Category: 4. Preschoolers
A common question that many parents ask us in the office is “Howcan I help my overweight child?”
Our newest podcast provides six simple rules for healthyeating. Listen in to find out the “5-4-3-2-1-0” rules of what to feed yourchildren, how to portion their foods, and how to change their behavior to helpthem lose excess pounds and maintain a healthy weight.
(If the podcast is not embedded in your RSS reader page,visit the www.TwoPedsInAPod.com home page directly.)
Julie Kardos, MD and Naline Lai, MD
©2010 Two Peds in a Pod
Three little kittens, they lost their mittens, and they began to cry.
Oh, mother dear, we sadly fear That we have lost our mittens.
What! Lost your mittens, you naughty kittens!
Then you shall have no Nintendo DS
-the modern version of a traditional poem
It’s only January and pictured here is a photo of my three kittens’ mittens (gloves) which are already missing mates.
Prolonged exposure to cold can lead to injury in body parts with relatively less blood flow such as the ears, fingers and toes. In frostbite, injury occurs secondary to ice crystals which form within or between the cells in your body. Injury can be so severe that the tissue dies and infection sets in.
Early signs of frostbite include tingling or achiness. Without treatment, the area will become pale and lose all sensation.
If you suspect your child’s hands are starting to become frostbitten, first remove all wet clothing. Rewarm the area by placing immediately in warm water. Think opposite of a burn- where you use cold water. Do not massage the hand as this may cause further injury, but do encourage your child to move his hands. As very cold hands warm up, they will become blotchy and painful or itchy. Ibuprofen (brand names Motrin and Advil)or acetaminophen (Tylenol) will be helpful. Warm for at least half an hour even if it is painful.
Signs of actual frostbite are blistering, numbness, or color changes. As my sister, an emergency room doctor says, red is good. Black and white are not.
Head over to the emergency room if you think your child has frostbite. To avoid the risk of over-heating and to manage the pain of treating frost bite, thawing for frost bite should be medically supervised. Just as you would seek care for a burn, seek medical care for a cold induced injury. To rewarm properly, the frostbitten part of the body should be submerged in warm 37-to-40 C (98 -to-104 F) water. No higher because then it’s like trying to defrost a chicken. You will end up cooking rather than thawing the tissue, says my sister. Also a big no-no: starting to thaw but then not completing the thaw. Thaw-refreeze-thaw will injure tissue, same as it ruins a defrosting chicken. So again, seek medical attention for your child if you suspect frost bite has set in.
For a recent interesting, but somewhat technical article with photographs on a case of frostbite, check out the New England Journal of Medicine, N Engl J Med 2009;361:2654-62
Naline Lai, MD
Two Peds in a Pod © 2010.
Here is how to tell if your child is VERY ill with fever vs not very ill:
Any temperature in an infant younger than 8 week old that is 100.4 (rectal temp) degrees or higher is a fever that needs immediate attention by a health care provider, even if the infant appears relatively well.
Any fever that is accompanied by moderate or severe pain, change in mental state (thinking), dehydration (not drinking enough, not urinating because of not drinking enough), increased work of breathing/shortness of breath, or new rash is a fever that NEEDS TO BE EVALUATED by your child’s health care provider. In addition, a fever that lasts more than three to five days in a row, even if your child appears well, should prompt you to call your child’s health care provider, who most likely will want to examine your child. Recurring fevers should also be evaluated.
Should you treat fever? Given the information from above and from Part 1 of this fever blog post, you can see that fever is an important part of fighting germs. Therefore, we do NOT advocate treating fever UNLESS the side effects of the fever are causing harm. Reduce fever if it prevents your child from drinking or sleeping, or if body aches or headaches from fever are causing discomfort. If your child is drinking well, resting comfortably or playing, or sleeping soundly, then he is handling his fever just fine and does not need a fever reducing agent just for the sake of lowering the fever.
A note about febrile seizures (seizures with fever): Some unlucky children are prone to seizures with sudden temperature fluctuations. These are called febrile seizures. This tendency often runs in families and usually occurs between the ages of 6 months to 6 years. Febrile seizures last fewer than two minutes. They usually occur with the first temperature spike of an illness (before parents even realize a fever is present) and while scary to witness, do not cause brain damage. No study has shown that giving preventative fever reducer medicine decreases the risk of having a febrile seizure. As with any first time seizure, your child should be examined by a health care provider, even if you think your child had a simple febrile seizure.
