Two Peds in a Pod®

How Sick is Sick? When to Worry about Your Child’s Illness

A friend of mine who has no children commented to me that many people tell him, “You just can’t know happiness until you have children of your own.” However, I know several adults who are very happy people and who have made a conscious decision to not have children. So I would actually amend the above adage to: “You just can’t know WORRY until you have children of your own.”

Especially in winter, many illnesses circulate. All these sick kids make for many worried parents. Some questions that I answer many times a day in the office are: “Okay, Doc, you just told me that my child is handling her illness right now, but how will I know if she is getting worse? When do I need to worry?”

Here is what I tell my patients’ parents:

First and foremost, trust your parent instincts that something is wrong.

Think about these THREE MAIN SYSTEMS: breathing, thinking, and drinking/peeing.

Breathing:

Normally, breathing is easy to do. It is so easy, in fact, that if you take off your child’s shirt and watch her breathe, it can be hard to see that she is breathing. You should try this while your child is healthy. Normal breathing does not involve effort. It does not involve the chest muscles.

If your child has pneumonia, bad asthma, bronchitis, or any other condition that causes respiratory distress, breathing becomes hard. It becomes faster than baseline. It involves chest muscles moving so it looks like ribs are sticking out with every breath. The chest itself moves a lot. Kids’ bellies may also move in and out. Nostrils flare in attempt to get more oxygen. Sometimes kids make a grunting sound at the end of each breath because they are having difficulty pushing the air out of their lungs before taking another breath in. Also, instead of a normal pink color, your child’s lips can have a blue or pale color. Pink is good, blue or pale is bad. Children old enough to talk may actually have difficulty talking because they are short of breath. Any of the above signs tell you that your child needs medical attention.

Thinking:

This refers to mental or emotional state. Normally, children recognize their parents and are comforted by their presence. They are easy to console by being held, rocked, massaged, etc. They know where they are, and they make sense when they talk.

Change in mental state, whether it comes from lack of oxygen/shortness of breath, pain, or severe infection, results in a child who is inconsolable. She may not recognize her parents or know where she is. Instead of calming, she may scream louder when rocked. She may seem disoriented or just too lethargic/difficult to arouse. Being very combative can also be a sign of not getting enough oxygen. In a baby, extreme pain can cause all these signs as well.

Drinking/peeing:

While this varies somewhat depending on the age of the child, most kids urinate every 3-6 hours or so. Young babies may urinate more frequently than this and some older kids urinate perhaps 2-3 times daily. You should know your child’s baseline. Normal urine reflects a normal state of hydration. If you don’t drink enough, you will urinate less.

If your child has fever, coughing, vomiting, or diarrhea, she will use up fluid in her body faster than her baseline. In order to compensate, she needs to drink more than her baseline amount of liquid to urinate normally. A child will refuse to drink because of severe pain, shortness of breath, or change in mental state, and may go for hours without urinating. This is a problem that needs medical attention. Occasionally a child will urinate much more than usual and this can also be a problem (this can be a sign of new diabetes as well as other problems). Basically any change from baseline urine output is a problem.

A note about fever: any infant 8 weeks of age or younger with fever of 100.4 F or higher, measured rectally, requires immediate medical attention, even if all other systems are good. Babies this young can have fever before any other signs of serious illness such as meningitis, pneumonia, blood infections, etc. and they can fool us by initially appearing well.

In older babies and children, fever is defined as 101 F or higher. Some kids can look quite well even at 104 and others can look quite ill at 101. Fever is a sign that your body’s immune system is working to fight off illness. In addition to fever, it is important to look at breathing, thinking, and hydration state because this will help you determine how quickly your child needs medical attention. A child with a mild runny nose and fever of 103 who can play still play a game with you while drinking her apple juice is less ill than a child with a 101 fever who doesn’t recognize her parents.

