stye photo

What’s causing this child’s eyelid swelling?

“When the moon hits your eye like a big pizza pie…”
Actually, that’s not amore, but that’s a stye on this child’s upper eyelid.

A stye (medical term = hordeolum) pops up seemingly overnight, although sometimes the child feels some tenderness at the eyelashes a day or two before it appears. Styes are tiny infections of eyelid glands that are self-limited and easily treated with warm wet compresses. We instruct patients to apply a clean, warm, wet cloth to the stye for 5-10 minutes four times per day.

Styes tend to improve after a few days but can take up to two weeks to completely resolve.
Persistent styes may actually be chalazions. Chalazions, the result of a dysfunctional eyelid gland, are firm and are not tender. They tend to “point” toward the inside of the eyelid rather than outward.

Insect bites may also masquerade as styes. However, insect bites are itchy rather than painful.

 

stye

stye: the view from the inside

Reasons to call your child’s doctor:
-the entire eyelid is red, painful, and swollen
-pain is felt inside the eye itself
-child is sensitive to light
-child has vision changes
-the inside white part of your child’s eye becomes red
-stye lasts more than two weeks despite treatment with warm compresses

 

Julie Kardos, MD and Naline Lai, MD
©2013, updated 2017  Two Peds in a Pod®

With special thanks to Dean Martin

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It’s 6 a.m., you are running late for work and your kid is “kinda” sick. Can you send him to daycare?

Dr. Kardos and Dr. Lai and a little friend talk about “Too Sick for School? The Latest Guidelines for Staying Home” at DVAEYC’s annual conference for early childhood educators

Yesterday we reviewed with an audience of early childhood education teachers the latest medical guidelines* for excluding children from early childhood education centers. Here are some of the updates we shared with the teachers attending the annual DVAEYC conference held at University of Pennsylvania:

When should a child go home from daycare? Remember the overriding goals for exclusion:

      To expedite the child’s recovery

To prevent undue burden on teachers

To protect other children and teachers from disease

Following are the guidelines that most surprised our audience, as well as other highlights from our talk.  

Pink eye (conjunctivitis)– most kids can remain in school

  • “Pink eye” is like a “cold in the eye” and can be caused by virus, bacteria, or allergies.
  • Just as kids with runny noses can still attend school, so too can kids with runny eyes.
  • A child with pink eye does not need to be on antibiotic eye drops in order to attend school. The presence or absence of treatment does not factor into letting a child attend school.
  • Any child with pink eye who suffers eye pain, inability to open an eye, or has so much discharge that she is uncomfortable, needs to go home.
  • If there is an outbreak (two or more kids in a room), the center’s health care consultant or the department of health can give ideas on how to help prevent further spread
  • Good hand washing technique prevents the spread of the contagious forms of pink eye (viral or bacterial).

fever in childrenFever – by itself, is not an automatic exclusion

  • For practical purposes, a fever (no matter how it is taken) in a child who is over 8 weeks old is a temperature of 101 degrees F. Therefore, 99 degrees F is NOT a fever, even if that number is higher than the child’s baseline temperature.
  • If a child with a fever acts well and does not require extra attention from teachers, then that child is medically safe to stay in school. Sending him home is unlikely to protect others. Kids are contagious the day before a fever starts, so febrile kids most likely already exposed their class to the fever-proking illness the day before the fever came.
  • If the fever causes the child to become dehydrated or makes the child too sleepy or miserable to participate in class, then that child should go home.
  • Any baby  two months of age or younger with a fever of 100.4 or higher needs immediate medical attention, even if he is not acting sick.
  • If a child has not received the recommended immunizations for his age, then he needs to be excluded for fever until it is known that he does NOT have a vaccine preventable illness.
  • If a child goes home with a fever, he does not need medical clearance to return to school.
  • Read more details about fever and “fever phobia” here.

Head lice, while icky and make our heads itch just to think about them, carry no actual disease.

  • The child with live lice should go home at regular dismissal time, receive treatment that night, and be allowed back in school the next day.
  • By the time you see lice on a child’s head, they have been there for likely at least a month. So sending him home early from school only punishes the child, causes the parent to miss work needlessly, and does nothing to prevent spread.
  • Lice survive off of heads for 1-2 days at most (they need blood meals, and die without them), so a weekend without people in school kills any lice left behind in the classroom by Monday morning.
  • Lice do not jump or fly and thus need close head-to-head contact to spread, hence the reasons behind why your child’s center spaces matts at nap time  a certain amount distance apart, and do not allow kids to share personal objects such as combs.

