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Unless your child is getting the flu mist, your child may receive not only the seasonal flu vaccine as an injection this year, but also the H1N1 vaccine as an injection. Here’s how you can take away the sting of any needle:


Set the stage. Your child looks to you for clues on how to act. If mommy and daddy are trembling in the corner of the room, it will be difficult to convince your child that the immunization is “no big deal.”  Do not tell your child days in advance that she will be immunized. The more you perseverate, the more your child will perceive that something terrible is about to happen. Simply announce to your child right before you leave to get the immunization, “We are going to get an immunization to protect you from getting sick.”


 


Do not say “I’m sorry.” Say instead,”Even if this is tough, I am happy that this will protect you.”  


 


Never lie.  If your kid asks “will it hurt?”say “less than if I pinched you.”


 


Watch your word choice. Calling an immunization “a shot” or “a needle” conjures up negative images. In general, avoid negative statements about injected vaccines. I cringe when parents in the office threaten children with,” If you don’t behave, then Dr. Lai will give you a shot.”


 


Remember the mantra, if all is well in the basic areas of eat, sleep, drink, pee, and poop, then any stressor is easier to handle. 


 


Kids talk. Be aware that kids, especially those in kindergarten, like to scare each other with tall tales. Ask your child what they have heard about vaccines. Let children know that Johnny’s experience will not be their experience.


 


The moment is here.


 


You may have heard about a topical cream which numbs up an area of skin. Unfortunately, because the creams anesthetize the surface of the skin and most vaccines go into muscle, I do not find the creams very effective at taking the pain away. 


 


Instead, practice blowing the worries away. Have your child practice breathing slowly in through her nose and blowing out worries through her mouth. For the younger children, bring bubbles or a pin wheel for your child to blow during the immunization. In a pinch, take a piece of the exam paper in the room and have your child blow the paper.


 


The cold pack: holding something very cold can distract your child’s brain from feeling the pain of an injection.


 


“Transfer” the immunization to mommy or daddy.  Have your child squeeze your hand and “take the immunization” for him.


 


Tell your child to count backwards from 10 and it will be over. In reality, it will be over before your child says the number seven.


 


Have as much direct contact with your child as possible. The more surfaces of his body you touch, the less your child’s brain will focus on the injection. Again, this is the distraction principle at work. By touching your child, you are also sending reassuring signals to him. For the younger child, if he is on the table, stay close to his head and hug his arms, or have him on your lap. For the older child and teen, hold their hand. I sometimes see parents of older teens and college students leave the room. Even the big kids may need someone to keep them company.


 


Help hold your child firmly. Holding him will make him feel safe and will  prevent him from  moving during the injection. Movement causes more pain or even injury.


 


After the drama is over. 


Have your older child sit quietly for a moment. As the anxiety and tension suddenly falls away, the body sometimes relaxes too suddenly and a child will start to faint.  This phenomenon seems to happen most often with the six foot tall stoic teenage boys.  We have a saying in my office- The bigger they are, the more likely they are to fall.


 


Compliment your child. Remind them that you will never let anyone really hurt them.


Now a story:


When my middle daughter was two years old, my family trouped into my office for the flu vaccine injection. We all sat calmly in a circle and smiled. 


First, the nurse gave me my immunization. I smiled. My middle daughter smiled.


Second, the nurse gave my husband his immunization. He smiled. My middle daughter smiled.


Then the nurse gave my oldest daughter her immunization. She smiled. My middle daughter smiled.


Then the nurse gave my middle daughter her immunization. She did not smile. She did not cry. Instead, she slugged the nurse with her little fist.  I think the nurse felt more pain than my child.


Someday all immunizations will be beamed painlessly into children via telepathy. Until then, I have no advice on how to take the sting away from the punch of a two year old. 


Naline Lai, MD


© 2009 Two Peds In a Pod

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I’ve heard some interesting things about milk over the years. I am going to share with you three myths about milk that  I heard when I was a kid and I still hear from my patients’ parents.


Myth #1: Don’t give milk to a child with a fever, the milk will curdle (or some other variation).


Truth: As long as your child is not vomiting, milk is a perfectly acceptable fluid to give your febrile child. In fact it is superior to plain water if your child is refusing to eat, which is very typical of a child with a fever. Fevers take away appetites. So if your child is not eating while he is sick, at least he can drink some nutrition. Milk has energy and nutrition, which help fight infection (germs). Take milk, add a banana and a little honey (if your child is older than one year), and maybe some peanut butter for protein, pour it into a blender, and make a nourishing milk shake for your febrile child. Children with fevers need extra hydration. Even febrile infants need formula or breast milk, NOT plain water. The milk will not curdle or upset them in any way. If, on the other hand, your child is vomiting, I advise sticking to clear fluids until his stomach settles.