To summarize, any deviation from normal breathing, thinking, or drinking/urinating (peeing) is a problem that needs medical attention, even if no fever is present. In addition, any change in the wrong direction (getting worse instead of getting better) is a problem that needs medical attention.

Finally, all parents have PARENT INSTINCT. Trust yourself. Ultimately, if you are wondering if you should seek medical advice, just do it. If parents could just worry every problem away, no one would ever be sick.

Julie Kardos, MD with Naline Lai, MD
© 2009 Two Peds in a Pod

November 12, 2009 by twopedsinapod

Dry chapped hands – home remedies

I wash my hands about sixty times a day, maybe more. This in combination with cold Pennsylvania fall air leads to chapped hands. It’s a sure sign winter is approaching when patients start to show me their raw hands. Here are the hands of a girl I saw a couple days ago.

To prevent dry hands:
• Don’t stop washing your hands, but do use a moisturizer afterwards.

• Whenever possible, use water and soap rather than hand sanitizers. Hand sanitizers are at minimum 60% alcohol- very drying.

• Wear gloves as much as possible even if the temperature is above freezing. Remember chemistry class, cold air holds less moisture than warm air and therefore is unkind to skin. Gloves will prevent some moisture loss.

• Before exposure to any possible irritants such as the chlorine in a swimming pool, protect the hands by layering heavy lotion (Eucerin cream) or petroleum based product (i.e. Vaseline or Aquaphor) over the skin.

To rescue dry hands:
• Prior to bed smother hands in 1% hydrocortisone ointment. Avoid the cream formulation. Creams tend to sting if there are any open cracks. Take old socks, cut out thumb holes and have your child sleep at night with the sock on his hands. Repeat nightly for a week or so. Alternatively, for mildly chapped hands, use a petroleum oil based product such as Vaseline or Aquaphor in place of the hydrocortisone.

• If your child has underlying eczema, prevent your child from scratching his hands. An antihistamine such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) will take the edge off the itch.

• For extremely raw hands, your child’s doctor may prescribe a stronger cream and if there are signs of a bacterial skin infection, your child’s doctor may prescribe an antibiotic.

Happy moisturizing. Remember how much fun it was to smear glue on your hands and then peel off the dried glue? It’s not so fun when your skin really is peeling.

Naline Lai, MD and Julie Kardos, MD

November 9, 2009 by twopedsinapod

Sleep Safety: How to decrease your baby’s risk of Sudden Infant Death Syndrome (SIDS)

Sudden Infant Death Syndrome, or SIDS, refers to the sudden unexplained death of an infant between the ages of 1-12 months and seems to occur during sleep. We (meaning pediatricians and the rest of the scientific community) still don’t know exactly what causes SIDS, although we do know that some babies seem to be more at risk, such as premature infants and infants of multiple births (twins, triplets, etc).While parents cannot control prematurity and multiple births, parents CAN control other risk factors.

Here is a summary of ways to reduce the risk of Sudden Infant Death Syndrome (SIDS) as recommended by the American Academy of Pediatrics:

· Place babies on their backs (supine) to sleep. Do not waste money buying positioners or wedges for the crib because they are not proven to prevent SIDS and are not endorsed by the American Academy of Pediatrics. A newborn cannot roll from back to stomach. If you start out always placing your infant down on his back to sleep, he will stay this way and learn to like to sleep this way. Side sleeping is not as safe as back sleeping.

· Do not sleep with your baby in a chair, couch, or adult bed. You can take your infant into your bed to nurse/feed but then put him back in his own sleep space.

· Do not let your infant sleep in a bed with older siblings. Put your baby in his own crib.

· Put nothing in the crib other than your baby. No stuffed animals, blankets, pillows, etc. Even bumpers are not recommended.

· Do not smoke in the room where your baby sleeps.

· Offer a pacifier. This has a protective effect.

· Breastfeeding has a protective effect.