The mouth ulcers and foot rash of Hand Foot Mouth

Hand-foot-mouth disease- not an automatic exclusion

  • This common virus, spread by saliva, causes a blister-like rash that can appear on hands, feet, in the mouth and in the diaper area, sometimes in all of these locations. Hand washing limits spread, and kids can attend school with this rash.
  • The child who refuses to drink because of painful mouth lesions should go home so the parent can help improve hydration. In addition the child who refuses to participate in activities  should stay home. You can read more about this virus here.

Poison ivy rash is not contagious to other people. The rash of poison ivy is an allergic reaction/irritation from wherever the oil of a poison plant touched the skin. The ONLY way to “catch” poison ivy is from the poison ivy plant itself. But if the itch from poison ivy makes a child too miserable to participate in class activities, she may need to go  home. Read more about poison ivy here.

Vomiting more than twice, associated with other symptoms (such as fever, hives, dehydration or pain),  or with vomit which is  green-yellow or bloody are all  reasons a child should leave school. Recent history of head injury  warrants exclusion and immediate attention since vomiting can be a sign of bleeding in the head.  See our post about vomiting.

Diarrhea, meaning an increase in stool frequency, or very loose consistency of stools, is a reason to go home if the diarrhea

  • cannot be contained in a diaper,
  • causes potty accidents in the toilet trained child
  • contains blood, is bloody or black
  • results in more than two stools above baseline for that child—too many diaper changes compromises the teacher’s ability to attend to other children.
  • is with other symptoms such as fever, acting very ill or jaundiced (yellow skin/eyes)
  • Read more about poop issues here.

Molluscum contagiosum is a benign “only skin deep” illness similar to warts—direct vigorous contact or sharing of towels or bath water can spread the virus among kids but the rash itself is harmless and not a reason to stay home from school. Read our prior post for More on this little rash with the big name.

MRSA is a skin infection that looks red and pus filled and is typically painful for the child. Treatment involves draining the infection and/or taking oral antibiotics. If the infected area is small and can be covered completely, a child may stay in school.

Measles This illness causes high fever, cough, runny nose, runny eyes, and cough and a total body rash. Your local Department of Public Health will provide recommendations about how long to exclude a child with measles as well other precautions a school should take. So they are safe, unvaccinated children will have to be excluded for period of time as well.

Also note, at times, the department of public health will exclude even children who are acting well from school for outbreak management of a variety of infectious diseases.

Surprised? As you can see, there are few medical reasons to keep your child home from daycare for an extended period of time. As Dr. Lai often says to the big kids, “If there is nothing wrong with your brain, you can go to school and learn.” Bottom line-  no matter the reason, if you realize at six in the morning that your child will not be able to learn and function at baseline, keep him home and seek the advice of your child’s pediatrician.

Julie Kardos, MD and Naline Lai, MD

©2017 Two Peds in a Pod®

*A straight-forward, comprehensive guide to the guidelines can be found in Managing Infectious Diseases in Child Care and Schools, 4th edition, Editors: Susan S. Aronson, MD, FAAP and Timothy R. Shope, MD, MPH, FAAP, published by the American Academy of Pediatrics.

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ringwormAlthough it’s called ringworm, this rash isn’t caused by a worm.  In fact, it barely looks like a worm. Otherwise known as tinea corporis, the patch of ringworm is usually a flesh or light-pink colored, slightly scaly oval with raised, red edges.

Caused by a fungus, sometimes the patch is itchy. The same organism also causes athlete’s foot (tinea pedis), jock itch (tinea cruris),  and scalp infections (tinea capitis).

Ringworm falls into the mostly-harmless-but-annoying category of skin rashes (cover it up and no one will notice). Your child’s doctor will diagnose the rash by examining your child’s skin. To treat the rash, apply antifungal medication until the rash is gone for at least 48 hours (about two to three weeks duration). Clotrimazole (for example, brand name Lotrimin) is over-the-counter and is applied twice daily. You will find it in the anti-athlete’s foot section.

On the scalp, ringworm causes hair loss where the rash occurs.  Treatment is not so straight forward. Ringworm on the scalp requires a prescription oral antifungal medication for several weeks. The fungus on the scalp lives not only on the skin, but also in hair follicles. So, topical antifungals fail to reach the infection.

Ringworm spreads through direct contact. Wrestling teams are often plagued with this infection. Cats may carry ringworm. If your family cat has signs of feline ring worm such as patches of hair loss, take him to the vet for diagnosis.

If your child’s “ringworm” fails to improve after a week of applying antifungal medication, have your child’s doctor examine (or re-examine) the rash. Other diagnoses we keep in mind include eczema and granuloma annulare. If the rash continues to enlarge we consider Lyme disease.

Kids are allowed to attend school and daycare with ringworm once treatment is started. Wrestlers are advised to cover the rash for the first three days of treatment.

The sooner you start to treat ringworm, the more quickly it resolves. Just remember, “the early bird catches the…” oh, never mind.

