hand foot mouth diseaseWe’re seeing a lot of this stuff around the office. It’s “hand-foot-mouth” disease, a common, self-limited illness caused by the Coxsackie virus, and it strikes most often in the spring and summer. Named for rashes which can affect the hands, feet, or mouth, this illness can cause fever for the first few days as well as some loose stools. 

If you look carefully at the photos above, you will see faint red bumps on this child’s feet. The rash may also look like tiny blisters and will always blanch (if you press on it and lift up your finger, the redness will briefly disappear- just as if you pressed on a sunburn). The same rash may appear on the hands and is not itchy. The child’s throat above is red in the back and has several ulcers, or canker sores. The hands, feet and mouth are not always simultaneously affected, and although we don’t call the illness “hand-foot-mouth-tush” disease,  sometimes kids also get a red bumpy rash on their buttocks. 

The throat ulcers can be quite painful and the rash on the feet may be slightly tender.  Usually the rash on the hands is not felt by the child. You can alleviate your child’s throat pain with acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil or Motrin). For toddlers and older, Magic Mouthwash, a mix of 1/4 tsp diphenhydramine (plain liquid Benadryl) and 1/4 tsp Maalox (the regular adult stuff) squirted over mouth ulcers prior to eating a meal (three times a day)  is an age-old way to sooth sores. 

Because this virus is contagious through saliva, prevent kids from sharing cups, eating utensils, and tooth brushes, and clean up toddler drool in order to prevent the virus from spreading to family members and friends. Children with this virus can still attend daycare as long as they are not feeling ill, typically after the first few days of illness when fever and pain start to subside. Most commonly the rash and mouth ulcers last about a week.

Unfortunately there is no treatment for hand-foot-mouth disease, but fortunately your child’s body is fully capable of fighting off the virus. Your role is to help soothe pain. Otherwise, kids may refuse to drink and end up dehydrated. When my son had this illness at age two, he liked sucking on a washcloth soaked in very cold water. I also gave him lots of sherbet, ice cream, milk shakes, and noodles because these foods were easier for him to swallow while his throat was sore. 

Kids can get this virus more than once, and many strains of this virus circulate. Even parents are not always immune.

So now add Coxsackie virus, or hand-foot-mouth disease, to your Dr. Mom and Dr. Dad list of manageable diseases. Knowledge is power. However, if your child’s fever lasts more than three days, if he does not drink enough to urinate his baseline amount, if he is inconsolable, seems disoriented, or if your parent gut-instinct tells you something more might be wrong, do get your child to medical attention.

Julie Kardos, MD with Naline Lai, MD

©2014 Two Peds in a Pod®

Originally posted June, 2011, and right on cue, Coxsackie is back again this summer.


Where do these tween/teen games come from?

Warn your kids about a game that Dr. Kardos learned about from some tweens recently.  Young teens at a party took intact packages of Smarties® candy and used their cell phones (!) to smash the candies into a fine dust inside their cellophane wrappers. Then they peeled off the end of the roll and sucked the dust into their mouths (imagine a “Smarties®” cigarette), and exhaled, causing  Smarties® smoke to spew from their mouths. They spit out any candy that was left in their mouths. The thrill came from creating Smarties® smoke.

I was glad that the kids who told me about this game saw that this was a not-so-smart game to play. No, this does not count as “smoking” and is likely not addictive, but this story begs several teaching points for parents of tweens/teens:

1-      Tweens and teens need supervision at parties.

2-      Teach your kids never to inhale anything except AIR. Anything else can cause coughing, irritation to the lungs, and possible infection.

3-      Young teens especially are prone to “mob mentality.” Teach them if their friends do something that they have never done before, to think long and hard about possible consequences before following the crowd. Ask them to think, “What’s the worst that can happen if I do this?”

4-      Know your children’s friends. If you know they are thrill seekers, attention grabbers, or prone to engage in questionable behaviors, make sure you have frequent talks with your kid about smart choices. Sign your child up for activities that allow opportunities to become friendly with an alternative crowd.

If you see kids engaged in risky behaviors, even if they are not your own children, stop them. Someone has to care. Hopefully someone else is watching out for your kids, too.

Julie Kardos, MD and Naline Lai, MD
©2014 Two Peds in a Pod®



vomitAward-winning journalist, mystery book author, and syndicated humor columnist Nicole Loughan interviews Two Peds about the “stomach flu” vs “real flu.”
Drs. Lai and Kardos

Despite up to date flu shots, my children and I found ourselves holding our hair back and praying to the porcelain goddess last week. I wondered why this terrible flu had happened to us? This rhetorical question usually just lingers, but this time, I had a chance to get answers and took it. I got the ear of Dr. Naline Lai, MD, FAAP and Julie Kardos, MD, FAAP from Two Peds in a Pod and cornered them about why exactly my brood and I experienced a terrible flu this season, and what we could have done to prevent it, and what’s to blame for it.

