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bilirubin jaundice

Can you pick out the jaundiced one?

Pediatricians often cringe when they find newborns swathed in a yellow blanket. The color always seems to accentuate a baby’s jaundice and we’re not fond of jaundice.

Jaundice, an orange-yellow coloration of the eyes and skin, is caused by a blood breakdown by-product called bilirubin. We all break down blood, but it’s more difficult for the newborn’s liver to process it into a form that his or her body can get rid of.  Eventually, we get rid of bilirubin  by peeing and pooping it out. Bilirubin is what gives the yellowish color to urine  and stool.

Why do we care about jaundice? In the 1950s and ’60s, infants who had died from a neurological issue called kernicterus were found to have extremely high levels of bilirubin (jaundice) – up into the 100s of mg/dl. High levels of bilirubin can cause hearing and vision issues. Even at lower levels, jaundiced babies tend to be more sleepy and eat sluggishly.

Nowadays, for a full term baby,  we generally let the bilirubin level rise to 20 mg/dl at most before starting treatment, and often we treat even earlier. More than 60% of newborns appear jaundiced in the first few days of life,  but most never need any special treatment because the jaundice self-resolves. Conveniently, the first line of treatment is simply feeding more: the more milk that goes in, the more pee and poop that comes out, bringing the bilirubin with it. If improving intake does not lower the bilirubin enough, the next step is shining special lights  (phototherapy) on a baby’s skin.

Jaundice first starts noticeably in the eyes and face. As bilirubin levels rise, the yellow (jaundice) appears more and more down the body. Yellow in the face of a newborn is expected. If you see yellow in the belly, call your pediatrician. Levels naturally rise and peak in the first few days and we have graphs and apps to predict if the bilirubin may reach treatable levels.

Some babies are more likely to have higher bilirubin numbers and thus appear more yellow:

  • Premature babies, because they have immature livers.
  • Babies who have different blood types than their moms. Certain blood type differences can cause some breakdown of blood even before a baby is born, therefore increasin chances of an elevated bilirubin after  birth.
  • Babies who acquire bruising during delivery; they have more blood to break down.
  • Be aware, there are a few other less common risk factors,  and if needed,  your pediatrician may address them with you.

Hydrating your baby will help jaundice. You should watch the number of wet diapers your newborn has in a day. Wet diapers are a sign of good hydration. In the first week, she should have about one wet diaper for every day of life (so on day of life one= one wet diaper, day of life two=two wet diapers, etc). Also  watch for bilirubin to start coming through the stool. At first, your baby will poop out the black stool called meconium, but as milk starts going through her system, expect the stool to turn yellowish. (click here for more information about the colors of newborn poop) . As with the urine, look for one bowel movement for every day of life (so day of life one=one bowel movement diaper, day of life two= two etc). Eventually some newborns poop every time they are fed, although some max out at 3 or 4 bowel movements per day.

So, if you hold up your newborn baby in a yellow blanket to show your pediatrician and call the baby “our little pumpkin” you’ll know why she raises an eyebrow.

Click here for other fun medical color facts.

Naline Lai, MD and Julie Kardos, MD

© 2016 Two Peds in a Pod®

Revised from July 24, 2016 at 10:58pm

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taking care of baby nails

The prom preparation aftermath

It’s not your imagination: baby and toddler nails are funky and warped. Now add the fact that babies and toddlers wiggle and squirm, and taking care of your young child’s nails will appear to be a daunting task.

Even soft newborn finger nails leave significant scratches on newborn faces. Newborns need their first “manicure” within days of birth. Although the nails are long enough to scratch, most of the nail is adherent to underlying skin. A nail clipper can not get underneath the edge of the nail easily. We recommend using an emery board or nail file for the first few weeks of nail trimming. File from the bottom up, not just across the nail, in order to shorten and dull the nail.

Babies gain weight rapidly in the first three months at a rate of about one ounce per day, and they grow in length at a rate of about an inch per month. Their finger nails grow rapidly as well and therefore need trims as often as two or three times a  week. Toe nails grow quickly as well but because they do not cause self-injury, infants seem to be okay with less frequent toe nail trimming.

Once the nails are easier to grab, you can advance to using nails scissors or clippers. Dr. Kardos used to hold her babies in a nearly sitting position on her lap facing outward. Once you have a good hold, gently press the skin down away from the nails and then clip or cut carefully.