Naline Lai, MD and Julie Kardos, MD
©2017 Two Peds in a Pod®, updated from 2012

 

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how to read to child

Charles West Cope (British, 1811 – 1890 ), Woman Reading to a Child, Gift of William B. O’Neal 1995.52.28

We know parents who started reading to their children before they were born, but don’t fret if you didn’t start when baby was in the womb. It’s never too late to start. A shout out to the librarians of the Bucks County, PA. Recently the librarians invited us to speak about child development— they inspired us to give you a developmental guide to reading with your young child:

By three months of age, most babies are sleeping more hours overnight and fewer hours during the day (and, hence, so are their parents). Now you have time to incorporate reading into your baby’s daily schedule. At this age babies can visually scan pictures on both pages of a book. Babies see better close-up, so you can either prop your baby on your lap with a book in front of both of you, or you can lie down next to your baby on the rug and hold the book up in front of both of you. The classic Goodnight, Moon by Margaret Wise Brown or any basic picture book is a great choice at this age.

By six months of age many babies sit alone or propped and it is easier have a baby and book in your lap more comfortably. Board books work well at this age because 6-month-olds explore their environment by touching, looking, and MOUTHING. Sandra Boynton’s Moo, Baa, La La La was a favorite of Dr. Kardos’s twins at this age, both to read and to chew on.

By nine months many babies get excited as you come to the same page of a known book that you always clap or laugh or make a funny noise or facial expression. They also enjoy books that involve touch- such as Pat the Bunny by Dorothy Kunhardt.

At one year, kids are often on the move. They learn even when they seem like they are not paying attention. At this age, your child may still want to sit in your lap for a book, or they may walk or cruise around the room while you read. One-year-olds may hand you a book for you to read to them. Don’t read just straight through a book, but point repeatedly at a picture and name it.

By 18 months, kids can sit and turn pages of a book on their own. Flap books become entertaining for them because they have the fine motor skills that enable them to lift the flap. The age of “hunter/gatherer,” your 18-month-old may enjoy taking the books off of the shelf or out of a box or basket and then putting them back as much as they enjoy your reading the books.

Two-year-olds speak in two word sentences, so they can ask for “More book!” Kids this age enjoy rhyming and repetition books. Jamberry, by Bruce Degen, is one example. You can also point out pictures in a book and ask “What is that?” or “What is happening?” or “What is he doing?” Not only are you enjoying books together, but you are preparing your child for the culture of school, when teachers ask children questions that the teacher already knows the answers to. And here is some magic you can work: you may be able to use books to halt an endless tantrum: take a book, sit across the room, and read in a soft, calm voice. Your child will need to quiet down in order to hear you and he may very well come crawling into your lap and saving face by listening to you read the book to him.

Three-year-olds ask “WHY?” and become interested in nonfiction books. They may enjoy a simple book about outer space, trucks, dinosaurs, sports, puppies, or weather. They can be stubborn at this age. Just as they may demand the same dinner night after night (oh no, not another plate of grilled cheese and strawberries!), they may demand the same exact book every single night at bedtime for weeks on end! Try introducing new books at other times of day when they may feel more adventurous, and indulge them in their favorite bedtime books for as long as they want. They may even memorize the book as they “read” the book themselves, even turning the pages at the correct time.

Four and five-year-olds have longer attention spans may be ready for simple chapter books. For example, try the Henry and Mudge books by Cynthia Rylant. Kids will still enjoy rhyming books (you can never get enough Dr. Seuss into a kid) and simple story books. At four, kids remember parts of stories, so talk about a book outside of bedtime. Some children this age know their letters and even have some sight words, but refrain from forcing your child to learn to read at this age. Studies show that by second grade, kids who have been exposed to books and reading in their homes are better readers than kids who have not, but the age children start to read has NO correlation with later reading skills. So just enjoy books together.

What about e-readers and books on ipads? The shared attention between a parent and a child is important for developing social and language skills, so share that ebook together.

Now that you have read our post, go read to your child, no matter how old he is. Even a ten year old enjoys sharing a book with their parents. Eventually, you will find your whole family reading the same book (although maybe at different times) and before you know it, you’ll have a book club…how nice, to have a book club and not worry about cleaning the house ahead of time…

Julie Kardos, MD and Naline Lai, MD
©2017 Two Peds in a Pod®

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juggling children

The octopus parent never had a problem splitting attention among the kids until the 9th came along.

You sit down to breast feed your newborn, when your three-year-old announces, “I have to go potty! And I need HELP!”

You are giving your newborn a bottle and your two year old starts eating the dog’s food out of the dog’s bowl.