Some parents admit to us that they place their babies stomach down (prone) to sleep because “the baby sleeps better that way.” Unfortunately, what seems to be easier in the short run isn’t always the best for children in the long run. For the same reason that you should insist your children wear bike helmets and seatbelts, even if they protest at times, you should put your children down on their backs (supine) to sleep as infants. The rate of SIDS in the USA has dropped by over 50% since 1994 after the start of a “Back to Sleep” campaign. This sleep position change has been the single most effective way, to date, of reducing the rate of SIDS. Of course if your child has any rare medical condition that may prevent supine sleep, your child’s doctor should advise you on the safest sleep position for your child.

The best way to form good habits is to use them from the beginning. It is perfectly safe to position your newborn on his belly during awake time/ playtime while you are with him. However, if you are putting your baby down to sleep, or if you are putting your baby down and walking away and during this time he might fall asleep, just put your baby down on his back. And remember to tell anyone else who cares for your baby the same instructions, including daycare workers, nannies, and even well-meaning grandparents, because safe sleep advice has changed over the generations.

Julie Kardos, MD and Naline Lai, MD
©2009 Two Peds in a Pod

November 5, 2009 by twopedsinapod

Technical talk

We noticed Atom 1.0 readers did not pick up the podcast. Try the RSS 2 feed instead.

Let us know about any technical glitches. We are still very new to cyberspace and appreciate your feedback. We say in our podcasts, “Right now our recording studio is our kitchen table”…. you should see our computer help desk

Naline Lai, MD and Julie Kardos, MD

November 5, 2009 by twopedsinapod

Podcast- The tired teen

Drs. Kardos and Lai advise parents on what they can do for their tired teen. Although we all enjoyed an hour’s extra sleep this past weekend with the resetting of the clocks, many teens are back to their “usual” sleep deprived state. Listen here to find out how to help reset your teen’s internal clock, and what to consider when you have a tired teen.

Julie Kardos, MD and Naline Lai, MD

November 4, 2009 by twopedsinapod

H1N1 as a source of artistic inspiration

Boo (boo-hoo)

A lot of Halloween festivities in our area have been dampened by H1N1 flu. For all the parents of the boys and ghouls in a similar situation, this picture will make you smile. It was sent to me by Ben’s mom. It is flu from the perspective of a kindergarten boy. The arrow points to Ben’s nose. Note the huge boogie to nose ratio. The red represents “boss germs” and the purple ones are the “just plain mean” ones.

Don’t let the “Boogie” man get your family this Halloween

Naline Lai, MD

© 2009 Two Peds In a Pod

October 31, 2009 by twopedsinapod

How Vaccines Work

Do you ever wonder how vaccines work?

To understand how vaccines work, I will give you a brief lesson on the immune system.

Trust me, it is interesting. Let me give you an example of me. When I was eight, I had chicken pox. It was a miserable week. I started out with fever and headache, then suffered days of intense body itching from blister-like spots, and ultimately, because I “scratched off” some scabs, ended up with scars.

During this time, my immune system cells worked to battle off the chicken pox virus. Immune cells called memory cells also formed. These cells have the unique job of remembering (hence the name “memory cells”) what the chicken pox virus looks like. Then, if ever in my life I was to contact chicken pox again, my memory cells could multiply and fight off the virus WITHOUT MY HAVING TO GET SICK AGAIN WITH CHICKEN POX. So after I was well again, I was able to play with my neighbor even while he suffered with chicken pox. I even returned to school where other children in my class had chicken pox, but I did not catch chicken pox again. Even now, as a pediatrician, I don’t fear for my own safety when I diagnose a child with chicken pox, because I know I am immune to the disease.

This is an amazing feat, when you think about it.

And now, how vaccines work.

A vaccine contains some material that really closely resembles the actual disease you will protect yourself against. Today’s chicken pox vaccine contains an altered form of chicken pox that is close to but not actually the real thing. However, it is so similar to the real thing that your body’s immune system believes it is, in fact, real chicken pox. Just as in the real disease, your body mounts an immune response, and makes memory cells that will remember what the disease looks like. So, if you are exposed to another person with chicken pox, your body will kill off the virus but YOU DON’T GET SICK WITH THE CHICKEN POX. What a beautiful system!