Unfortunately, no matter how careful you are, many well-intentioned parents end up cutting their child’s skin at some point. Both Dr. Kardos and Dr. Lai have nicked their kids accidentaly. Dr. Kardos recalls snipping a bit of skin from one of her twins when he was a few months old. Picture a tiny benign paper-cut that seems to cause a disproportunate amount of bleeding. He wasn’t even all that upset, but the guilt! If you accidentally cut your child, wash the cut with soap and running water to prevent infection and apply pressure for a few minutes with a clean wash cloth to stop the bleeding. Avoid band-aids: they are a choking hazard in babies who spend most of their waking moments with their fingers in their mouths. Thankfully, rapidly growing  kids heal wounds rapidly.

While Dr. Lai gave most of her kids manicures while they were sleeping, Dr. Kardos trimmed her kids’ nails while awake to get them used to the feeling of a “home manicure.” She likes to think this practice avoided some later toddler meltdowns over nail trimming. However, as she found out in one of her three kids, some kids are just adverse to nail trimming, or have sensitive, ticklish feet and balk at trims. Yet, trim we must! Clip an uncooperative toddler’s nails about 10-20 minutes after she has fallen asleep- this, or wait until you have another adult at home with you. Have your helper hold onto your child’s hand or foot while distracting the toddler with singing, book reading, or watching a soothing video together. Then you can (quickly) trim nails.

However, even in infants, the sides of big toe nails grow into the skin. Luckily the nails are very soft, and with some soaking in warm water, you can pull the skin away from the nail and cut the nail to avoid having them dig in and result in infection, or paronychia.

While it’s tempting to complete your child’s mani-pedi with a coat of nail polish, keep in mind that a young children spend a lot of time with their hands, and their toes, in their mouths.  We’ve seen kids as old as ten years bite on their toe nails. Unfortunately, the nail polish on your bureau may contain toxic hydrocarbons such as toluene and formaldehyde. Even non-toxic nail polishes will still contain dyes, and just because a manufacturer uses the term non-toxic, it doesn’t necessarily mean a product is absolutely harmless. There are no specific standards for the use of the term non-toxic.  Bottom line, the only route that avoids any chemicals is not to apply any polish in the first place. (If you are wondering about any cosmetic, the California department of public health keeps a database of cosmetics with ” ingredients known or suspected to cause cancer, birth defects, or other reproductive harm.” )

Who ever thought parental obligations would include cutting someone else’s finger and toe nails? If you haven’t perfected the process yet, take heart.  You’ll have plenty of practice over the years, and if you are lucky, you’ll get a chance like Dr. Lai did last weekend to help prep nails for the prom.

Julie Kardos, MD and Naline Lai, MD

© 2010, rev 2016 Two Peds in a Pod®

 

 

 

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flatheadSqueezed through the birth canal, many babies are born with pointy, cone-shaped heads. Others, delivered by caesarian section, start off life with round heads. Few babies begin 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 prevent and treat the flatness. In fact, the flat shape begins to correct itself as 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, check out our post on making tummy time more tolerable for your baby.

Encourage your baby to look to both sides while lying down. Too much time turned to one side will cause flattening on that side. Alternate how you place the baby in crib so that sometimes she turns to the right and other times she turns to the left to face into the room and away from the wall. If your baby seems to prefer looking only to the right or only to the left, place toys or bright objects toward the non-preferred side. If bottle feeding, switch off which arm you use to feed your baby, so that the baby sometimes turns to the right and sometimes to the left . If breastfeeding, start and end on the side that the baby tends to avoid. These actions will help prevent neck muscles from becoming too tight on one side and thus allow your baby to turn easily to both sides.

Some babies wear helmets to correct their abnormal head flattening. Neurosurgeons, who are head and brain specialists, and plastic surgeons prescribe these helmets for babies who have extreme flattening. Fortunately, the majority of babies with positional plagiocephaly do not need to wear helmets. 

 You also may have heard of babies who need corrective surgery for an abnormal head shape. This condition, called craniosynostosis, is rare. Pediatricians monitor the size and shape of the head , check the soft spot on the top of the head and for ridges on the skull at every check-up. A baby’s skull develops in pieces as a fetus, and these pieces eventually come together at predictable places called sutures.  If the pieces come together too early or the soft spot closes too soon, corrective surgery may be needed.