Myth #2: Don’t give children milk when they have a cold because the milk will give them more mucus.


Truth: There is NOTHING mucus-inducing about milk. Milk will not make your child’s nose run thicker or make his chest more congested. Let your runny-nosed child have his milk! Yet my own mother cringes when I give any of my children milk when they have colds. Never mind my medical degree; my mom is simply passing on the wisdom (?) of her mother which is that you should not give your child milk with a cold. Then again, my grandmother also believed that your body only digests vitamin C in the morning which is why you have to drink your orange juice at breakfast time. But that’s a myth I’ll tackle in the future.


Myth #3: You can’t over-dose a child on milk.


Truth: Actually, while milk is healthy and provides necessary calcium and vitamin D, too much milk can be a bad thing. To get enough calcium from milk, your child’s body needs somewhere between 16 to 24 ounces of milk per day. Of course, if your child eats cheese, yogurt, and other calcium-containing foods, she does not need this much milk. The recommended daily intake of  Vitamin D was increased recently to 400 IU (International Units).  This amount translates into 32 ounces of milk daily.  But, we pediatricians know that over 24 ounces of milk daily leads to iron deficiency anemia because calcium competes with iron absorption from foods. You’re better off giving an over-the-counter vitamin such as Tri-Vi-Sol or letting older children chew a multivitamin that contains 400 IU of vitamin D. In addition to iron deficiency anemia, drinking excessive amounts of milk is bad for teeth (all milk contains sugar).  Extra milk can also lead to obesity from increased calories. Ironically, too much can also lead to poor weight gain in children who are picky eaters.  The milk will fill them up, leaving them without an appetite for food.


In summary, you can safely continue serving your children milk in sickness and in health, in moderation, every day. Now, all this talk about milk really puts me in the mood to bake cookies…


Julie Kardos, MD

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Well it finally happened.  The day all mothers with daughters regard with mixed feelings.  No, I’m not talking about my daughter’s first period.  Today I discovered that my oldest daughter’s foot size is the same as mine.

I took it as a sign.  Time to blog a little about shoes and feet.

First shoes:  Shoes are to prevent injury to feet. While indoors, let your infant stand and walk without shoes.  Bare feet are best.  Your baby will learn to balance better when he or she can feel the floor directly under her feet.  However, for protection, shoes are needed.  Start with a sturdy sneaker.  No need for the clunky white leather shoes of the past.  Also, avoid sandals, toddlers are more liable to trip and there is not much protection against stinging insects.

For school: The average length of recess per day is about 30 minutes(
www.centerforpubliceducation.org)  Therefore, pick comfy shoes which allow your children to utilize this time for physical activity.

Athlete’s foot: Caused by a fungus, athlete’s foot appears as wet, moist, itchy areas usually between the toes.  The fungus loves moist areas and can be treated with over the counter antifungal creams or powders such as clotrimazole (Lotrimin AF), and tolnaftate (Tinactin). While common in teens, athlete’s foot is much less common in general than foot eczema. Vinegar soaks are helpful- put half a cup of vinegar into a small basin of warm water and have your child soak for 10 minutes daily. 

If your child has eczema on other areas of his or her body, be more suspicious of eczema than athlete’s foot. Both can look alike, but be careful, the steroid creams used for eczema may worsen athlete’s foot.

Flat feet: Most children with flat feet have flexible flat feet which do not require any intervention. Nearly all toddlers have flexible flat feet. A child with flexible flat feet will not have an arch upon standing.  However, the arch should reappear when the child’s feet are relaxed in a sitting position off the floor. Any pain in the arch or suspicion of an inflexible flat foot should be brought to a physician’s attention.

Ingrown toe nails: Ingrown toe nails occur when the sides of the nails grown into the skin.  After enough irritation, bacteria can settle in and pus pockets form.  To prevent ingrown toe nails from becoming infected, at the first sign of redness, soak feet in warm water with Epsom salts.  Gently pull the skin back from the area of the nail which is in grown.  Attempt to cut off any area of the nail which is pushing into the skin.

Clipping newborn toe (and finger) nails: A newborn’s nails have not separated enough from the nail bed to easily get a nail clipper under a nail. For the first few weeks, stick to filing the nails down.  Parental guilt warning: at some point almost every parent mistakenly cuts their child’s skin instead of their nail.