Please see our “How sick is sick?” blog post for further information about how to tell when to call your child’s health care provider.
Julie Kardos, MD and Naline Lai, MD
©2010 Two Peds in a Pod
So now that your children have been back in school, there has been plenty of opportunity for germs to circulate. In addition to washing hands, your child’s body has many ways to fight germs. I receive many worried questions about fever, so here is what every parent needs to know:
Fever is a sign of illness. Your body makes a fever in effort to heat up and kill germs without harming your body.
Here is what fever is NOT:
· Fever is NOT an illness.
· Fever does NOT cause brain damage.
· Fever does NOT cause your blood to boil.
· Unlike in the movies and popular media, fever is NOT a cause for hysteria or ice baths.
· Fever over 100 degrees F is NOT a sign of teething.
Here is what fever IS:
· Fever is a body temperature that is equal to or higher than 100.4 degrees F rectally in a newborn until the age of 8 weeks old.
· Fever is a body temperature of 101 degrees F or higher in anyone older than 8 weeks old.
· Fever is a very effective defense against disease.
To understand fever, you need to understand how the immune system works.
Your body encounters a virus or bacteria (germ) that it perceives to be harmful. Your brain sends messages to your body to HEAT UP and kill the germs. Your body will never let the fever get high enough to harm itself or to cause brain damage. Only if your child is experiencing Heat Stroke (locked in a hot car in July, for example) can your child get hot enough to cause death. This is because the heat source is EXTERNAL (a hot car) and not generated by your child’s body.
When your body has succeeded in fighting the germ, the fever goes away. If you “treat” the fever with a fever reducing agent (Tylenol, Motrin, etc) the fever goes away temporarily but WILL COME BACK if your body still needs to kill off more germs.
Symptoms of fever include: feeling very cold, feeling very hot, muscle aches, headache, and/or shaking/shivering.
Fever may be a sign of any illness. Your child may develop fever with cold viruses, the flu, stomach viruses, pneumonia, sinusitis, meningitis, appendicitis, measles, and countless other illnesses. The trick is knowing how to tell if your child is VERY ill or just having a simple illness with fever.
Our Fever: Part 2 post reveals how to tell.
Julie Kardos, MD and Naline Lai, MD
©2010 Two Peds in a Pod
Ode to the Binkie
Bed time when toddlers start to shout,
It is you, dear binkie, who knocks them out.
Those thumb suckers look so snide,
But haven’t been without you on a long car ride.
None in the diaper bag, none in the crib?
Take one from our infant sib.
If you touch the ground, I’ll give you a quick blow,
Back into the mouth you’ll just go.
But now my child can run and jump with both feet off the ground,
Two to three word sentences she can sound.
If old enough to politely ask for you,
Then old enough to make permanent teeth go askew.
Oh dear binkie, you once had your place,
Now let’s take the cork from the face.
Once you were our beloved binkie,
But right now… you are just stinky.
Whether you love or hate the pacifier, at some point, to avoid the possibility of dental and speech articulation impairment, your child needs to wean. Besides, it’s nice to see your child’s entire face. The easiest time to wean is usually around two to three years old. At that point, your child’s dependence on sucking for self-comfort begins to lessen and he begins to want to dissociate himself from being a “baby.”
Now that it’s the New Year, here are some ways to say bye-bye to the binkie, if this is on your child’s (or your) resolution list.
- Throw the pacifier across the room and entice your child to say with you, “Yucky, binkies are for babies.”
- Restrict pacifiers to specific places such as your home, crib, or bed
- Take a “Binkie finding hunt” with your child and gather all the binkies into a basket. Have the binkie fairy come overnight, take the basket, and leave a present in the morning. Alternatively, one set of parents told me that they told their child that they were gathering binkies for babies who didn’t have any.
- If giving your child a pacifier is part of your bedtime routine, start to introduce something else such as a special blanket or stuffed animal.