Before chicken pox vaccine, about 100 children per year in the US died from complications of chicken pox disease. Many thousands were hospitalized with secondary pneumonia, skin infections, and even brain damage (encephalitis) from chicken pox disease. Now a shot in the arm can prevent a disease by creating the same kind of immunity that you would have generated from having the disease, only now you have one second of pain from the injection instead of a week of misery and possible permanent disability or death. I call that a Great Deal!

How vaccines are safer than the diseases they prevent.

All vaccines operate by this principle: create a safe environment for your immune system to make memory cells against a potentially deadly disease. Then when you are exposed to someone who actually has the disease, you will not “catch” it. Your body will fight the germs, but you do not become sick. If everyone in the world were vaccinated, then the disease itself would eventually be completely eradicated. This happened with small pox, a disease that killed 50 percent of infected people. There is no longer small pox because nearly everyone on earth received the small pox vaccine. Now we do not need to give small pox vaccine because the disease no longer exists. This is a huge vaccine success story.

Friedrich Nietzsche said “What doesn’t kill us makes us stronger.” We pediatricians feel this is unacceptable risk for children. We would rather see your child vaccinated against a disease in order to become immune rather than risking the actual disease in order to become immune.

Hopefully this blog post answers your questions about how vaccines work. For more details or more in depth explanations, I refer you to the AAP (American Academy of Pediatrics), the Children’s Hospital of Philadelphia’s Vaccine Education Center, and the book Vaccines: What You Should Know, by pediatricians Dr. Paul Offit and Dr. Louis Bell.

Julie Kardos, MD and Naline Lai, MD

updated 1/18/2015

October 29, 2009 by twopedsinapod

How to Take the Sting Out of Injectable Vaccines

Unless your child is getting the flu mist, your child may receive not only the seasonal flu vaccine as an injection this year, but also the H1N1 vaccine as an injection. Here’s how you can take away the sting of any needle:

Set the stage. Your child looks to you for clues on how to act. If mommy and daddy are trembling in the corner of the room, it will be difficult to convince your child that the immunization is “no big deal.” Do not tell your child days in advance that she will be immunized. The more you perseverate, the more your child will perceive that something terrible is about to happen. Simply announce to your child right before you leave to get the immunization, “We are going to get an immunization to protect you from getting sick.”

Do not say “I’m sorry.” Say instead,”Even if this is tough, I am happy that this will protect you.”

Never lie. If your kid asks “will it hurt?”say “less than if I pinched you.”

Watch your word choice. Calling an immunization “a shot” or “a needle” conjures up negative images. In general, avoid negative statements about injected vaccines. I cringe when parents in the office threaten children with,” If you don’t behave, then Dr. Lai will give you a shot.”

Remember the mantra, if all is well in the basic areas of eat, sleep, drink, pee, and poop, then any stressor is easier to handle.

Kids talk. Be aware that kids, especially those in kindergarten, like to scare each other with tall tales. Ask your child what they have heard about vaccines. Let children know that Johnny’s experience will not be their experience.

The moment is here.

You may have heard about a topical cream which numbs up an area of skin. Unfortunately, because the creams anesthetize the surface of the skin and most vaccines go into muscle, I do not find the creams very effective at taking the pain away.

Instead, practice blowing the worries away. Have your child practice breathing slowly in through her nose and blowing out worries through her mouth. For the younger children, bring bubbles or a pin wheel for your child to blow during the immunization. In a pinch, take a piece of the exam paper in the room and have your child blow the paper.

The cold pack: holding something very cold can distract your child’s brain from feeling the pain of an injection.

“Transfer” the immunization to mommy or daddy. Have your child squeeze your hand and “take the immunization” for him.