Naline Lai, MD

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Parents often ask how they can tell if their child has The Flu or just a common cold. Here’s how:


A cold, usually caused by one of many viruses such as rhinovirus, starts out gradually. Think back to your last cold: first your throat is scratchy, then the next day your nose gets stuffy or then starts running profusely, then you develop a cough. Sometimes during a cold you get a fever for a day or two. Sometimes you get hoarse, losing your voice. Usually kids still feel well enough to play and attend school with colds, as long as their fevers stay below 101 and they are well hydrated and breathing without difficulty. The average length of a cold is 7-10 days although sometimes you feel lingering effects of a cold for 2 weeks or more.


The flu, caused by influenza virus, comes on suddenly and basically makes you feel as if you’ve been hit by a truck. Flu always causes fever of 101 or higher and some respiratory symptom such as runny nose, cough, or sore throat (many times, all three at once actually). Children, more often than adults, sometimes have vomiting and/or diarrhea with the flu along with their respiratory symptoms. Usually the flu causes total body aches, headaches, and the sensation of your eyes burning. The fever usually lasts 5-7 days. All symptoms come on at once; there is nothing gradual about coming down with the flu.


Fortunately, vaccines against the flu can prevent the misery of coming down with the flu. In addition, vaccines against influenza save lives by preventing flu related complications that can be fatal such as flu pneumonia, flu encephalitis (brain infection), and severe dehydration. Hand washing also helps prevents spread of flu as well as almost every other disease of childhood. Please see our blog post on flu posted on September 6, 2009 for more information on prevention and care of children with flu.


The much touted “Tamiflu” is a prescription medication that can ameliorate the effects of the flu. In an otherwise healthy person, this medicine can shorten duration of symptoms by ½ to 1 day. Are you underwhelmed by this fact? So is the medical profession, which is why we reserve this medicine for people ill enough to need hospitalization or who we know have underlying medical conditions, because this medicine has been shown to decrease hospital stays and complication of flu in people who have asthma, diabetes, immune system defects, and heart disease.


Because of all the hype over the novel H1N1 flu (again, please see our blog post on this subject) I am already getting many anxious phone calls and office visits from parents who are worried that their child might have “the flu” when their children are having runny noses and some cough but no fever. Hopefully this blog post will help you sort out your child’s symptoms.


Julie Kardos, MD

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Saturday morning at my home this past weekend. Three sets of misplaced shin guards. Three new coaches to remember. Three kids running in different directions.  And nearly forgotten as we fly out the door… three water bottles.  Forget the balls, forget the money for pictures, even forget the coaches’ names. But even in this beautiful cool autumn air, don’t forget the water bottles.

We are all accustomed to reminding our children to hydrate well during summer sports, but when the weather grows cooler we sometimes let our guard down.  Because thirst does not always correlate with dehydration,  children often misjudge their own hydration status.    Teach your children to recognize  headache and nausea as one of the first symptoms of dehydration.  If  they “just don’t feel right ,” take a break.

Don’t depend on the coach.   Learn to recognize when your child needs to rest and hydrate.   A mother I met at field hockey Saturday says she can always tell if one of her girls needs a break because a subtle white ring appears around her mouth. 

For hydration outside of sports, the best liquids for kids over two years old are skim milk and water.  Reserve juice for constipated children or the picky eater who will not eat fruit.  Even then, limit juice to once a day.  Consumption of sweet beverages multiple times a day encourages a sweet tooth and gives only empty calories.  Also, even juice diluted with water has the power to decay teeth- just ask my nephew who had over ten cavities filled two days ago. 

Drink water up to half an hour prior to a sports activity.  For young children who only play for an hour or so, water is a good choice for hydration.  Enforce drinking approximately every 20 minutes.   For the more competitive players who churn up a sweat, electrolyte replenishers such as Gatorade and Powerade  become important.  After 20-30 minutes of sweating, a body can lose salt and sugar.   At that point, switch to rehydration with electrolyte replenishers.   My sister, an Emergency Medicine doctor,  tells the story of a young woman played ultimate frisbee all day, and lost a large amount of salt through  sweating.  Because she also drank large amounts of water, she “diluted” the salt that was still in her blood and had a seizure.  If your child plays an early morning sport, start the hydration process the night before so that they don’t wake up already behind on fluids. 

Avoid caffeine which is found in  some sodas, iced tea and many of the energy drinks.   Caffeine tends to dehydrate.  Alcohol also dehydrates (think of the copious amount of fluid lost in urine after consumption of beer).  

So, before your kid’s next sports activity, remember the helmet, remember the shin guards, remember the padding and remember one of the most protective pieces of equipment  of all – the water bottle.