- Sometimes as parents, we are the ones who have to be weaned. When your child is upset, do not automatically pop a binkie into your child’s mouth. Seek other ways to help your child calm himself
- Vow to yourself not to buy new pacifiers at the grocery store. Gradually the pacifiers left in the house will disappear or the mold on them will prompt you to throw them away.
- Cut a small hole in the tip of the nipple- the binkie will not “be the same.” Tell your child that the binkie is broken and throw it away.
- Vacations disrupt schedules. Therefor, sometimes in an unfamiliar bed, children wean habits. Conveniently forget the binkie while going on vacation and do not introduce it on return home.
- By age three, most kids appreciate the value of a good bribe. Offer them a reward for going a whole week (or at least 3 days) without the binkie. One night doesn’t count because often the second night is more difficult for the child than the first when he is giving up the binkie. Once you have gone a week, the child will have no desire to go back. Just make sure you have disposed of every last binkie in your home so they will not have reminders of the “good old days.”
Naline Lai, MD with Julie Kardos, MD
Poem by Dr. Lai
©2010 Two Peds in a Pod®
Special note: all of Dr. Lai’s and Dr. Kardos’s children are former binkie users. You could call us “binkie specialists.” Leave a comment about how your child weaned.
Acetaminophen, brand name Tylenol, has been in the news recently, and parents are asking me if it is safe.
This medication, used as a pain reliever and as a fever reducer, is safe to give to babies older than two months, but you must be very careful about the dose that you give. Medicine doses are based on the weight, not the age, of a child. So when checking the label on the bottle that tells how much acetaminophen to give, look at the weight recommendations if there is a discrepancy between your child’s weight and age. If you are not sure, then ask your child’s health care provider. I cannot stress proper dosing enough because of how dangerous an overdose can be.
Here are some facts you need to know in order to avoid over-dosing your child with Tylenol:
1) Always measure the medicine in the dropper or cup provided by the manufacturer of that particular medicine bottle.
2) Be aware that Tylenol infant drops are more concentrated than the children’s suspension liquid. This means that if you were to pour out equal amounts of infant drops and children’s suspension, the amount of drug is actually HIGHER in the measurement of infant drops than in the same measurement of children’s suspension. For example, one full infant dropper of Infant Tylenol Drops, measured to the 0.8ml line of the dropper, is 80mg of Tylenol. The same 0.8ml of Children’s Tylenol Suspension Liquid is only 25mg.
Another way to look at this medicine math: if you intended to give 80mg = 2.5ml = 1/2 teaspoon of Children’s Tylenol Suspension Liquid but you actually gave your child 2.5ml = ½ teaspoon of Infant Tylenol instead of Children’s Tylenol, you would be giving them over 240 mg of Tylenol, which is THREE TIMES the amount that you wanted to give. Again, use the dropper provided to give Infant Tylenol drops and use the cup provided when dosing the Children’s Tylenol Suspension Liquid.
3) Note that other medications have acetaminophen (Tylenol) in them. I advise my patients’ parents to avoid combination cold and flu medicines for two reasons. First, there is little evidence that shows that they actually provide symptom relief. Second, from a safety perspective, parents can accidentally overdose their child with acetaminophen because many contain acetaminophen in them. For example, as of this writing, the following medications all contain acetaminophen as stated in the ingredient list:
Benadryl Allergy and Cold Tablets, Sudafed PE nighttime Cold Maximum Strength Tablets, Theraflu Nighttime Severe Cold and Cough Powder, Tylenol Plus Children’s Cold and Allergy Suspension, Tylenol Sore throat Nighttime liquid, Tylenol Chest Congestion Liquid, and Nyquil.
4) Be aware that “APAP” in the ingredient list means acetaminophen.
Tylenol overdoses can be fatal by causing liver failure. If your child has a chronic liver disease, it is likely that she should avoid Tylenol altogether.
Because of the risk of overdose, I also avoid advising my patients to “alternate Tylenol (acetaminophen) with Motrin (ibuprofen).” I discourage this practice because I am afraid of parents forgetting which medicine they gave last and possibly over-dosing by mistake. Tylenol is meant to be dosed every 4 to 6 hours unless otherwise specified on the label or by your child’s health care provider.