 

So, avoid head flatness by rotating your baby’s position frequently (think rotisserie chicken!) and provide plenty of “tummy time” when awake. Start when the baby first comes home. 

 If you are worried about your baby’s head shape, just head on over to your baby’s pediatrician and bring up your concern. It is unlikely that your concern will “fall flat.”

 

Julie Kardos, MD and Naline Lai, MD

©2012, rev. 2016 Two Peds in a Pod®

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photo credit: Laikipia Pixabay.com

photo credit: Laikipia Pixabay.com

The Zika virus in the news these days reminds us of another microcephaly-causing virus which scourged our world in the not-so-distant past. In the years right before the Two Peds doctors were born (late 1960s), the virus Rubella routinely swept through the United States and the rest of the world. The airborne germ Rubella, just like the mosquito-spread Zika virus, caused most people just a mild illness that they usually never even knew that they had. After they were sick, they became immune to the virus. But when pregnant women contracted Rubella early in pregnancy, their unborn children sometimes ended up with microcephaly.

Microcephaly is a condition where a small, underdeveloped, or abnormal brain leads to a small head at birth. Many children with microcephaly have significant mental disabilities.

So what happened to Rubella? It’s the R in the MMR vaccine. We give this vaccine to all children, first at 12-15 months, and again at 4-6 years of age. We vaccinate girls to protect their unborn fetuses when they are pregnant, and we also vaccinate boys. Although boys will not become pregnant, they can contract the disease and spread it to others who are pregnant. It is standard practice for obstetricians to test all of their pregnant patients for immunity to Rubella. If a woman is not immune, she is given the MMR vaccine after delivery to prevent coming down with Rubella during future pregnancies.

Because of the success of this safe vaccine, it is extremely rare to have child born with Congenital Rubella Syndrome and its accompanying problems. The syndrome  not only included the mental impairments associated with microcephaly but also was associated with blood disorders, heart defects, deafness, visual impairment, developmental delay, and seizures. In the United States where the vaccine rates are high enough, no cases have been reported since 2004. In the rest of the world, cases still occur in countries with limited access to vaccines against Rubella.  Approximately 100,000 cases of Rubella worldwide per year still occur according to the Centers for Disease Control.

Scientists are working on a vaccine against the Zika virus because, as is often the case, preventing a disease is often easier, less costly, and more successful than attempting to cure it. For a basic explanation of how vaccines work, please see our prior post on this topic. Trials for a vaccine for Zika may begin as early as summer 2017.

But if we look at history, Rubella was once a dreaded virus too. Now, with the widespread use of a vaccine, although still dreaded, the rates of Rubella have dropped dramatically.  Zika hopefully will not be far behind.

Naline Lai,  MD and Julie Kardos, MD

©2016 Two Peds in a Pod®,  updated April 2017

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Dr. Kardo's fourth child nicely wears her coat in the snow.

Dr. Kardos’s fourth child wears her coat in the snow without fuss.

 

There is snow on the ground, so every morning I ask my elementary school-aged son if he wears gloves and a hat at recess. Every morning I get back the same blank stare and the question, “Why?”

It’s an age-old battle between parents and kids. Parents insist the kids are underdressed and the kids insist they are overdressed. In fact, I remember in fourth grade many an embarrassing moment when my mother would suddenly appear with mittens at the bus stop.  So how can parents decide how warmly to dress their children?

Infants are particularly poor at regulating their own temperatures. In general for cool weather, dress a baby in one more layer of clothing than you are comfortable wearing. Another good way to keep a newborn from losing too much heat is to keep the hat on for a couple of weeks. It’s not an old wives tale; people do lose a fair amount of heat through their heads.

However, beware of over-swaddling.  Over-heating has been suggested as a factor in death from SIDS (Sudden Infant Death Syndrome). For more risk factors of SIDS please visit our post about SIDS. If your partner insists on keeping the house the temperature of a sauna and you are sweltering all year, then dress your baby in a simple onesie. Just as infants have difficulty regulating body temperature in the cold, they also have difficulty regulating their temperature in heat. In general, if you feel cold, your baby will feel colder. If you are warm, your baby will feel warmer than you do.