Firstborns, in their “forever quest” to hoard all of your attention for all their waking moments, learn very quickly how to interrupt the feeding of a baby sibling if they feel ignored.  Ways to entertain the first born:

Turn Feeding Your Newborn into a special treat for your older child. Say, “Oh YES! It is time to feed the baby, now we can…” Complete with whatever special treat your older child would enjoy:

               …look at the Elmo flap book and open EVERY SINGLE FLAP as often as you want.

               …listen to you sing every song from Frozen.

               …listen to you tell every joke that you’ve ever learned.

               …watch Peppa Pig together! And I will not fall asleep this time.

               …bring out the special colored pencils for you to use that we only take out while we feed the baby.

               … continue this long chapter book that we save for the times we feed the baby.

               … take out this special puzzle that we only take out when the baby eats.

               …(and if you are outside) get the spray bottle of water for you to water all of our trees and plants and grass! (most toddlers cannot resist a spray water bottle- hoard it for baby feeding times) or …get out the sidewalk chalk so you make art all over the driveway!

You get the idea. Now, instead of your saying, “Sorry Honey, we have to stop playing now because Baby has to eat,” you can make the experience a special privilege for your older child.

If your older child is napping during a feeding, then of course you can reward yourself with reading Two Peds in a Pod’s back posts during the feed!

Julie Kardos, MD and Naline Lai, MD

©2017 Two Peds in a Pod®

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flu cartoon

“Now what kind of soup did the doctor recommend? Was that tomato soup? Mushroom barley?”

Happy New Year and welcome to Flu Season 2017! Parents ask us every day how they can tell if their child has the flu or just a common cold. Here’s how:

Colds, even really yucky ones, start out gradually. Think back to your last cold: first your throat felt scratchy or sore, then the next day your nose got stuffy or then started running profusely, then you developed a cough. Sometimes during a cold you get a fever for a few days. Sometimes you get hoarse and lose your voice. Kids are the same way. In addition, they often feel tired because of interrupted sleep from cough or nasal congestion. This tiredness leads to extra crankiness.

Usually kids still feel well enough to play and attend school with colds, as long as they well enough to participate. The average length of a cold is 7-10 days although sometimes it takes two weeks or more for all coughing and nasal congestion to resolve.

Important news flash about mucus: the mucus from a cold can be thick, thin, clear, yellow, green, or white, and can change from one to the other, all in the same cold. The color of mucus does NOT tell you if your child needs an antibiotic and will not help you differentiate between a cold and the flu.

The flu, caused by influenza virus, comes on suddenly and makes you feel as if you’ve been hit by a truck. Flu always causes fever of 101°F or higher and some respiratory symptoms such as runny nose, cough, or sore throat (many times, all three). Children, more often than adults, sometimes will vomit and have diarrhea along with their respiratory symptoms, but contrary to popular belief, there is no such thing as “stomach flu.” In addition to the usual respiratory symptoms, the flu causes body aches, headaches, and often the sensation of your eyes burning. The fever usually lasts 5-7 days. All symptoms come on at once; there is nothing gradual about coming down with the flu.

So, if your child has a runny nose and cough, but is drinking well, playing well, sleeping well and does not have a fever and the symptoms have been around for a few days, the illness is unlikely to “turn into the flu.”

Remember: colds = gradual and annoying. Flu = sudden and miserable.

Fortunately, a vaccine against the flu is available for all kids over 6 months old (unfortunately, the vaccine isn’t effective in younger babies) that can prevent the misery of the flu. In addition, vaccines against influenza save lives by preventing flu-related complications that can be fatal such as pneumonia, encephalitis (brain infection), and severe dehydration.  Even though we are starting to see a lot of flu, it is not too late to get the flu vaccine for your child, so please schedule a flu vaccine ASAP if your child has not yet received one for this season. Parents and caregivers should also immunize themselves- we all know how well a household functions when Mom or Dad have the flu… not very well!

Be sure to read our guest article on ways to prevent colds and flu and our thoughts on over the counter cold medicines.  Now excuse us while we go out to buy yummy-smelling hand soap to entice our kids to wash germs off their hands. After that you’ll find us cooking up a pot of good old-fashioned chicken soup, just in case…

Julie Kardos, MD and Naline Lai, MD
revised from our 2009 and 2015 posts

©2017 Two Peds in a Pod®

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As we think about how to keep our parenting New Year’s resolutions, we find interesting advice from a fellow board member of Happy Healthy Kids. In her new book, WHAT GREAT PARENTS DO: 75 Simple Strategies for Raising Kids Who Thrive, Dr. Erica Reischer, a California based psychologist and parent educator cautions against motivating kids solely through reward economies such as sticker charts. — Drs. Lai and Kardos

Here’s an excerpt:

“REWARD ECONOMY” IS a term I coined for the arrangements that many parents make with their children to motivate “good” behavior, such as paying for chores or routinely using sticker charts that trade good behavior for prizes or rewards (even if the reward is something wholesome like books). I call them reward economies because they can create a transactional system in which children learn to trade their desirable behavior for a reward.