Click here to read on.

Nicole Loughan

Nicole writes for two daily newspapers in the Greater Philadelphia area, blogs as “The Starter Mom,” and has two books out: To Murder a Saint and All Saints’ Secret. She is the mom of two young children.



Photo by Lexi Logan

Today we welcome Bereavement Counselor Amy Keiper-Shaw who shares with us how to discuss the death of a pet with your child.

–Drs. Lai and Kardos


When I first graduated from college I worked as a nanny.  One day the mom shared with me that their family goldfish recently died. As this was her daughter’s first experience with death, we schemed for nearly 20 minutes to find the best way to talk to her child. The mom and I thought it could be an excellent teaching moment.

We pulled the girl away from her playing to explain that the fish had died. We told the girl we’d help her have a funeral if she wanted, and we would find a box (casket) to bury the fish so she could say her goodbyes.  We explained what a casket was and what a funeral was in minute detail.  After our monologue we stopped, we asked if she had any questions.

After a slight pause she asked, “Can’t we just flush it?”

The lesson I learned from that experience, and still use to this day, is to keep things simple, and know my audience.  Sometimes as parents we overcompensate for our own fears and make situations more challenging than they need to be.

Here are some tips on how to talk to your children about pet loss:

Tell your child about the death, and then pause. Ask her what she thinks death means before moving on with further explanations.  This will help you know if she has questions or if she has enough information for the moment.  Children often need a small amount of information initially and will later come back to you several times later to ask more questions after they process the information.Remember to express your own grief, and reassure your child that many different feelings are ok.  Be sure to allow children to express their feelings.  If your child is too young to express herself verbally, give her crayons and paper or modeling clay too help express grief.

Avoid using clichés such as: Fluffy “went to sleep.” Children may develop fears of going to bed and waking up. The phrase “God has taken” the pet could create conflicts in a child and she may become angry at a higher power for making the pet sick, die, or for “taking” the pet from them.

Be honest. Hiding a death from a child can cause increased anxiety.  Children are intuitive and can sense is something is wrong. When the death isn’t explained they make up their own explanation of the truth, and this is often much worse than the reality of what occurred.

Children are capable of understanding that life must end for all living things.  Support their grief by acknowledging their pain.  The death of a pet can be an opportunity for a child to learn that adult caretakers can be relied upon to extend comfort and reassurance through honest communication.

Developmental Understanding of Death

Two and three-year-olds
Often consider death as sleeping, therefore tell them the pet has died and will not return.

Reassure children that the pet’s failure to return is unrelated to anything the child may have said or done (magical thinking).

A child at this age will readily accept another pet in the place of a loved one that died.

Four, five, and six-year-olds

These children have some understanding of death but also a hope for continued living (a pet may continue to eat, play & breathe although deceased).

They can feel that any anger that they had towards the pet may make them responsible for the pet’s death (“I hated feeding him everyday”).

Some children may fear that death is contagious and could begin to fear their own death or worry about the safety of their parents.

Parents may see temporary changes in their child’s bladder/bowels, eating and sleeping.

Several brief discussions about the death are more productive than one or two prolonged discussions.

Seven, eight, and nine-year-olds

These children have an understanding that death is real and irreversible.

Although, to a lesser degree than a four, five or six-year-old, these children may still possibly fear their own death or the death of their parents.

May ask about death and its implications (Will we be able to get another pet?).

Expressions of grief may include: somatic concerns, learning challenges, aggression, and antisocial behavior. Expression may take place weeks or months after the loss.


Reactions are similar to an adult’s reaction.

May experience denial which can take the form of lack of emotional display so they could be experiencing the grief without outwards manifestations.

Resources:– a gentle and compassionate website for pet lovers who are grieving the death or an illness of a pet- they have a Pet Loss Candle Ceremony every week

Your local veterinarian- often your veterinarian has or knows of a local pet loss group– our group of counselors offer grief support to children, teens, and their families centered in Bucks County Pennsylvania.

Books on pet loss for children:

Badger’s Parting Gifts (children) by Susan Varley

Lifetimes by Brian Mellonie & Robert Ingpen

The Tenth Good Thing About Barney (children) by Judith Viorst

Amy Keiper-Shaw, LCSW, QCSW, GC-C

©2013 Two Peds in a Pod®

Amy Keiper-Shaw is a licensed grief counselor who holds a Masters Degree in clinical social work from the University of Pennsylvania. For over a decade she has served as a bereavement counselor to a hospice program and facilitates a bereavement camp for children. She directs Handsholdinghearts, a resource  for children who have experienced a significant death in their lives. 