Naline Lai, MD with Julie Kardos, MD
Updated June 3, 2012, Two Peds in a Pod®

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It is one week before the start of school and I watch as my daughter’s sixth grade teacher stabs an onion with a needle.  It’s a back to school ritual for my family.  Usually a piece of fruit is a proxy for my daughter’s thigh, and the needle contains epinephrine, a potentially life saving medication that my daughter would need if she were to eat a cashew. 



Two of my children are part of a growing number of people with food allergies.   According to the Food Allergy & Anaphylaxis Network, an estimated 11 million Americans have a food allergy.  Despite the numbers, the etiology of food allergies remains a mystery.  One of the most popular theories is that a child develops a sensitivity when the gut is exposed to a bit of the offending food during an unknown critical time in development–perhaps even in utero.  My son had an allergic reaction to peanuts at eight months of age without ever ingesting a peanut. He had been touched by an unwashed hand that had just handled peanuts.  To add to the confusion, experts wonder if there is a relationship between allergies and how food is processed.  In China, despite an abundance of peanut containing entrees, relatively few people are allergic to peanuts.  It is postulated that the smaller number is somehow connected to the fact that most peanuts are boiled not roasted.  Strangely, only eight categories of food:
milk, egg, soy, peanut, tree nut (i.e. cashews and pecans), fish, wheat and shellfish cause ninety percent of allergic reactions.



Reactions can range widely from a single, pesky, itchy welt to a choking off of all airway passages.  The type of suffocation that occurs can be impossible to ventilate, even with a respirator.  The medication  which can thwart allergic reactions, epinephrine, is available in a portable form.  Yet one study showed that even after medical evaluation, epinephrine was prescribed to only half of children and less than one quarter of adults with nut allergies.   More distressing, as a pediatrician, I find families fail to recognize the symptoms of respiratory distress and do not realize the urgency of the situation.  Even when respiratory symptoms are obvious, families are sometimes too panicked to think clearly.  I know of cases of parents who injected the medicine into their own fingers rather than into their child.

Unfortunately, even epinephrine can not always stop catastrophic consequences.  The only real treatment is avoidance.  This can be tough in a world where many confuse food allergies with a personal choice—like a person who chooses to be a vegetarian.  Adding to the confusion is the mistaken belief that food intolerance is synonymous with food allergy.  For instance, in milk intolerance, people have difficulty digesting the sugar in cow’s milk, whereas people with a milk allergy are reacting to the protein in cow’s milk. 



Watching an allergic person eat at a restaurant is like watching a person eat Japanese puffer fish- every bite could be lethal.  It took only one cashew to cause my daughter to break out in hives, vomit and experience a tightening of her throat.  During my first two weeks of college, I remember a  freshman at my college dying  because of peanut butter hidden as “the special thickening ingredient” in a restaurant’s chili.  Perils are everywhere.  A milk allergic person worries if a meat slicer has been previously used for cheese, the fish allergic individual needs to worry about Worcestershire sauce because it often contains anchovies and the egg allergic person needs to be suspicious of  foamy toppings on specialty drinks.   In my pediatric practice, one of my patients, a peanut-allergic girl, started wheezing simply because the child next to her in the car opened up a bag of peanut butter filled snacks.



Despite the sometimes small amount of an allergen required to set off an allergic reaction, one study showed that at least the major allergen in peanuts is relatively easy to clean from hands with simple soap and water.  Common household cleaning products remove the allergen from counter and table tops.  But kids, especially toddlers, are not known for their meticulous sanitation practices.  Schools and daycares often find keeping an entire classroom free of an offensive food easier than keeping kids from touching each other.



So when that letter comes home this fall identifying someone in your child’s class with a food allergy, don’t moan and groan.  Abstain from sending in potentially allergenic foods with your child.  Imagine sending your children to school knowing that a well meaning friend might try to share a deadly snack.  Like the millions of allergic Americans, your picky eater could learn to modify his or her diet.  Our family went from eating daily peanut butter and jelly sandwiches to becoming a nut free home.  What is an inconvenience to you may save a kid’s life.


 


 


Naline Lai, MD


 



For more info:
Food Allergy, Asthma and Anaphylaxis Network
www.foodallergy.org



 an online  resource and discussion group 



References:

Distribution of Peanut Allergen in the Environment


Perry TT et al.  J Allergy and Clinical Immunology.  2004;113:973-976


 


Prevalence of Peanut and Tree Nut allergy In the United States Determined By Means of A Random Digit Dial Telephone Survey: A 5 Year Follow-Up Study


Sicherer S. et al. Journal of Clinical Immunology 2003;112:203-1207

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With school starting in the next few weeks, many families will have to shift their children from “summer time sleep mode” to “school year sleep mode.” Your children will have an easier time if their bedtimes are shifted gradually over the period of a week or two toward the desired time period. Remember, the average school aged child needs 10-11 hours of sleep at night and even teenagers function optimally with at least 9-10 hours of slumber per night.