The problem with reward economies is not that they don’t usually work to produce the desired behavior-if you have the right reward, these systems often appear to work well. As research has shown, the problem is that, over time, reward economies may negatively affect children’s motivation and may also create an expectation in children that they should be compensated for activities that are part of being a responsible and helpful member of the family.

One telltale sign that you’ve inadvertently created a reward economy in your family: When you ask you kids to do something outside of their regular tasks and to-dos, such as “Please go fold the laundry,” and they reply, “What will you give me?” Another sign: You tell them you’ll give them a reward/prize/sticker if they do something like helping to clean the kitchen, and they respond, “No, thanks,” and don’t feel obliged to help since they aren’t accepting the “compensation” you are offering.

Although sticker charts and similar systems seem like a good solution in the short term—we get helpful and cooperative behavior—in the long term we may be inadvertently creating a bigger problem: children who see their role in the family as a job for which they receive compensation. Moreover, reward economies often don’t give children many opportunities to develop self-discipline and self-mastery, which are critical life skills.

You might be wondering what could possibly be motivating about many of the things we ask our kids to do: homework, chores, etc. My response is this: Kids who learn how to do what needs to be done—even if they don’t feel like doing it—develop a strong sense of autonomy, competence, and self-mastery. There are similar benefits for kids who learn how to stop themselves from doing something desirable in the here and now in order to achieve an even more desirable future outcome (e.g. delayed gratification, as with the well- known marshmallow study).

……

TRY THIS:

If you currently use sticker charts or similar reward systems, and you decide to stop, start by letting your kids know that you are going to make that change. (Sticker charts, however, can be used to good effect as a simple tracking chart, to help kids visualize their to-dos and track their progress. The key difference between a reward chart and a tracking chart is that the latter does not involve earning rewards. So kids might put a sticker on their chart to show that they finished cleaning their room, with the sticker being just a satisfying visual symbol of completion. ) If they are in the middle of earning something important to them, let them finish and get their prize (that is, follow through on the commitment you made to them when you offered the incentive).

Your primary tools for rewarding good behavior going forward will be your acknowledgment and praise. For tasks your kids don’t like or don’t want to do, use empathy, reason, and especially rehearsals.

If your kids seem to ignore you when you make a request, first be sure they have actually heard you. Give them a reason to go with your request and, if you have to ask a second time, add fair warning of consequences. Other useful tools are scaffolding and rehearsals. In scaffolding, parents provide support and assistance in many different areas of their children’s lives (scaffolding), while avoiding doing the work itself (building). You may also have to be more involved in following up.

For example: “Sweetie, in five minutes, it will be time to clean up your toys in the living room.” “Noooo… I don’t want to.” “I know you don’t want to, honey. You wish you could just keep playing (empathy). At the same time, we all share the house, so you need to do your part to keep it clean (request/reason).” “Nooo…” (Or silence/ignoring)

Now go over to your child and try to involve her in cleaning up. Try reframing to make the activity more appealing (e.g., sing a cleanup song or have a cleaning contest). If she still refuses to help, matter-of-factly restate your request, and then give fair warning of consequences.

“Honey, it’s time to clean up now. I know you would rather leave your toys on the floor. If you don’t help clean up, then I will keep the toys that I find in the living room for [insert appropriate time frame for your child’s age] since you aren’t being responsible for them (fair warning).”

If necessary, follow through on your consequence of keeping the toys for the time you specified.

To avoid a repeat of this situation in the future, stage a rehearsal with your child in which she will practice cleaning up in a “pretend” scenario.

If she does help, be enthusiastic and specific in your praise: “Look we did it and the living room looks so organized! Even though you didn’t want to clean up, I’m really proud of you for being a helper and putting all your cars in the box.” Remember to praise your child for any part that she did well, even if she didn’t meet all your expectations. Praise reinforces good behavior.

…………..
Rewards can, however, be useful occasionally for helping children reach milestones (such as toilet training) or for motivating them to participate in unpleasant activities (such as getting shots at the doctor’s office). The key is to avoid using rewards frequently or systematically as a way of managing the regular activities of family life, unless you are getting specific guidance from a professional to do so.

Erica Reischer, Ph.D.

Adapted from WHAT GREAT PARENTS DO: 75 Simple Strategies for Raising Kids Who Thrive by Erica Reischer, Ph.D. © 2016 by Erica Reischer. TarcherPerigee, an imprint of Penguin Random House LLC.

Erica Reischer, Ph.D., is a clinical psychologist and parent educator who leads popular parenting classes and workshops at UCSF Benioff Children’s Hospital, Habitot Children’s Museum, and the University of California. Her writing about children and families appears in Psychology Today, The New York Times, The Washington Post, and The Atlantic.