Sleep always seems to bring out red cheeks and sweaty heads in toddlers. Are they too hot or cold? As you peek in on them after tucking them to bed, feel their hands and cheeks. Warm (but not flushed) cheeks mean they will be comfortable even if their hands are a bit cool.

For older kids, simply dress them the same way you dress yourself. Make sure areas prone to frostbite such as toes, ears and fingers stay warm. Quick tidbit: do not re-warm nearly frostbitten  areas  by massaging. The rubbing action causes more injury. Instead, place the area in warm water. For more information on signs of frostbite and when to seek help, visit our post Baby It’s Cold Outside .

Sorry, for the older kids, you can’t use the rational, “Dress warmly or you will catch a cold.” Cold temperatures do not cause colds. Germs cause colds. However,  there is one study on mice that suggests cooler noses allow the rhinovirus (a common cold germ) to grown more easily. Also, there is a phenomenon called nonallergic rhinitis which manifests itself as a drippy nose which can be set off by cold air. Likewise, inhaling cold air can set off coughing  in kids with asthma. For more about the health benefits and hazards of cold weather for both kids and adults, please this article from Harvard Health Publications.

Why it’s not “cool ” to stay warm, I’ll never understand. But the tide may be turning. Although the older boys insist on wearing shorts even in near freezing temperatures, fuzzy lined UGGs, formerly a female accessory, seem to be coming into fashion for the boys.

Luckily, the groundhog says it’ll be an early spring.

Naline Lai, MD with Julie Kardos, MD
©2016, updated from 2010 Two Peds in a Pod®

(For a laugh: we love this tongue-in-cheek post about how kids dress for cold weather).

 

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crybabyonesieWhy do babies cry? In short, newborns cry to communicate. Remember, newborns cannot talk. They can’t even smile back at you until around six weeks of age.
Ah, but what are they trying to tell us? Babies cry when they…

  • Are tired.
  • Are hungry.
  • Feel too cold.
  • Feel too hot.
  • Need to be changed –I never really believed this reason before I had my twins. My firstborn couldn’t have cared less if he was wet and could nap right through a really poopy diaper. Then I had my twins.  I was amazed that their crying stopped if I changed the tiniest bit of poop or a wet diaper. Go figure.
  • Are bored. Perhaps she is tired of the Mozart you play and prefers some good hard rock music instead. Maybe she wants a car ride or a change of scenery. Try moving her to another room in the house.
  • Feel pain. Search for a piece of hair wrapped around a finger or toe and make sure she isn’t out-growing the elastic wrist or ankle band on her clothing.
  • Need to be swaddled. Remember a fetus spends the last trimester squished inside of her mom. Discovering her own randomly flailing arms and legs can be disconcerting to a newborn.
  • Need to be UN-swaddled. Hey, some like the freedom to flail.
  • Need to be rocked/moved. Dr. Lai’s firstborn spent hours tightly wrapped and held by her dad in a nearly upside down position nicknamed “upside-down-hotdog” while he paced all around the living room.
  • Need to burp. Lay her down for a minute and bring her up again to see if you can elicit a burp.
  • Are gassy. Bicycle his legs while he is on his back. Position him over your shoulder so that his belly presses against you. You’d be gassy too if you couldn’t move very well. The gassy baby is a topic for this entire post– talk to your doctor for other ideas.
  • Are sick. Watch for fever, inability to feed normally, labored breathing, diarrhea or vomiting. Check and see if anything is swollen or not moving. Listen to his cry. Is it thin, whimper-like (sick) or is it loud and strong (not so sick)? Do not hesitate to check with your pediatrician. Fever in a baby younger than eight weeks old is considered 100.4 degrees F or higher measured rectally. A feverish newborn needs immediate medical attention.

What if you’re certain that the temperature in the room is moderate, you recently changed his diaper, and he ate less than an hour ago?