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.

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 Two Peds in a Pod®
With special thanks to Dean Martin


summer pediatric hintsYesterday morning we were aghast to read medical misinformation in the print edition of our local newspaper. Aghast, because we were the pediatricians interviewed for the content of a summer time tips article.

Although a more accurate online version appeared, the print version contained several inaccuracies.

How can you tell if the medical article you are reading is accurate? 

  • Readers should always question what they read, and cross check to see if the information is consistent when compared with other credible sources. In this instance, we served as the “expert” sources of two articles for the same publication (print and online), yet the articles contain conflicting medical information. Cross reference our information with other experts in our field, such as the American Academy of Pediatrics, the Centers for Disease Control, and of course your own pediatrician.
  • Look twice if the interpretation of the information is coming from a secondary source. The information we give on Two Peds in a Pod is “straight from the horse’s mouth.” We edit and publish our own material. In our office, we talk to patients directly. Remember that “telephone” game you played at birthday parties? The message changes the more intervening people are involved in relaying information.
  • Medical information changes as new discoveries occur and more studies are conducted. There is a saying in medical school, “Even though half of what you learn in medical school will be inaccurate in ten years, learn it all, because you don’t know which half will be disproven.”  We keep up with evolving knowledge in pediatrics by reading journals, taking courses, reviewing cases with our colleagues, and retaking our medical boards on a scheduled rotation. Be sure you read information that is current as well as backed by credible sources.

Despite our dismay at the inaccuracies in the print version, you will find the online article helpful. In addition, please check our prior summertime posts about bee stings, Lyme disease, tick removal, poison ivy, splinter removal, and stay tuned for near-future articles about swimming and sunscreen.  

Whoever said, “You can’t believe everything you read on the internet,” was right… except perhaps this time.

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


how do I know if my baby has autism

April is Autism Awareness Month. Here are some signs which may be indicative of autism in your infant. Later this month, we will bring you information about what to look for in toddlers.
Drs. Kardos and Lai

Autism is a communication disorder where children have difficulty relating to other people. Pediatricians watch for  speech delay as a sign of autism. Even before your child is expected to start talking, 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. I mean, 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 2 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 health care provider.

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. 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 remember 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. 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 normal 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 do not 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.

As an informal screen for autism, children below one year of age should be monitored for signs of delayed or abnormal development of social and communication skills. Home videos of children diagnosed with autism reveal that even before their first birthdays, many autistic children demonstrate abnormal social development that went unrecognized.

Julie Kardos, MD and Naline Lai, MD
©2013 Two Peds in a Pod®
modified from the original  2/3/2010 post



breast feeding at work cartoon

Even if breastfeeding is going great for you early on, it’s still normal to feel more tired than ever before. Today, pediatrician and breast feeding expert Dr. Esther Chung gives motivating advice on nursing:

Breastfeeding has many health benefits for babies, mothers and society.  Babies who are breastfed have lower rates of ear infections and diarrheal illnesses. They are at lower risk for asthma, obesity and even leukemia.  Mothers who breastfeed are also at lower risk for breast and ovarian cancer and they have less postpartum bleeding. 

Remember in our post about the early weeks of breastfeeding where we encouraged you to stick with it because it gets easier? Dr. Chung concurs:

For some women, breastfeeding comes easily.  They experience little discomfort, their babies latch on easily, and they produce a lot of milk.  For most, breastfeeding is challenging in the first 1-2 weeks following birth, but by the time the baby is 4-5 weeks old, breastfeeding is easy.  Having patience and trusting that your body will produce enough milk are the keys to breastfeeding success.  Maternity hospitals that employ trained professionals with International Board Certified Lactation Consultant (IBCLC) credentials have higher rates of breastfeeding.  After leaving the hospital, families can find IBCLCs in their neighborhood by entering their zip code into the International Lactation Consultant Association website,

Dr Chung’s Tips to Successful Breastfeeding

  • Hold your baby skin-to-skin on your chest. This means your baby’s body is in direct contact with your skin.  You may choose to wear a gown that opens in the front and your baby should wear a hat and diaper to minimize heat loss.  Skin-to-skin contact allows your baby to maintain a normal temperature and prepares him/her to feed.  As a result, most babies will search for the breast and breastfeed.
  • Initiate breastfeeding within the first hour of life. 
  • Request that your baby stay in your room (“rooming in”) so you can breastfeed when your baby is ready.
  • Request that your baby only breastfeed – no bottles, no formula.
  • Expect to breastfeed throughout the night.  Rest while your baby is resting.
  • Take your baby to see his/her health care provider 2 to 3 days after leaving the hospital/birthing center.
  • Find out how your workplace supports breastfeeding mothers – for example, do they provide a lactation room or other facility for mothers to pump milk during breaks?
  • Discuss with your baby’s health care provider and/or your breastfeeding support group the many ways to maintain your milk supply after returning to work.
  • Learn more about breast pumps, which you can rent or buy.  Some health insurance will cover related costs.

