
©2010 Two Peds in a Pod

AH-CHOO! Coping with seasonal allergies

It’s only 3 p.m. on a Saturday and one of my children is in the shower for the second time today washing off the pollen which has turned her face into a puffy, slimy raspberry. It’s that beautiful time of year when the blooming flowers trigger allergic symptoms such as runny noses and red itchy eyes.

In addition to washing pollen off your child’s body, you can make some changes in your child’s environment to help decrease allergic reactions to the “great” outdoors. For one, turn on the air conditioner and close the windows to limit the outdoors from entering your child’s bedroom. Also, have your child wash her hands as soon as she comes in from playing outside to decrease the chances of her rubbing allergens into her eyes and nose.

Many kinds of medications can help allergy symptoms. The most commonly used oral medications are the antihistamines. These medicines work by limiting the “histamines” your body makes in response to allergies. Histamine causes itchy skin, red eyes, and runny noses. Examples of antihistamines are diphenhydramine (brand name Benedryl), loratadine (brand name Claritin), cetirizine (brand name Zyrtec) and fexofenadine (brand name Allegra). The most common side effect of antihistamines is drowsiness, especially with older antihistamines such as diphenhydramine. Most antihistimines are now available over the counter.

Allergy eye drops and nose sprays act topically on the eyes or nose to combat allergy symptoms. Some prescription nose sprays contain topical steroids or antihistamines. Eye drops may contain antihistamines or mast cell stabilizers (more cells which cause allergy symptoms!).

Another allergy medicine heavily advertised is Singulair. This medicine is a leukotriene inhibitor which prevents the body from releasing another type of substance (leukotrienes) that causes allergy symptoms.

Decongestants such as phenylephrine or pseudoephedrine can help decrease nasal stuffiness. This is the “D” in “Claritin D” or “Allegra D.” However, they are discouraged in young children because of potential side effects such as rapid heart rate, increased blood pressure, and sleep disturbances.

Some of the above mentioned medicines can be taken together and SOME CAN NOT. Parents may inadvertently give more than one oral antihistamine simultaneously. Read the labels carefully for the active ingredients and do NOT give more than one oral antihistamine at a time. In contrast, most antihistamine eye drops and nose sprays can be given together with oral antihistamines.

Please consult your child’s health care provider to determine which allergy medications will best help your child this allergy season. A carefully thought out allergy plan can go a long way to helping your child’s allergy symptoms.

Sure beats taking five showers a day or having your nose removed for allergy season!

Naline Lai MD and Julie Kardos, MD

We are patting our non-technological backs

Our Face Book fan page was stagnant until now… we’ve finally figured out how to get our posts out to our fans. Become our fan on Face Book and tell parents about us . Fan page is called Two Peds in a Pod .What’s the use of an advice blog if no one is listening?

We’re determined to grow baby step by baby step.

Drs. Lai and Kardos

When your child’s friend moves away

This sign now sits on my friend’s lawn. I still remember four years ago when I pulled my big blue minivan up in front of their house after the moving van left. A mommy sat on the stoop with her children. “How old are they? I hollered out. The ages of the children matched my children’s and I was delighted. Indeed they became good friends. And now, there’s the “For Sale” sign.

It’s nearing the end of the school year, and “For Sale” signs dot lawns all over the United States. Chances are, one of them belongs to your child’s friend. Just as the child who moves will have to adjust to a new environment, your child will have to adjust to a world without a friend who was part of his daily routine.

Much has been written about how to transition the child who moves into a new environment, but how can you help your child when his close friend moves away?

Your child may experience a sense of loss and feel that he was “left behind.” Some children perseverate over the new hole in their world. Others take the change in stride.

In the late 1960’s, psychiatrist Elisabeth Kubler-Ross described “the five stages of grief.” The stages were initially applied to people suffering from terminal illness, but later they were applied to any type of deep loss such as your child’s friend moving. The first stage is denial: “I don’t believe he moved.” Anger follows in the second stage: “Why me? That’s not fair!” Your child may then transition into the third stage and bargain: “If I’m good maybe he will hate it there and come back.” The fourth stage is sadness: “ I really miss my friend,” or, “Why make friends when they end up moving away?” The final stage is acceptance: “Everything is going to be okay. We will remain friends even if he doesn’t live here.”

Some pass through all stages quickly and some skip stages altogether. The process is personal and chastising your child to “just get over it” will not expedite the process. However, there are ways to smooth the journey:

· Reassure your child that feeling sad or angry is common. Parents need to know that sad children may not show obvious signs of sadness such as crying. Instead, rocky sleep patterns, alterations in eating, disinterest in activities or a drop in the quality of school work can be signs that a child feels sad. If feelings of depression in your child last more than a month or if your child shows a desire to hurt himself, consult your child’s health care provider.

