Do you live in the Central Bucks School District in Pennsylvania? We just got back from filming a segment on sleep and breakfast hints on Parent Connections- running through September.

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7:30 pm on Tuesday, Thursday and Sundays

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

Just in time for Father’s Day— the book Dad to Dad: Parenting Like a Pro. Written by our pediatrician colleague, Dr. David Hill, this North Carolina based Pediatrician brings a humorous, yet practical perspective on fatherhood. His book includes chapters on nontraditional parenting relationships, talking to kids about sexual development and helping your child sleep. Two Peds in a Pod is pleased to give you a sneak peek:

My youngest child clambered off the bus Friday afternoon with a fixed grin across his face.

 “What are you doing here?” he asked curiously. Usually, I am not home in time to greet the afternoon bus.

“I came to walk you home from the bus stop and then go for a run,” I said beaming, and kissed him on the forehead.

As my son stiffly kissed me back, the strange fixed grin remained on his face.  Then I noticed his hands were behind his back. With a sly glance, I saw he clutched a crinkled brown paper bag. I smiled. Hidden crumpled paper bags close to Mother’s Day mean only one thing — a “surprise” gift.

“Don’t you want to go running now?” my son asked as we walked up our driveway, carefully rotating his body so that he continued to face me.

“Yes, good idea” I said, and resisted the temptation to look back.

As I jogged through the neighborhood, I mused over the upcoming holiday and what it meant to be a “happy” mother on mother’s day. Last week I had gained some insights after participating on a panel at Brown University’s Women’s Leadership Conference. The topic of the discussion was “Happy Kids/Happy Parents: What’s the Secret Sauce?” The talk was lively, and since it was a women’s conference, discussion focused on motherhood. Ultimately the conclusion made by moderator Clare Hare was “There is not one right way to parent,” but, perhaps, some good guidelines. Here are some ideas to think about:

On the dilemma of working outside the house vs. working full time as a mom at home: As a mom it is easy to give, give, and give so much of yourself to others that you can lose a little (or a lot) of your own self-identity. By maintaining a self-identity you become a more confident mother. Some women draw confidence from forging a career outside the home. Others draw from organizing local community-based activities. A mom ultimately needs to feel at the end of the day that she raised her own child, no matter how she does it. Stop comparing yourself to others and do what is right for your own family. In an economy where it is often not financially feasible for one partner to stay at home, working outside the home may be less of a choice and more of an obligation; however, the crucial point remains— if you are not the person you want your child to see, then become the person you want her to see.

On helicopter parenting: Worried that you are too much of a helicopter parent? Know where to draw the line. Use the “cry now or cry later” philosophy. If you know your child will be crying in 30 years when he is obese and diabetic because you didn’t insist on a healthy diet with limited “junk”, stand your ground and let him cry now and you refuse him a second helping of cake. If you know your child will NOT be crying in 30 years because you didn’t insist that he continue piano lessons, let it go.

On keeping you and your child sane during the college admission process: Yes, statistically it’s tougher than ever to get into colleges- this is a matter of demographics. There are more college-bound seniors because of population growth, and hence more applicants per spot. But the pressure for students to overextend themselves in multiple activities is imposed by parents and the kids themselves, not by the admission offices. In the years preceding applying to college, encourage your child to concentrate on excelling in specific areas—think quality not quantity. Do what comes from the heart. When your child seems overwhelmed, as Dr. Kardos and I always say, insure basic needs are met — eat, sleep, drink, pee and poop. And don’t forget to leave time for play and relaxation.

On ignoring hype:  Be willing to change your opinion in light of data. Use evidence, not hype, to drive your actions. Despite data showing teens naturally awaken later in the morning than younger children, one audience member recounted how she still encountered many difficulties when she advocated for later high school start times in her school district. 

All thoughts to nosh on.

You never realize the soaring magnitude of your own mother’s love until you meet your child. No matter your approach to raising children, we wish you “happy” as you remember how you felt when you were the child who brought home a brown crinkled paper bag to surprise your own mom. And again “happy” as you feel gratitude and awe for the privilege of now receiving the surprise.

Dr. Kardos and I wish you a Happy Mother’s Day.

Naline Lai, MD

Special thanks to my fellow panelists: Clare Hare, Principle of Clare Hare Design; Jill Hereford Caskey, Director, Alumni College Advising Program, Office of Alumni Relations, Brown University; Judith Owens , Director of Sleep Medicine, Children’s National Medical Center; Peg Tyre, Director of National Advocacy, Edwin Gould Foundation, author of The Trouble With Boys and The Good School.