Tell your child to count backwards from 10 and it will be over. In reality, it will be over before your child says the number seven.

Have as much direct contact with your child as possible. The more surfaces of his body you touch, the less your child’s brain will focus on the injection. Again, this is the distraction principle at work. By touching your child, you are also sending reassuring signals to him. For the younger child, if he is on the table, stay close to his head and hug his arms, or have him on your lap. For the older child and teen, hold their hand. I sometimes see parents of older teens and college students leave the room. Even the big kids may need someone to keep them company.

Help hold your child firmly. Holding him will make him feel safe and will prevent him from moving during the injection. Movement causes more pain or even injury.

After the drama is over.

Have your older child sit quietly for a moment. As the anxiety and tension suddenly falls away, the body sometimes relaxes too suddenly and a child will start to faint. This phenomenon seems to happen most often with the six foot tall stoic teenage boys. We have a saying in my office- The bigger they are, the more likely they are to fall.

Compliment your child. Remind them that you will never let anyone really hurt them.

Now a story:

When my middle daughter was two years old, my family trouped into my office for the flu vaccine injection. We all sat calmly in a circle and smiled.

First, the nurse gave me my immunization. I smiled. My middle daughter smiled.

Second, the nurse gave my husband his immunization. He smiled. My middle daughter smiled.

Then the nurse gave my oldest daughter her immunization. She smiled. My middle daughter smiled.

Then the nurse gave my middle daughter her immunization. She did not smile. She did not cry. Instead, she slugged the nurse with her little fist. I think the nurse felt more pain than my child.

Someday all immunizations will be beamed painlessly into children via telepathy. Until then, I have no advice on how to take the sting away from the punch of a two year old.

Naline Lai, MD

October 26, 2009 by

Tamiflu for influenza- be careful when dosing

If your child’s health care provider prescribes the liquid form of Oseltamivir, brand name Tamiflu, to treat your child’s flu, pay particular attention to how you dose the medication.

The dosing syringe that comes with the manufacturer’s liquid formulation is marked in milligrams (mg), not in the customary milliliters (ml) or teaspoons (tsp).

Also, be aware that if your pharmacist makes up a liquid version from the tablets (because the liquid formulation is in short supply), the concentration (amount of medicine per amount of liquid volume) is different than what the manufacturer makes. The manufacturer makes 12mg/ml and the commonly used recipe your pharmacist will use for making a liquid formulation makes a 15mg/ml formulation.

Confused? Before you leave the pharmacy with Tamiflu, just make sure you clarify the proper amount to give with your pharmacist.

Naline Lai, MD and Julie Kardos, MD

October 21, 2009 by twopedsinapod

A lot of Pediatricians

We just returned from this year’s American Academy of Pediatrics National Conference and Exhibition in Washington D.C. It was heartening and motivating to meet with thousands of pediatricians from across the country all dedicated to improving the health and welfare of children locally and globally. We attended numerous seminars, workshops, and lectures and even ran a 7 a.m. 5K race to benefit the American Academy of Pediatrics Friends of Children Fund. We plan to incorporate what we’ve learned these past few days both in our offices and in future blog posts.

We were fortunate to find other pediatricians who promote pediatric education outside of the office setting. We enjoyed exchanging ideas with fellow pediatric blogger Dr. Roy Benaroch. In addition to writing his blog, Dr. Benaroch has authored two books for parents: A Guide to Getting the Best Health care for Your Child and Solving Health Behavioral Problems from Birth Through Preschool: A Parent’s Guide. Also, we spent time with Dr Kardos’s medical school friend Dr. Laura Jana, author of Heading Home with your Newborn, from Birth to Reality and Food Fights. She is also a pediatric media spokesperson.

It was also nice to meet Dr David Hill from North Carolina whose work can be found as well on the internet.

With pediatricians like these, the health of our nation’s children is in good hands.

Julie Kardos, MD and Naline Lai, MD

October 21, 2009 by twopedsinapod