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RSV Naline Lai

“A baby in my child’s daycare was hospitalized for RSV,” panicked parents said to us the other day. But RSV (Respiratory Syncytial Virus) is not just a daycare phenomenon. As we are currently experiencing in our office, this virus causes MANY more run-of-the-mill office visits than hospitalizations.

Right now, RSV season is in full swing. RSV is one of the most common causes of the common cold. It is THE most common cause of childhood bronchiolitis (inflamed tiny airways in the lungs), but most of the time RSV causes a really miserable cold without any other complications. Most of us have had RSV many times. RSV tends to be particularly tough on babies and toddlers because the worst episode of RSV is usually the first time you catch the germ.

RSV glues to cells from the nose down to the lungs, causing breathing difficulties. The boogies from RSV tend to be very thick and kids’ lungs goo-up, sometimes causing a wheeze (like that of a person with asthma). The cough from RSV can easily last a month. The disease can be very dangerous in young infants, babies born earlier than 38 weeks (premature), and babies with chronic lung and heart disease, because of their inability to clear the gunk that RSV produces in their airways. Some kids get fever with RSV and some do not.

Like all cold viruses, no medication kills RSV, so the germ needs to “run its course.” The third through the fifth day of the illness are generally the peak days for symptoms. Here are ways to help your ill child:

  • Stay away from the over-the-counter cough and cold medicines– they can have more side effects than helpful effects.
  • If your child is over one year old, honey can help relieve the cough . Try giving 1 teaspoon 3-4 times a day.
  • For the little ones who can’t (or won’t) blow their noses, put a drop or two of nasal saline in each nostril and use a suction device like a bulb syringe to pull out the discharge. Warning: over-zealous bulb suctioning, more than three to four times a day, can be irritating to the nose. Sometimes just the saline alone, without suction, is enough to promote sneezing which will catapult out the mucus.
  • Run a cool mist humidifier in her bedroom or sit with your child in a steamy bathroom so water vapor loosens her congestion.
  • Give acetaminophen (if over two months of age) or ibuprofen (over six months of age) as needed for fever or discomfort from a clogged head.

Just like you when you have a cold, your child may lose her appetite because she has a belly full of post nasal drip and overall feels lousy. Do not fret over her lack of food intake, but do hydrate her well. Breast milk or formula, because of their nutrition, is the best choice for hydrating infants with a cold. For older children, encourage water, but if your child is not eating, make sure there is salt and sugar in her fluids to keep her going. Don’t be afraid to give your child milk when she has a cold. Good old-fashioned chicken broth is another great source of hydration.

For kids under two years of age, avoid the use of smelly chest rubs containing menthol or camphor (e.g. Vicks Vapor Rub) and in older children, don’t introduce a rub for the first time when your child is ill. When he is sick is a terrible time to discover that a chest rub sends your child into an allergic coughing fit or to discover that he hates the smell.

How do you know if you need to take your child to the doctor? Read here to help you decide. Watch for signs of difficulty breathing: rapid breathing, ribs sticking out each time your child breathes in (click here for our video example of this), and/or belly moving in and out with each breath, and grunting. A child who is short of breath will be unable to breathe and drink at the same time. A child who is inconsolable with RSV might have additional infections such as pneumonia, ear infections or sinus infections.

Since our immune systems do not make a long-lasting antibody response to RSV, our bodies do not “remember” RSV, and we can catch it again and again. This makes the creation of an RSV vaccine difficult, because vaccines work by boosting our natural defense systems. Vaccines cannot boost an immune response that does not occur naturally.

Take heart, even if your child gets RSV every winter, each episode will usually be less severe than the last. Just look at us pediatricians, we have contracted it so many times, we may sneeze only once before the germ retreats.

Hopefully your family escapes RSV this year! Continue good hand washing and encourage your child to cough into his sleeve to prevent spread of RSV and other Really Sick Viruses.

Naline Lai, MD and Julie Kardos, MD

©2017 Two Peds in a Pod®, revised from 2014

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Autism is a communication and socialization disorder. Pediatricians watch for  speech delay as a sign of autism. But even before your child is expected to start talking at around a year old, you can watch for communication milestones. Problems attaining these milestones may indicate autism or other disorders such as hearing loss, vision loss, isolated language delay, or other developmental delays:

By six weeks of age, your baby should smile IN RESPONSE TO YOUR SMILE. This is not the phantom smile that you see as your baby is falling asleep or that gets attributed to gas. Your baby should see you smile and smile back at your smile. Be aware that babies at this age will also smile at inanimate objects such as ceiling fans, and this is normal for young babies to do.