© 2012 Two Peds in a Pod®

Squeezed through the birth canal, many babies are born with pointy, cone-shaped heads. Others, delivered by caesarian section, start off life with round heads. No baby begins with a flat head. But as parents put babies on their backs to sleep in accordance with Sudden Infant Death Syndrome prevention guidelines, babies are developing flat heads. 

Called positional plagiocephaly, a young infant’s head flattens when prolonged pressure is placed on one spot. Tricks to prevent positional plagiocephaly all encourage equal pressure over the entire head. Because babies’ heads are malleable, parents can easily prevent and treat the flatness. In fact, the flat shape begins to correct itself after six months of age, when babies spend less time lying down and more time sitting and crawling. Additionally, increased hair growth hides some of the flatness.

To prevent positional plagiocephaly, place your baby prone (belly down) frequently WHILE AWAKE, starting in the newborn period. This tummy time decreases pressure on the back of the head. Some babies are not fond of tummy time and will cry until they are back on their backs.  For those kids, in our next post, guest blogger physical therapist Deborah Stack will address ways to make the time tolerable. 

When your baby turns one, you’ll realize he has a much stronger will. My oldest threw his first tantrum the day he turned one. At first, we puzzled: why was he suddenly lying face down on the kitchen floor? The indignant crying that followed clued us to his anger. “Oh, it’s a tantrum,” my husband and I laughed, relieved.

Parenting one-year-olds requires the recognition that your child innately desires to become independent of you. Eat, drink, sleep, pee, poop: eventually your child will learn to control these basics of life by himself. We want our children to feed themselves, go to sleep when they feel tired, and pee and poop on the potty. Of course, there’s more to life such as playing, forming relationships, succeeding in school, etc, but we all need the basics. The challenge comes in recognizing when to allow your child more independence and when to reinforce your authority.

Here’s the mantra: Parents provide unconditional love while they simultaneously make rules, enforce rules, and decide when rules need to be changed. Parents are the safety officers  and provide food, clothing, and a safe place to sleep. Parents are teachers. Children are the sponges and the experimenters. Here are concrete examples of how to provide loving guidance:

Eating: The rules for parents are to provide healthy food choices, calm mealtimes, and to enforce sitting during meals. The child must sit to eat. Walking while eating poses a choking hazard. Children decide how much, if any, food they will eat. They choose if they eat only the chicken or only the peas and strawberries. They decide how much of their water or milk they drink. By age one, they should be feeding themselves part or ideally all of their meal. By 18 months they should be able to use a spoon or fork for part of their meal.

If, however, parents continue to completely spoon feed their children, cajole their children into eating “just one more bite,” insist that their child can’t have strawberries until they eat  their chicken, or bribe their children by dangling a cookie as a reward for eating dinner, then the child gets the message that independence is undesirable. They will learn to ignore their internal sensations of hunger and fullness.

For perspective, remember that newborns eat frequently and enthusiastically because they gain an ounce per day on average, or one pound every 2-3 weeks. A typical one-year-old gains about 5 pounds during his entire second year, or one pound every 2-3 months. Normal, healthy toddlers do not always eat every meal of every day, nor do they finish all meals. Just provide the healthy food, sit back, and enjoy meal time with your toddler and the rest of the family.  

A one-year-old child will throw food off of his high chair tray to see how you react. Do you laugh? Do you shout? Do you do a funny dance to try to get him to eat his food? Then he will continue to refuse to eat and throw the food instead. If you say blandly,” I see you are full. Here, let’s get you down so you can play,” then he will do one of two things:

1)      He will go play. He was not hungry in the first place.

2)      He will think twice about throwing food in the future because whenever he throws food, you put him down to play. He will learn to eat the food when he feels hungry instead of throwing it.

Sleep: The rule is that parents decide on reasonable bedtimes and naptimes. The toddler decides when he actually falls asleep. Singing to oneself or playing in the crib is fine. Even cries of protest are fine. Check to make sure he hasn’t pooped or knocked his binky out of the crib. After you change the poopy diaper/hand back the binky, LEAVE THE ROOM! Many parents tell me that “he just seems like he wants to play at 2:00am or he seems hungry.” Well, this assessment may be correct, but remember who is boss. Unless your family tradition is to play a game and have a snack every morning at 2:00am, then just say “No, time for sleep now,” and ignore his protests.

Pee/poop: The rule is that parents keep bowel movements soft by offering a healthy diet. The toddler who feels pain when he poops will do his best not to have a bowel movement. Going into potty training a year or two from now with a constipated child can lead to many battles. 