    • Walk outside with your baby– this can be a magic “crying be gone” trick. Fresh air seems to improve a newborn’s mood.
    • Offer a pacifier. Try many different shapes of pacifiers. Marinade a pacifier in breast milk or formula to increase the chance your baby will accept it.
      Pick him up, dance with him, or walk around the house with him. You can’t spoil a newborn.
    • Vacuum your house. Weird, but it can work like a charm. Place him in a baby frontal backpack or in a sling while cleaning.
    • Try another feeding, maybe he’s having a growth spurt.
    • When all else fails, try putting him down in his crib in a darkened room. Crying can result from overstimulation. Wait a minute or two. He may self-settle and go to sleep. If not, go get him. The act of rescuing him may stop the wailing.
    • If mommy or daddy is crying at this point, call your own mom or dad or call a close friend. Your baby knows your voice and maybe hearing you speak calmly to another adult will lull him into contentment.
    • Call your child’s health care provider and review signs of illness.

If you feel anger and resentment toward your crying baby, just put him down, walk outside and count to ten. It is impossible to think rationally when you are angry and you may hurt your child in order to stop your frustration. Seek counseling if these feelings continue.

Now for the light at the end of the newborn parenting tunnel: the peak age when babies cry is six weeks old. At that point, infants can cry for up to THREE HOURS per day. Babies with colic cry MORE than three hours per day. (Can you believe people actually studied this? I am amused that Dr. Lai won a prize in medical school for a paper on the history of colic). By three months of age crying time drops dramatically.

While most crying babies are healthy babies and just need to find the perfect upside-down-hot-dog position, an inability to soothe your baby can be a sign that she is sick. Never hesitate to call your baby’s doctor if your baby is inconsolable, and don’t listen to the people who say, “Why do babies cry?…They just do.”

Julie Kardos, MD and Naline Lai, MD
©2015, 2010 Two Peds in a Pod®

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photo by Lexi Logan

photo by Lexi Logan

The guidelines for school are straight forward. If your child is sick, the school nurse will tell you exactly what criteria your child needs to meet before she returns to school. The list generally looks like this: no fever of 101 degrees or higher for over 24 hours, no constant running to the bathroom, no vomiting for 24 hours, etc. However, Grandpa’s house is not school. A friend’s home is not school. The guidelines to attending holiday gatherings are not as straightforward.

First and foremost: If you are invited to a social gathering and you have an ill child, tell your family and friends who will be there that you have an ill child. You never know if there will be people present who are particularly vulnerable to illness. Some of you have an Uncle Harry who has been too embarrassed to tell you that he is undergoing chemotherapy for prostate cancer or a sister Sarah just found out she is pregnant. Young babies and the elderly are more likely to develop complications if they are ill. On the other hand, if family members or friends all have intact immune systems and have no special risk factors for illness complications, they may be more forgiving and will want to see their ill nephew/cousin/friend who they just flew 400 miles to see. The key is communication.

Babies under two months old, because of their age and unimmunized status, are vulnerable to life threatening infections. Remember that a nagging cough in a toddler can be a life threatening cough for an infant. So you might reconsider bringing your coughing toddler to a gathering where there will be very young infants.

Don’t get lulled into believing that germs are killed by Tylenol (acetaminophen) or Motrin (ibuprofen). Even if you have hidden your child’s fever with a fever reducing medicine, she is contagious as long as something is spewing from any orifice (nose, eyes, mouth, or bottom).

So if you are going to a family gathering, and your child is mildly ill, here’s how to minimize spread of germs:

  1. Handwashing – wash your ill child’s hands often to prevent spread of their germs. Also you should wash your healthy children’s hands to prevent illness.
  2. Handwashing (again!) -wash hands before eating and after bathroom use
  3. Handwashing (again!!)- wash your own hands after you have helped your child do the above suggestions.
  4. When all the children are piled in a heap watching The Grinch, take time to separate your ill child from the batch. Daycares put two feet between sleeping cots in order to minimize spread of germs. Protect airspaces.
  5. Elderly people will be happy to observe your runny-nosed children frolicking about from the distance. No need to force your five year old with the runny nose to kiss great- grandma’s face.
  6. Teach kids to cough into crook of elbow, to use tissues…and then wash hands.

If you realize that you will be dragging a medicine cabinet with you to a party, reconsider going. One mom says she cringes whenever she sees her sister show up to parties carting along a medication nebulization machine for her child. Consider what is best for your child. No matter how much your child, and you, have anticipated the holiday gathering, home is always the most comfortable place for a child to recover from illness.

Thinking hard about whether or not you should attend a holiday gathering? Then you are thinking too hard. Just stay home. Besides, you haven’t been a real parent until you’ve missed at least one party because of a child’s illness.