By two months of age, babies not only smile but also coo, meaning they produce vowel sounds such as “oooh” or “aaah” or “OH.” If your baby does not smile at you by their two month well-baby check up visit or does not coo, discuss this delay with your child’s doctor.

By four months of age, your baby should not only smile in response to you but also should be laughing or giggling OUT LOUD. Cooing also sounds more expressive (voice rises and falls or changes in pitch) as if your child is asking a question or exclaiming something.

Six-month-old babies make more noise, adding consonant sounds to say things like “Da” and “ma” or “ba.” They are even more expressive and seek out interactions with their parents. Parents should feel as if they are having “conversations” with their babies at this age: baby makes noise, parents mimic back the sound that their child just made, then baby mimics back the sound, like a back and forth conversation.

All nine-month-olds should know their name. Meaning, parents should be convinced that their baby looks over at them in response to their name being called. However, sometimes parents have so many nicknames for their baby that this milestone might be delayed a bit until parents are more consistent with always using the same name to address their child. Baby-babble at this age, while it may not include actual words yet, should sound very much like the language that they are exposed to primarily, with intonation (varying voice pitch) as well. Babies at this age should also do things to see “what happens.” For example, they drop food off their high chairs and watch it fall, they bang toys together, shake toys, taste them, etc.

Babies at this age look toward their parents in new situations to see if things are ok. When I examine a nine month old in my office, I watch as the baby seeks out his parent as if to say, “Is it okay that this woman I don’t know is touching me?” They follow as parents walk away from them, and they are delighted to be reunited. Peek-a-boo elicits loud laughter at this age (“You’re gone, you’re back, haha!”). Be aware that at this age babies do flap their arms when excited or bang their heads with their hands or against the side of the crib when tired or upset; these “autistic-like” behaviors are in fact common at this age.

By one year of age, children should be pointing at things that interest them. This very important social milestone shows that a child understands an abstract concept (I look beyond my finger to the object farther away) and also that the child is seeking social interaction (“Look at what I see/want, Mom!”). Many children will have at least one word that they use reliably at this age or will be able to answer questions such as “What does the dog say?” (child makes a dog sound). Even if they have no clear words, by their first birthday children should be vocalizing that they want something. Picture a child pointing to his cup that is on the kitchen counter and saying “AAH AAH!” and the parent correctly interpreting that her child wants his cup.

Kids at this age also will find something, hold it up to show a parent or even give it to the parent, then take it back. Again, this demonstrates that a child is seeking out social interactions, a desire that autistic children typically fail to demonstrate. It is also normal that at this age children have temper tantrums in response to seemingly small triggers such as being told “no.” Unlike in school-age children, difficulties with “anger management” are normal at age one year.

Pediatricians often use a questionnaire called the M-CHAT (Modified Checklist for Autism in Toddlers) as a screening tool . This test can be downloaded for free. In our office we administer the M-CHAT at the 18-month well child visit and again at the two-year well visit, but the test is valid down to 16 months and in kids as old as 30 months. Not every child who fails this test has autism, but the screening helps us to identify which child needs further evaluation.

At 15-18 months of age, children should show the beginnings of pretend play. For example, if you give your child a toy car, the toddler should pretend to drive the car on a road, make appropriate car noises, or maybe even narrate the action: “Up, up, up, down, down, rrrroooom!” Younger babies mouth the car, spin the wheels, hold it in different positions, or drag a car upside down, but by 18 months, they perceive a car is a car and make it act accordingly. Other examples of pretend play are when a toddler uses an empty spoon and pretends to feed his dad, or takes the T.V. remote and then holds it like a phone and says “hello?” You may also see him take a baby doll, tuck baby into bed, and cover her with a blanket.

Eye contact in American culture is a sign that the child is paying attention and engaged with another person. Lack of eye contact or lack of “checking in” with parents and other caregivers can be a sign of delayed social development.

Kids try periodically to get their parents to pay attention to what they are doing. Lack of enticing a parent into play or lack of interest in what parents or other children are up to by this age is a sign of delayed social development. Ask yourself, “Does my child bring me things? Does he show me things?”Also, although they may not share or take turns, a toddler should still be interested in other children.

Many two-year-olds like to line things up. They will line up cars, stuffed animals, shapes from a shape sorter, or books. The difference between a typically-developing two-year-old and one that might have autism is that the typically-developing child will not line things up the exact same way every time. It’s fine to hand your child car after car as he contently lines them up, but we worry about the toddler who has a tantrum if you switch the blue for the green car in the lineup.

Two-year-olds should speak in 2-3 word sentences or phrases that communicate their needs. Autism is a communication disorder, and since speech is the primary means to communicate, delayed speech may signal autism. Even children with hearing issues who are speech-delayed should still use vocal utterances and gestures or formal sign language to communicate.