Even if your child does not show interest in potty training for another year or two, talk up the advantages of putting pee and poop in the potty as early as age one. Remember, repetition is how kids learn.

Your one-year-old will test your resolve. He is now able to think to himself, “Is this STILL the rule?” or “What will happen if I do this?” That’s why he goes repeatedly to forbidden territory such as the TV or a standing lamp or plug outlet, stops when you say “No no!”, smiles, and proceeds to reach for the forbidden object.

When you feel exasperated by the number of times you need to redirect your toddler, remember that if toddlers learned everything the first time around, they wouldn’t need parenting. Permit your growing child to develop her emerging independence whenever safely possible. Encourage her to feed herself even if that is messier and slower. Allow her to fall asleep in her crib and resist rocking her to sleep. Everyone deserves to learn how to fall asleep independently. You don’t want to train a future insomniac adult.

And if you are baffled by your child’s running away from you one minute and clinging to you the next, just think how confused your child must feel: she’s driven towards independence on the one hand and on the other hand she knows she’s wholly dependent upon you for basic needs. Above all else, remember the goal of parenthood is to help your child grow into a confident, independent adult… who remembers to call his parents every day to say good night… ok, at least once a week to check in…. ok, keep in touch with those who got him there!

Julie Kardos, MD with Naline Lai, MD
©2012 Two Peds in a Pod®

Recently I’ve seen some very tired parents of newborns in my office.

Sleep deprivation, while common, leaves you prone to emotional distress and more susceptible to illness. Driving sleep deprived is as dangerous as driving drunk.  Lack of sleep can even cause brain wave patterns similar to those seen in people with seizures. 

Ask for help. If you live near family, take them up on offers to cook a meal or come hold the baby while you take a nap during the day. If you don’t have friends or family to provide free help, look for local teens trying to earn some community service hours or volunteer seniors from your local house of worship or YMCA. For a relatively small expense you could probably pay a money-starved teen to complete some household chores or to babysit in your home while you, the parents, grab some much needed sleep. Remember, too, that this is the time to get to know the baby as a family member, not to entertain others. If the people standing in your kitchen are not willing to do the dishes, then point them to the door. 

For a larger expense but sanity-saving measure, pay someone to help out overnight a few times a week, or ask a kind relative to sleep over. My husband and I still credit our neighbor, who helped us out some nights after our twins were born, for saving our marriage (sleep deprivation does not enhance a spousal relationship). Even breastfeeding moms can make this work. The helper should wake mom to breastfeed, then take the baby away so the mom can go immediately back to sleep.  Meanwhile the helper burps, changes, soothes, and settles the infant. 

Even if you never took naps before, you will learn to extract super-human refreshment from a series of short naps throughout the day and night. Remember that the frequent awakenings are temporary because newborns only have newborn sleep patterns for as long as they are, well, newborns. Although this time FEELS like centuries while you are living it, in reality it lasts at most for about three months. After that, babies naturally lengthen time between feeds because their growth rate slows and thus they are able to stay asleep for longer periods of time. Sleep when the baby sleeps. Do not try to do anything “productive.”

Other tricks to fend off the effects of sleep deprivation, I learned as a pediatric resident. In those days I worked 36 hour shifts every fourth day for three years. I found seeing sunlight and smelling coffee helps ameliorate sleepiness.  A shower FEELS like about two hours of sleep.

New parents need to force themselves to nap and put the rest of their household on hold. Hire a cleaning service if you can afford it, order take-out or eat breakfast cereal for dinner, and don’t worry about keeping up with laundry.

Sleep is an essential of life, just like food and water. If this post put you to sleep, then you are not getting enough. Sleep, that is. Hey, did you just see a sheep?  Count it!

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

Many of our patients have dogs in their homes, and many choose to add a dog to their family during summer. Unfortunately, dog bite rates are also highest in summer, and occur most often in five to nine year olds, according to the Centers for Disease Control. Our guest expert today, veterinarian Dr. Sharin Skolnik, provides tips on how to introduce a dog into a home with children and how to best avoid dog bites. Interestingly, we noticed similar behavioral management strategies work for dogs and kids.

–Julie Kardos, MD and Naline Lai, MD

Two Peds: Are some breeds of dogs better for children?

Dr. Skolnik: Breed recommendations are tough, because there are such different personalities within every breed. Breeds bred to protect will tend to guard their family, but may not be friendly with other kids. I have had to euthanize golden retrievers and labs for severe aggression, and know some truly stellar pit bulls. I would like every family bringing a dog into their home to think about how much time and energy they can devote to the following: exercise/walks/play dates/ mental stimulation, grooming, feeding, veterinary care and arranging travel concerns/contingency plans. If I had to pick a good family breed, I would suggest a Cavalier King Charles spaniel, but only if you forced me to pick one!