If you ever have questions about possible overdose, call the national US Poison Control Center at 1-800-222-1222.
Julie Kardos, MD
©2009 Two Peds in a Pod
Addendum 10/11/2011: The manufacturers of Tylenol (acetaminophen) responded to the hazard of parents and caregivers accidentally giving the wrong dose of infant drops ( see point #2 above) and stopped making the “concentrated infant drops.” Instead, they now manufacture the “infant drops” and “children’s liquid” using the same concentration as each other. Continue to use the measuring dropper or cup provided with the medication for proper measuring.
A friend of mine who has no children commented to me that many people tell him, “You just can’t know happiness until you have children of your own.” However, I know several adults who are very happy people and who have made a conscious decision to not have children. So I would actually amend the above adage to: “You just can’t know WORRY until you have children of your own.”
Especially in winter, many illnesses circulate. All these sick kids make for many worried parents. Some questions that I answer many times a day in the office are: “Okay, Doc, you just told me that my child is handling her illness right now, but how will I know if she is getting worse? When do I need to worry?”
Here is what I tell my patients’ parents:
First and foremost, trust your parent instincts that something is wrong.
Think about these THREE MAIN SYSTEMS: breathing, thinking, and drinking/peeing.
Normally, breathing is easy to do. It is so easy, in fact, that if you take off your child’s shirt and watch her breathe, it can be hard to see that she is breathing. You should try this while your child is healthy. Normal breathing does not involve effort. It does not involve the chest muscles.
If your child has pneumonia, bad asthma, bronchitis, or any other condition that causes respiratory distress, breathing becomes hard. It becomes faster than baseline. It involves chest muscles moving so it looks like ribs are sticking out with every breath. The chest itself moves a lot. Kids’ bellies may also move in and out. Nostrils flare in attempt to get more oxygen. Sometimes kids make a grunting sound at the end of each breath because they are having difficulty pushing the air out of their lungs before taking another breath in. Also, instead of a normal pink color, your child’s lips can have a blue or pale color. Pink is good, blue or pale is bad. Children old enough to talk may actually have difficulty talking because they are short of breath. Any of the above signs tell you that your child needs medical attention.
This refers to mental or emotional state. Normally, children recognize their parents and are comforted by their presence. They are easy to console by being held, rocked, massaged, etc. They know where they are, and they make sense when they talk.
Change in mental state, whether it comes from lack of oxygen/shortness of breath, pain, or severe infection, results in a child who is inconsolable. She may not recognize her parents or know where she is. Instead of calming, she may scream louder when rocked. She may seem disoriented or just too lethargic/difficult to arouse. Being very combative can also be a sign of not getting enough oxygen. In a baby, extreme pain can cause all these signs as well.
While this varies somewhat depending on the age of the child, most kids urinate every 3-6 hours or so. Young babies may urinate more frequently than this and some older kids urinate perhaps 2-3 times daily. You should know your child’s baseline. Normal urine reflects a normal state of hydration. If you don’t drink enough, you will urinate less.
If your child has fever, coughing, vomiting, or diarrhea, she will use up fluid in her body faster than her baseline. In order to compensate, she needs to drink more than her baseline amount of liquid to urinate normally. A child will refuse to drink because of severe pain, shortness of breath, or change in mental state, and may go for hours without urinating. This is a problem that needs medical attention. Occasionally a child will urinate much more than usual and this can also be a problem (this can be a sign of new diabetes as well as other problems). Basically any change from baseline urine output is a problem.
A note about fever: any infant 8 weeks of age or younger with fever of 100.4 F or higher, measured rectally, requires immediate medical attention, even if all other systems are good. Babies this young can have fever before any other signs of serious illness such as meningitis, pneumonia, blood infections, etc. and they can fool us by initially appearing well.
In older babies and children, fever is defined as 101 F or higher. Some kids can look quite well even at 104 and others can look quite ill at 101. Fever is a sign that your body’s immune system is working to fight off illness. In addition to fever, it is important to look at breathing, thinking, and hydration state because this will help you determine how quickly your child needs medical attention. A child with a mild runny nose and fever of 103 who can play still play a game with you while drinking her apple juice is less ill than a child with a 101 fever who doesn’t recognize her parents.