Another marker for autism can be atypically terrible “terrible twos”. Having a sensory threshold above or below what you expect may be a sign of autism. While an over-tired toddler is prone to meltdowns and screaming, parents can often tell what triggered the meltdown. For example, my oldest, at this age, used to have a tantrum every time the butter melted on his still-warm waffle. Yes, it seemed a ridiculous reason to scream, but I could still follow his logic. Autistic children are prone to screaming rages beyond what seems reasonable or logical. Look also for the child who does not startle at loud noises, or withdraws from physical contact because it is overstimulating.

By three years, children make friends with children their own age. They are past the “mine” phase and enjoy playing, negotiating, competing, and sharing with other three-year-olds. Not every three year old has to be a social butterfly but he should have at least one “best buddy.”

Regression of skills at any age is a great concern. Parents should alert their child’s pediatrician if their child stops talking, stops communicating, or stops interacting normally with family or friends.

It’ s okay to compare. Comparing your child to other same-age children may alert you to delays. For example, I had parents of twins raise concerns because one twin developed communication skills at a different pace than the other twin.

Although you may wonder if your child has autism, there are other diagnoses to consider. For instance, children need all of their senses intact in order to communicate well. I had a patient who seemed quite delayed, and it turned out that his vision was terrible. He never complained about not seeing well because he didn’t know any other way of seeing. After my patient was fitted with strong glasses at the age of three, his development accelerated dramatically. The same occurs for children with hearing loss—you can’t learn to talk if you can’t hear the sounds that you need to mimic, and you can’t react properly to others if you can’t hear them.

If you or your pediatrician suspect your child has autism, early and intensive special instruction, even before a diagnosis is finalized, is important. Every state in the United States has Early Intervention services that are parent-prompted and free for kids. The sooner your child starts to works on alternate means of communication, the quicker the frustration in families dissipates and the more likely your child is to ultimately develop language and social skills. Do not be afraid of looking for a diagnosis. He will be the same child you love regardless of a diagnosis. The only difference is that he will receive the interventions he needs.

Julie Kardos, MD, and Naline Lai, MD

©2017 Two Peds in a Pod®

modified from the original  2010 and 2013 posts

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cold remedies

For kids over one year of age, the Honey Bear offers grrr-eat relief

So many children (and their parents) have colds now. Really yucky colds, often accompanied by fever. Take heart that it’s not quite flu season- the yearly flu epidemic has not yet fully hit the United States. Are you staring at the medicine display in the pharmacy, wondering which of the many cold medicines on the shelf will best help your ill child? How we wish we had a terrific medication recommendation for  treatment of a kid’s cold. Unfortunately, we do not. And antibiotics-as powerful as they can be at killing bacteria- do not cure colds, which are caused by viruses.

Watching your child suffer from a cold is tough. But why give something that doesn’t help her get better and has potential side effects?

Don’t despair, even if you can’t kill a cold virus, there are plenty of things you can do to make your child feel better:

  • -If she has a sore throat, sore nose, headache, or body aches, consider giving acetaminophen or ibuprofen to treat the discomfort.
  • -Give honey for her cough and also to soothe her throat if she is over one year of age.
  • -Run a cool mist humidifier in her bedroom, use saline nose spray or washes, have her take a soothing, steamy shower, and teach her how to blow her nose.
  • -Break up that mucus by hydrating her well — give her a bit more than she normally drinks.
  • -For infants, help them blow their noses by using a bulb suction. However, be careful, over-zealous suctioning can lead to a torn-up nose and an overlying bacterial infection. Use a bulb suction only a few times a day.

The safety and effectiveness of cough and cold medicine has never been fully demonstrated in children.  In fact, in 2007 an advisory panel including American Academy of Pediatrics physicians, Poison Control representatives, and Baltimore Department of Public Health representatives recommended to the U.S. Food and Drug Administration (FDA) to stop use of cold and cough medications under six years of age.

Thousands of  children under twelve years of age go to emergency rooms each year after over dosing on cough and cold medicines according to a 2008 study in Pediatrics . Having these medicines around the house increases the chances of accidental overdosing. Cold medications do not kill germs and will not help your child get better faster. Between 1985 and 2007, six studies showed cold medications didn’t have significant effect over placebo.  

nasal bulb suction

The self billed “snot sucker” Nose Frida

So you can ignore the shelf of children’s cough and cold medicine. Instead,  buy saline nose drops or spray to help suffy noses, acetaminophen (Tylenol) or ibuprofen (Motrin, Advil), to treat discomfort, and fluids-  and yes, milk is ok during a cold– to prevent dehydration.

Fortunately, when your kids have a cold, unlike you, they can take as many naps as they want.

Naline Lai, MD and Julie Kardos, MD

© 2016, modified from 2015, Two Peds in a Pod®

updated from our  2011 post

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