Two Peds: Any suggestions for screening a dog before bringing it into the family?

Dr. Skolnik: Many rescue groups use experienced foster homes to really get an idea of where a dog is at before placement, which is wonderful. Look for a puppy or dog that is not too hyper or timid, unless you have the time and energy to devote to modifying these behaviors. An inquisitive but not pushy dog is ideal. Having said that, dogs are incredibly trainable in the right hands. Use care when bathing, feeding, or taking things away from a newly adopted dog. Trust is a two-way deal, and positive and gentle first interactions will set the stage for the relationship.

Two Peds: Why are young kids prone to dog bites by the family dog?

Dr. Skolnik: Many factors: kids are usually very bad at reading dog body language. For that matter, many adults I meet think that a wagging tail indicates a friendly dog, when in fact it means the dog is willing to interact, positively or negatively. Kids are usually loud and move unpredictably and quickly. Never leave kids and dogs unsupervised, because the kids may not understand how to be gentle and respectful of the dog. It is important to set clear and consistent expectations for both kids and dogs on what counts as acceptable behavior

Two Peds: What should parents teach their children about approaching a dog?

Dr. Skolnik: Teach them to always ask an owner’s permission with unknown dogs. Look for “soft” features like relaxed ears, floppy wagging tail, wiggling body. Tense body, rigid tail (wagging or not), backing up, dilated pupils– leave that dog alone. Supervision by responsible adults is key.

Two Peds: How can a dog be taught to “respect” a child?

Dr. Skolnik: Same way dogs learn to leave people’s houses and other pets alone. “Claim” items as yours, and not the dog’s, while meeting their needs. When I adopt a new dog: Guinea pigs/cats/shoes/etc. are mine. Every time the dog shows an interest in one of these things, he is told firmly “No.” The dog is given plenty of walks through the woods, praise for desired behaviors, some one-on-one time, and a few weeks later and we usually are on the same page. Consistency in training is key. The dog can’t be allowed to chase the cat when you are not home, so keep them separated! Set the dog up for praise, gently but firmly correct missteps, don’t overcorrect or correct after the fact. The latter only increase anxiety and the likelihood of future behavior problems

A common mistake in dog discipline is relying too much on punishment/ negative corrections and ignoring “good” behavior. For example; yelling at the dog for grabbing at the kids’ clothes, hands, whatever and ignoring the dog when it is chewing one of its own toys. Dogs are pack creatures; they rarely will play by themselves. Single-dog homes especially need to budget enough time each day to meet the dog’s mental and physical needs.

Two Peds: Should a dog that bites a kid be given a second chance? Can dogs be rehabilitated?

Dr. Skolnik: Depends on the scenario. A very forward dog with a history of unprovoked aggression towards kids is going to require a huge commitment to prevent injury and likely needs to go where there are no children, or humanely put to sleep. Most vets are pretty intolerant of dog aggression towards children. Now if an adult dog unfamiliar with kids snaps when a kid grabs an ear, or tries to take something away, or if the dog gave some warning that the kid should back off– I would blame the adults that put those two in the situation. Dogs (and people) can be rehabilitated, but there will always be the possibility of relapse. There are no guarantees with behavior modification.

Sharin Skolnik, DVM, holds a Bachelor’s degree from Cornell University School of Agriculture and Life Science and a veterinary degree from University of Pennsylvania School of Veterinary Medicine. She has been practicing veterinary medicine for 17 years and is a member of the AVMA and the NJVMA. She currently works at Chesterfield Veterinary Clinic in Bordentown, New Jersey.

Her “children” include five horses, eight dogs, eight cats, nine guinea pigs, nine hamsters, six sheep, 40 chickens, and 50 rabbits. She is also a long time friend of Dr. Kardos’s. Their children play well together under close supervision.

©2011 Two Peds in a Pod®

The antihistamine quandry

Junior’s nose is starting to twitch

His nose and his eyes are starting to itch.

As those boogies flow
You ask oh why, oh why can’t he learn to blow?

It’s nice to finally see the sun

But the influx of pollen is no fun.

Up at night, he’s had no rest,

But which antihistamine is the best?

It’s a riddle with a straight forward answer. The best antihistamine, or “allergy medicine” is the one which works best for your child with the fewest side effects. Overall, I don’t find much of a difference between how well one antihistamine works versus another for my patients. However, I do find a big difference in side effects.