To summarize, any deviation from normal breathing, thinking, or drinking/urinating (peeing) is a problem that needs medical attention, even if no fever is present. In addition, any change in the wrong direction (getting worse instead of getting better) is a problem that needs medical attention.
Finally, all parents have PARENT INSTINCT. Trust yourself. Ultimately, if you are wondering if you should seek medical advice, just do it. If parents could just worry every problem away, no one would ever be sick.
Julie Kardos, MD with Naline Lai, MD
© 2009 Two Peds in a Pod
I wash my hands about sixty times a day, maybe more. This in combination with cold Pennsylvania fall air leads to chapped hands. It’s a sure sign winter is approaching when patients start to show me their raw hands. Here are the hands of a girl I saw a couple days ago.
To prevent dry hands:
• Don’t stop washing your hands, but do use a moisturizer afterwards.
• Whenever possible, use water and soap rather than hand sanitizers. Hand sanitizers are at minimum 60% alcohol- very drying.
• Wear gloves as much as possible even if the temperature is above freezing. Remember chemistry class, cold air holds less moisture than warm air and therefore is unkind to skin. Gloves will prevent some moisture loss.
• Before exposure to any possible irritants such as the chlorine in a swimming pool, protect the hands by layering heavy lotion (Eucerin cream) or petroleum based product (i.e. Vaseline or Aquaphor) over the skin.
To rescue dry hands:
• Prior to bed smother hands in 1% hydrocortisone ointment. Avoid the cream formulation. Creams tend to sting if there are any open cracks. Take old socks, cut out thumb holes and have your child sleep at night with the sock on his hands. Repeat nightly for a week or so. Alternatively, for mildly chapped hands, use a petroleum oil based product such as Vaseline or Aquaphor in place of the hydrocortisone.
• If your child has underlying eczema, prevent your child from scratching his hands. An antihistamine such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) will take the edge off the itch.
• For extremely raw hands, your child’s doctor may prescribe a stronger cream and if there are signs of a bacterial skin infection, your child’s doctor may prescribe an antibiotic.
Happy moisturizing. Remember how much fun it was to smear glue on your hands and then peel off the dried glue? It’s not so fun when your skin really is peeling.
Naline Lai, MD
And speaking of vaccines…
Do 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 was well again, I was able to play with my neighbor even while he suffered with chicken pox. I even returned to school where other children in my class had chicken pox, but I did not catch chicken pox again. Even now, as a pediatrician, I don’t fear for my own safety when I diagnose a child with chicken pox, because I know I am immune to the disease.
This is an amazing feat, when you think about it.
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!
Before chicken pox vaccine, about 100 children per year in the US died from complications of chicken pox disease. Many thousands were hospitalized with secondary pneumonia, skin infections, and even brain damage (encephalitis) from chicken pox disease. Now a shot in the arm can prevent a disease by creating the same kind of immunity that you would have generated from having the disease, only now you have one second of pain from the injection instead of a week of misery and possible permanent disability or death. I call that a Great Deal!
All vaccines operate by this principle: create a safe environment for your immune system to make memory cells against a potentially deadly disease. Then when you are exposed to someone who actually has the disease, you will not “catch” it. Your body will fight the germs, but you do not become sick. If everyone in the world were vaccinated, then the disease itself would eventually be completely eradicated. This happened with small pox, a disease that killed 50 percent of infected people. There is no longer small pox because nearly everyone on earth received the small pox vaccine. Now we do not need to give small pox vaccine because the disease no longer exists. This is a huge vaccine success story.
Friedrich Nietzsche said “What doesn’t kill us makes us stronger.” We pediatricians feel this is unacceptable risk for children. We would rather see your child vaccinated against a disease in order to become immune rather than risking the actual disease in order to become immune.
Hopefully this blog post answers your questions about how vaccines work. For more details or more in depth explanations, I refer you to the AAP (American Academy of Pediatrics) website www.aap.org, the Children’s Hospital of Philadelphia’s Vaccine Education Center at www.chop.edu, 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 Two Peds In a Pod®