Returning to school and work may pose challenges for some women.  In 24 states, there are laws related to breastfeeding and the workplace (see Section 4207 of the Affordable Care Act is a federal law that requires all employers to provide time and space for women to pump milk, but employers with less than 50 employees can apply for exemption if there is undue hardship (see

Esther K. Chung, MD, MPH, FAAP

Currently a Professor of Pediatrics at Jefferson Medical College and Nemours, Dr. Chung won the 2009 Physician of the Year Award from the Pennsylvania Resource Organization for Lactation Consultants (PRO-LC) and the 2008 Special Achievement Award from the Pennsylvania Chapter of the American Academy of Pediatrics (AAP), for breastfeeding advocacy work. A member of several breastfeeding advocacy groups including the International Lactation Consultants Association, she frequently lectures nationally to healthcare professionals on breastfeeding topics.


For Two Peds in a Pod’s suggestions for how to continue breastfeeding when returning to work,  see our earlier post on this subject. Drs. Kardos and Lai

©2012 Two Peds in a Pod®



The cut of mental illness can be  sharper than any surgeon’s knife. What happens when a child’s emotional turmoil escalates beyond a family’s control?  In the  newly released book Suicide by Security Blanket, and Other Stories from the Child Psychiatry Emergency Service: What Happens to Children with Acute Mental Illness, Drs. Laura Prager and Abigail Donovan bring us behind the scenes of the Massachusetts General Hospital psychiatric emergency room. Although the discussion can be somewhat technical, the real-life stories are poignant and are fascinating not only for healthcare professionals, but for anyone interested in child mental health.

In this excerpt, a dialogue occurs between Dr. E, a child psychiatrist, and Tommy, a depressed fourth grader who has just tried to strangle himself:

“I hate myself. I want to die.” Tommy’s voice lacked any inflection.


“I’m bad. The world is bad. No one likes me. No one wants me as a friend.”

“No one?”

“I’m a loser. No one wants to be friends with a loser. They all hate me.”

“Why are you a loser?”

“I’m fat. I can’t do anything right. I got in to trouble at school.”

“What happened at school?”



“I wrote bad stuff.”

“Bad stuff?”

“This one kid farts all the time and I wrote ‘fart’ on his notebook.”

“Then what happened?”

“The teacher made me apologize.”

“That’s it?”

“My parents get mad when I do stuff like that.”

“Were they mad this time?”

“I don’t know. I always get in trouble. No one in my family likes me, either. They won’t care if I’m dead.”

…Tommy’s voice got just a bit louder. “After school, I was really mad. I went down to the playroom and I tried to strangle myself. I didn’t have any rope, so I used my scarf. I also thought about going upstairs and trying to jump out a window.”

Did you hurt yourself when you tied the scarf around your neck?”

“No, I couldn’t get it that tight.”

“Did you think that you could kill yourself that way?”

“If I pulled hard enough.”

“So what happened then?”

“My mother came downstairs and found me.”

“I guess it was lucky that your mother was keeping an eye on you. Do you know why she came down?”

“I don’t know. She took the scarf and called the doctor. Here’s the scarf.” Tommy pushed the sheet away from him. He was wearing maroon hospital PJ’s that were slightly too big for him. Around his neck hung a dirty grey-colored knit scarf that looked as if it might once have been another color, perhaps light blue. It had remnants of fringe hanging from each end. The scarf hung loosely, and the ends tumbled into his lap. As he spoke, Tommy absentmindedly started stroking the tattered fringe on one end.

Dr. E tried to regroup. How could the nurses have let this kid sit in a bay with a scarf around his neck when apparently he had just tried to strangle himself with that very scarf?

“Is this the same scarf?”

“Yes. I just told you that. I had it with me.”

“Is this scarf your security blanket? Do you sleep with it?” Dr. E hoped she didn’t sound quite as incredulous as she felt.

“Well, I don’t take it to school, usually. It usually stays on my bed during the day.” He paused before adding, “I had it with me today. It was in my backpack. It used to be light blue. I’ve had it for as long as I can remember. I think my father gave it to my mother but she didn’t like it.”

“You tried to strangle yourself with the scarf you have held on to forever?”

Tommy was silent.

Dr. E fell silent, too.

Reprinted with permission. Courtesy of Praeger Publishers/ABC-Clio, 2012. Available on

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


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.

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
©2012 Two Peds in a Pod®