Oral antihistamines differ mostly by how long they last, how well they help the itchiness and their side effect profile.  During an allergic reaction, antihistamines block one of the agents responsible for producing swelling and secretions in your child’s body, called histamine.  

Prescription antihistamines are not necessarily “stronger.” In fact, at this point there are very few prescription antihistamines. Most of what you see over-the-counter was by prescription only just a few years ago. And unlike some medications, the recommended dosage over-the-counter is the same as what we used to give when we wrote prescriptions for them.

The oldest category, the first generation antihistamines work well at drying up nasal secretions and stopping itchiness but don’t tend to last as long and often make kids very sleepy.  Diphendydramine (brand name Benadryl) is the best known medicine in this category.  It lasts only about six hours and can make people so tired that it is the main ingredient for many over-the-counter adult sleep aids.  Occasionally, kids become “hyper” and are unable to sleep after taking this medicine. Other first generation antihistamines include Brompheniramine (eg. brand names Bromfed and  Dimetapp) and Clemastine (eg.brand name Tavist).

The newer second generation antihistamines cause less sedation and are conveniently dosed only once a day. Loratadine (eg. brand name Alavert, Claritin) is biochemically more removed from diphenhydramine from than Cetirizine (eg. brand Zyrtec) and runs a slightly less risk of sleepiness. However, Cetirizine tends to be a better at stopping itchiness.

Now over-the-counter, fexofenadine (eg brand name Allegra) is a third generation antihistamine.  Theoretically, because a third generation antihistamine is chemically the farthest removed from a first generation antihistamine, it causes the least amount of sedation. The jury is still out.

If you find your child’s allergies are breaking through oral antihistamines, discuss adding a different category of oral allergy medication, eye drops or nasal sprays with your pediatrician.

Because of decongestant side effects in children, avoid using an antihistamine and decongestant mix.

Back to our antihistamine poem:

Too many choices, some make kids tired,

While some, paradoxically, make them wired.

Maybe while watering flowers with a hose,

Just turn the nozzle onto his runny nose.

Naline Lai, MD with Julie Kardos, MD

©2011 Two Peds in a Pod®

Have a teenage couch potato from January through March?  We all tend to decrease our activity level in the winter months. Physical Therapist Deb Stack gives us ideas to keep teens active.

Let’s face it, it’s hard to move when it’s cold and it’s freezing at my home.  I believe today’s high is 20 degrees Fahrenheit.  Now while this may not deter younger children from bundling up and going sledding, teen couch potatoes are busy whining that it’s “too cold.”  So there they sit.

What’s the secret to keeping them active in the winter months?  Have them schedule an activity, and be an example yourself.  Ideas for teens (and you) to do when it’s cold outside:

Have a 15-minute dance party

Have a Wii contest

Try swimming (indoors please!)

Dust off the treadmill or stationary bike in the basement and GET ON IT

Play ping-pong

Do a few chores

Jump rope

Jog during T.V. commercials

Pull out some “little kid games” such as hopscotch, hula-hoop or Twister

Let each child in your house choose an activity for everyone to try

Teens, like everyone else, need exercise to stay healthy.  Staff from the Mayo Clinic recommend kids ages 6-17 years should have one hour of moderate exercise each day.  Exercise can help improve mood (through the release of endorphins), improve sleep and therefore attention (critical with finals coming up), and improve cardiovascular endurance. Those spring sports really ARE just around the corner. 

Here are some numbers to get the kids moving:  All activities are based on 20 minutes and a teen who weighs 110 pounds.  The number of calories burned depends on weight.  If your teen weighs more, he will burn a few more calories, if he weighs less, he’ll burn a few less.  Below the table are links to some free and quick calorie calculators on the web so your teen can check it out for him self.  For those attached to their phones, there are web apps too.

What’s the worst that can happen?  You’ll have a more fit, better rested, and happier teen!  Or at least you’ll have a cleaner home!

Try these activity calculators:

http://primusweb.com/fitnesspartner/calculat.htm

www.caloriesperhour.com/index_burn.php

http://www.caloriecontrol.org/healthy-weight-tool-kit/lighten-up-and-get-moving

References:

www.mayoclinic.com/health/fitness/FL00030.   
www.caloriesperhour.com/index.burn.php

Deborah Stack, PT, DPT, PCS

Dr. Stack has been a physical therapist for over 15 years and heads The Pediatric Therapy Center of Bucks County in Pennsylvania www.buckscountypeds.com. She holds both masters and doctoral degrees in physical therapy from Thomas Jefferson University.

© 2011 Two Peds in a Pod®