Julie Kardos, MD and Naline Lai, MD

©2015 Two Peds in a Pod®, revised from our 2009 post

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thanksgiving 2016

A foster mom brought a new child into the office the other day and I smiled picturing her with her last foster child. This thanksgiving, Two Peds in a Pod is grateful for the foster parents who open their homes for dinner today and everyday. Dr. Heather Forkey, Clinical Director of Foster Children Evaluation Service at UMass Children’s Medical Center, provides a post on becoming a foster parent. –Dr. Lai with Dr. Kardos

There are approximately 400,000 children in the US foster care system, with 225,000 entering each year. Most of these children spend time with foster families who open their homes and lives to kids that need a safe nurturing environment while their own parents take the time to address issues which put the child at risk. All types of people make great foster parents, but it is not for everyone. Foster parents must be able to meet the physical, emotional and developmental needs of a child or teen in partnership with community agencies, social workers, schools, and counselors.

If you are considering foster parenting, consider whether you can:

  • Provide 24-hour care and supervision on a daily basis
  • Be able to care for yourself financially without the child’s stipend
  • Be flexible, patient and understanding
  • Have a sense of humor
  • Recognize the impact of trauma
  • Have a home free of fire and safety hazards
  • Complete a criminal/protective services background check
  • Have the ability to work as a member of a team

If interested, you need to become licensed or approved by your state or county, and that process is different in each locality. One should start by doing an internet search for “becoming a foster parent in (your state or county)”. The child welfare agency for your state (Department of Children and Family Services or Department of Social Services) will also have information about how to start the process.

Children come to foster care often after adverse experiences which we know have health, emotional and developmental consequences. Foster parents who can look at the child’s health and behavior from a perspective of “what happened to the child” rather than “what is wrong with the child”, and observe a child’s behavior through the trauma lens (and help foster and child welfare personnel to do the same) allow the child in their care to view their health and emotions as normal adaptations to unhealthy situations, rather than evidence of illness. This allows the child to go forward with a better understanding of their experience, their own responses and, ultimately, foster health.

Heather C. Forkey, M.D.

Dr. Heather Forkey serves as the Clinical Director, Foster Children Evaluation Service (FaCES) and the Chief of the Child Protection Program at Mass Children’s Medical Center

2015 Two Peds in a Pod®

 

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gift ideas by developmentFor those of you who plan ahead: It’s gift-giving season! We love pop culture, but if you are tired of GameStop gift cards or feeling a bit overwhelmed by  Frozen, Star Wars and Minecraft marketing, here’s another list of ideas arranged by ages and developmental stages.

0-3 months: Babies this age have perfect hearing and enjoy looking at faces and objects with contrasting colors. Music, mobiles, and bright posters are some age appropriate gift ideas. Infants self-soothe themselves through sucking- if you can figure out what your nephew’s favorite type of binkie is, wrap up a bunch-they are expensive and often mysteriously disappear.

3-6 months: Babies start to reach and grab at objects. They enjoy things big enough to hold onto and safe enough to put in their mouths- try bright colored teething rings and large plastic “keys.” New cloth and vinyl books will likewise be appreciated; gnawed books don’t make great hand-me-downs.

6-12 months: Around six months, babies begin to sit alone or sit propped. Intellectually, they begin to understand “cause and effect.” Good choices of gifts include toys with large buttons that make things happen with light pressure. Toys which make sounds, play music, or cause Elmo to pop up will be a hit. For a nine-month-old old just starting to pull herself up to a standing position, a water or sand table will provide hours of entertainment in the upcoming year. Right now you can bring winter inside if you fill the water table with a mound of snow. Buy some inexpensive measuring cups and later in the summer your toddler will enjoy standing outside splashing in the water.

12-18 months: This is the age kids learn to stand and walk. They enjoy things they can push while walking such as shopping carts or plastic lawn mowers. Include gifts which promote joint attention. Joint attention is the kind of attention a child shares with you during moments of mutual discovery. Joint attention starts at two months of age when you smile at your baby and your baby smiles back. Later, around 18 months, if you point at a dog in a book, she will look at the dog then look back at you and smile. Your child not only shows interest in the same object, but she acknowledges that you are both interested. Joint attention is thought to be important for social and emotional growth.