· When you discuss the move with your child, keep in mind your child’s developmental stage. For instance, preschool children are concrete and tend to be okay with things being “out of sight, out of mind.” Talking endlessly about the move only conveys to the child that something is wrong. Children around third or fourth grade can take the move hard. They are old enough to feel loss, yet not old enough to understand that friendships can transcend distance. For teens, who are heavily influenced by their peers, a friend’s moving away can cause a great deal of disruption. Acknowledge the negative emotions and reassure your child that each day will get better. Reassure him that despite the distance, he is still friends with the child who moved.

· Prior to the move, don’t be surprised if arguments break out between the friends. Anger can be a self defense mechanism employed subconsciously to substitute for sadness.

· Set a reunion time. Plan a vacation with the family who moved or plan a trip to their new home.

· After the move, send a care package and write/ help write a letter with your child.

· Answer a question with a question when you are not sure what a child wants to know. For example if he asks,” Will we always be friends?” Counter with “What do you think will happen?”

· Share stories about how you coped with a best friend moving when you were a child.

As for my children, when I told one of my kids that I will sign her up for soccer, she squealed with delight, “Oh, that’s the league Kelly belongs to.”

My heart sank. I said as gently as I could, “She’s moving- she won’t be here for soccer season.”

And so we begin the process…

Naline Lai, MD

“Ya gotta have heart!” Heart murmurs explained.

When the Tin Man was a child in Oz, I’m sure his pediatrician never told his parents, “Has anyone ever said your child has a heart murmur? I hear one today.”

I know that when I tell parents about a heart murmur in their child, their hearts skip and jump. But not all heart murmurs are bad.

A heart murmur is an extra sound that we pediatricians hear when we listen to a child’s heart with a stethoscope. A normal heart beat sounds like this: “lub, dub. lub, dub. lub, dub.” A heart murmur adds a whooshing sound. So what we hear instead is “lub, whoosh, dub” or “lub, dub, whoosh.”

The “whoosh” is usually caused by blood flowing through a relatively narrow opening somewhere in or around the heart. Think of your blood vessels and heart like a garden hose. If you run the water (blood) very hard, or put a kink or cut a hole in the hose, the whoosh of the water grows louder in those locations.

Heart murmurs signal different issues at different ages. In a newborn, some types of heart murmurs are expected. Normal newborn hearts contain extra holes that close up after the first hours or days of birth. One type of murmur occurs as the infant draws in his first breath and holes in the heart, present inside the womb, begin to seal. As the holes get narrower, we sometimes hear the “whoosh” of blood as it flows through the narrowing opening. Then these holes close completely and the murmur goes away.

However, some murmurs in infancy signal “extra holes” in the heart. As pediatricians we experience our own heart palpitations when moms want to leave the hospital early with their infants who are less than 48 hours old. We worry because many infants who have abnormal hearts may not develop their abnormal heart murmurs and other signs of heart failure until the day after birth.

Preschool and early school age children often develop “innocent” heart murmurs. “Innocent” implies that extra blood flows through their hearts, but the hearts are structurally normal. These murmurs are fairly common and can run in families. However, there are heart problems which do not surface until this age. For this reason, remember to schedule those yearly well child checkups.

For teens, during the pre participation sports physical, pediatricians listen carefully for a murmur that may indicate that an over grown heart muscle has developed.

Again, holes are not the only culprit behind a murmur. The whoosh sound can also arise when a person is anemic and blood flows faster than normal. In anemic kids, the blood flows faster because it lacks enough oxygen-carrying red blood cells and the heart needs to move blood faster in order to supply oxygen to the body. The most common cause for anemia is a lack of sufficient iron intake. Subsequently, we hear these flow murmurs in children whose diets lack iron, in teenagers who are growing rapidly and quickly use up their iron stores, and in girls who bleed too much at each period. Replenishing the iron level makes a heart murmur from anemia go away.

Even a simple fever (see our earlier blog posts to learn more about fevers) can cause a heart murmur on physical exam. The murmur goes away when the fever goes away.

Pediatric health care providers can often distinguish between “innocent” heart murmurs and not-so- innocent heart murmurs by the sound of the murmur itself (not all “whooshes” sound alike). If any question exists, your child will be referred for more testing, which could include a chest x-ray, an EKG (electrocardiogram), and ECHO (echocardiogram, or ultrasound of the heart) or evaluation by a pediatric cardiologist.

If your child’s pediatrician tells you that your child has a heart murmur, “take heart”. Many times a murmur comes and goes or just becomes part of your child’s baseline physical exam. Even if your child has a serious heart problem, most cases respond well to medication, surgery, or both. While not all heart problems cause heart murmurs, and while not all murmurs signal heart problems, the presence of a heart murmur in a child can signal that your child needs further testing.

Unless, of course, your child is the Tin Man. In this case, extra sounds indicate that your child needs more oil!

Hand Held Health Hazards: your kids and their devices

This spotted the other day- tendonitis. In plain English, wrist pain at the base of the thumb from the strain of playing too much Nintendo DS/iPod touch or texting on your phone with your thumbs.

Imagine what the iPad will bring.

Naline Lai, MD 2010

© Two Peds in a Pod