At 12 months your baby no longer needs to suck from a bottle or the breast for hydration. Although we don’t believe mastery of a  sippy cups is a necessary developmental milestone, Dr. Lai does admire the WOW cup because  your child can drink from it like she does from a regular cup. Alternatively, you can give fun, colored actual traditional plastic cups, which difficult to break and encourage drinking from a real cup.

18-24 months: Although kids this age cannot pedal yet, they enjoy riding on toys such as “big wheels” “Fred Flintstone” style. Dexterous enough to drink out of a cup and use a spoon and fork, toddlers can always use another place setting. Toddlers are also able to manipulate shape sorters and toys where they put a plastic ball into the top and the ball goes down a short maze/slide. They also love containers to collect things, dump out, then collect again.

Yes, older toddlers are also dexterous enough to swipe an ipad, but be aware, electronics can be a double edged sword— the same device which plays karaoke music for your daddy-toddler sing-along can be transformed into a substitute parent. The other day, a toddler was frighted of my stethoscope in the office. Instead of smiling and demonstrating to her toddler how a stethoscope does not hurt, the mother repeatedly tried to give her toddler her phone and told the child to watch a video. Fast forward a few years, and the mother will wonder why her kid fixates on her phone and does not look up at the family at the dinner table. Don’t train an addiction.

2-3 years: To encourage motor skills, offer tricycles, balls, bubbles, and boxes to crawl into and out of. Choose crayons over markers because crayons require a child to exert pressure and therefore develop hand strength. Dolls, cars, and sand boxes all foster imagination. Don’t forget those indestructible board books so kids can “read” to themselves. By now, the plastic squirting fish bath toys you bought your nephew when he was one are probably squirting out black specks of mold instead of water- get him a new set. Looking ahead, in the spring a three- year-old may start participating in team sports (although they often go the wrong way down the field) or in other classes such as dance or swimming lessons. Give your relatives the gift of a shin guards and soccer ball with a shirt. Offer to pay for swim lessons and package a gift certificate with a pair of goggles.  

3-4 years: Now kids engage in elaborate imaginary play. They enjoy “dress up” clothes to create characters- super heroes, dancers, wizards, princesses, kings, queens, animals. Kids also enjoy props for their pretend play, such as plastic kitchen gadgets, magic wands, and building blocks. They become adept at pedaling tricycles or even riding small training-wheeled bikes. Other gift ideas include crayons, paint, markers, Play-doh®, or side-walk chalk. Children this age understand rules and turn-taking and can be taught simple card games such as “go fish,” “war,” and “matching.” Three-year-olds recognize colors but can’t read- so they can finally play the classic board game Candyland, and they can rote count in order to play the sequential numbers game Chutes and Ladders.  Preschool kids now understand and execute the process of washing their hands independently… one problem… they can’t reach the faucets on the sink. A personalized, sturdy step stool will be appreciated for years. 

5-year-olds: Since 5-year-olds can hop on one foot, games like Twister® will be fun. Kids this age start to understand time. In our world of digital clocks, get your nephew an analog clock with numbers and a minute hand… they are hard to come by. Five-year-olds also begin to understand charts— a calendar will also cause delight. They can also work jigsaw puzzles with somewhat large pieces.

8-year-olds: Kids at this point should be able to perform self help skills such as teeth brushing. Help them out with stocking stuffers such as toothbrushes with timers. They also start to understand the value of money (here is one way to teach kids about money). The kids will appreciate gifts such as a real wallet or piggy bank. Eight-year-olds engage in rough and tumble play and can play outdoor games with rules. Think balls, balls, balls- soccer balls, kickballs, baseballs, tennis balls, footballs. Basic sports equipment of any sort will be a hit. Label makers will also appeal to this age group since they start to have a greater sense of ownership.

10-year-olds: Fine motor skills are quite developed and intricate arts and crafts such as weaving kits can be manipulated. Give a “cake making set” (no, not the plastic oven with a light bulb) with tubes of frosting and cake mix to bake over the winter break. Kids at this age love doodling on the long rolls of paper on our exam table. Get your kid a few rolls of banner paper to duplicate the fun. Buy two plastic recorders, one for you and one for your child, to play duets. The instrument is simple enough for ten-year-olds or forty-year-olds to learn on their own. Ten-year-olds value organization in their world and want to be more independent. Therefore, a watch makes a good gift at this age. And don’t forget about books: reading skills are more advanced at this age. They can read chapter books or books about subjects of interest to them. In particular, kids at this age love a good joke or riddle book.

Tweens: Your child now has a longer attention span (30-40 minutes) so building projects such as K’nex models will be of interest to her. She can now also understand directions for performing magic tricks or making animal balloons. This is a time when group identity becomes more important. Sleepovers and scouting trips are common at this age so sleeping bags and camping tents make great gifts. Tweens value their privacy – consider a present of a journal with a lock or a doorbell for her room.

Teens: If you look at factors which build a teen into a resilient adult, you will see that adult involvement in a child’s life is important. http://www.search-institute.org/research/developmental-assets

We know parents who jokingly say they renamed their teens “Door 1” and “Door 2,” since they spend more time talking to their kids’ bedroom doors than their kids. Create opportunities for one-on-one interaction by giving gifts such as a day of shopping with her aunt, tickets to a show with her uncle, or two hours at the rock climbing gym with dad.

Encourage physical activity. Sports equipment is always pricey for a teen to purchase- give the fancy sports bag he’s been eying or give a gym membership. Cool techy trackers like Fitbit will always appreciated or treat your teen to moisture wicking work-out clothes.

Sleep! Who doesn’t need it, and teens often short change themselves on sleep and fall into poor sleep habits.  Help a teen enjoy a comfortable night of rest and buy  luxurious high thread count pillow cases, foam memory pillows, or even a new mattress. After all,  it been nearly 20 years since you bought your teen a  mattress and he probably wasn’t old enough at the time to tell you if he was comfortable. Since a teen often goes to bed later than you do, a remote light control will be appreciated by all.

Adolescence is the age of abstract thinking and self awareness— Google “wall decals” and find a plethora of inexpensive ways to jazz up his or her room with inspiring quotes.

Enjoy your holiday shopping.

Naline Lai, MD and Julie Kardos, MD
©2012, 2014, 2015 Two Peds in a Pod®

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vaccine

Recent comments by politicians have brought vaccines back into the public eye. In this post, we get down to basics.

Did you ever wonder how a vaccine works?

To understand how vaccines work, I will give you a brief lesson on the immune system. Trust me, it is interesting. Let me give you an example of me. When I was eight, I had chicken pox. It was a miserable week. I started out with fever and headache, then suffered days of intense body itching from blister-like spots, and ultimately, because I scratched off some scabs, ended up with scars. During this time, my immune system cells worked to battle off the chicken pox virus. Immune cells called memory cells also formed. These cells have the unique job of remembering (hence the name “memory cells”) what the chicken pox virus looks like. Then, if ever in my life I was to contact chicken pox again, my memory cells could multiply and fight off the virus WITHOUT MY HAVING TO GET SICK AGAIN WITH CHICKEN POX. So after I recovered, I was able to play with my neighbor even while he suffered with chicken pox.  I returned to school where other children in my class had chicken pox, but I did not catch chicken pox again. Even now, as a pediatrician, I don’t fear for my own safety when I diagnose a child with chicken pox, because I know I am immune to the disease.

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

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

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

I used the example of chicken pox because the vaccine was invented during my own lifetime. However, I could have used the example of polio, which, prior to its vaccine development in 1955, paralyzed 10,000 children per year in the United States, or measles, which infected 4 million children per year and killed 3000 per year in the United States before doctors began to give children a vaccine against measles in 1963.

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

Friedrich Nietzsche said “What doesn’t kill us makes us stronger.” We pediatricians feel this is unacceptable risk for children. We would rather see your child vaccinated against a disease in order to become immune rather than risking the actual disease in order to become immune. The vaccines that we give children protect against diseases that can cause serious, lifelong disability or death.

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

Julie Kardos, MD and Naline Lai, MD

© 2009, 2015 Two Peds In a Pod®, updated 9/2015

For more information about vaccines, please see our prior posts: Should I vaccinate my child?, Closure: there is no link between the MMR vaccine and autism, Fact or Fiction: a flu vaccine quiz for all teachers, babysitters, parents, and anyone else who breathes on children, Do vaccines cause autism?, Measles outbreak: would you recognize measles in your child?, A vaccine parable , and Are my teen’s vaccines up to date?

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