Here are some straight forward rules to follow to help ensure good quality sleep for your child:


1)      Keep sleep onset and wake up times as consistent as possible 7 days a week. If you allow your child to “sleep in” during the weekends, she will have difficulty falling asleep earlier on Sunday night, have difficulty waking up Monday morning, and start off her week over-tired, more cranky and less able to process new information—not good for learning.


2)      Limit or eliminate caffeine intake. Often teens who feel too sleepy from failing to follow rule number 1 from above may drink tea, coffee, “energy drinks” or other caffeine laden beverage in attempt to self-medicate in order to concentrate better. What many people don’t realize is that caffeine stays in your body for 24 hours so it is entirely possible that the caffeine ingested in the morning can be the reason your child can’t fall asleep later that night. Caffeine also has side effects of jitteriness, heart palpitations, increased blood pressure, and gastro-esophageal reflux (heartburn).


3)      Keep a good bedtime routine. Just as a soothing, predictable bedtime ritual can help babies and toddlers settle down for the night, so too can a bedtime routine help prepare the school aged child/teen for sleep.


4)      Avoid TV/computer/ screen time just before bed. Although your child may claim the contrary, watching TV is known to delay sleep onset. We highly recommend no TV in a child’s bedroom, and suggest that parents confiscate all cell phones and electronic toys, which kids may otherwise hide and use without parent knowledge, by one hour prior to bedtime. Quiet activities such as reading for pleasure, listening to music, and taking a bath, are all known to promote falling asleep.


5)      Encourage regular exercise. Kids who exercise daily have an easier time falling asleep at night than kids who don’t exercise. Gym class counts. So does playing outside, dancing, walking, and taking a bike ride. Of course, participating in a team sport with daily practices not only helps insure better sleep but also promotes social well being.


Getting enough sleep is important for your child’s academic success as well as for their mental health. I have had parents ask me about evaluating their child for ADD or ADHD because of his inability to pay attention and then come to find out that their youngster fights bedtime and averages 7-8 hours of sleep per night when he really need 1-2 hours more, or their teen is so over-involved in activities that she averages 6 hours of sleep per night. Increasing the amount of sleep these kids get can alleviate their attention problems and resolve their hyperactivity. Additionally, sleep deprivation can cause symptoms of depression. Just recall the first few weeks of having a newborn:  maybe you didn’t think you were depressed but didn’t you cry from sheer exhaustion at least once?


Unfortunately for children, the older they get, their natural circadian rhythm shifts them toward the “night owl” mode of staying up later and sleeping later, and yet the higher up years in school start earlier so that teens in high school start school earliest at a time their bodies crave “sleeping in.” A few school districts in the country have experimented with starting high school later and Grade School earlier and have met with good success with less tired, more productive teens. Unless you live in one of these districts, however, your teens need to conform until they either go to college and can choose classes that start later in the day or choose a job that allows them to stay up later and sleep later in the day in order to be better in sync with their age specific body rhythms.


Some children seem to get plenty of sleep at night and are still tired during the day. Some medical conditions that interfere with sleep quality include but are not limited to:



  • Asthma: kids cough themselves awake multiple times during the night
  • Obstructive sleep apnea: children often are obese or have enlarged tonsils and adenoids or have anatomically “floppy” airways. These kids snore and pause their breathing, then rouse themselves in order to start breathing again, multiple times per night.
  • Medication side effects
  • Psychological conditions such as depression or anxiety
  • Illicit drug use

If your child seems to be sleeping enough but still seems excessively tired during and after school, you should consult with your child’s health care professional to look for medical and psychological causes of fatigue. It is always ok to ask your child/teen directly if they feel depressed or anxious. Even if they deny this, they will appreciate your concern and may come back to you later with a more truthful answer.  A night time ritual of “tell me about your day” can help kids decompress, help them fall asleep, and keep you connected with your child.


Julie Kardos, MD

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It’s that time of year again, supply #3 on my back-to-school shopping list, glue sticks, are sold out at the Target down the street.  At this time of year, I see many of my patients embarking on their next stage of schooling.  Kids I remember starting kindergarten are off to high school.  Babies are starting daycare and the teens are starting college.  With all of these transitions to independence, the basic rules of daycare drop off still hold:



  • Always convey to your child that the transition is a positive experience.  You give your child cues on how to act in any situation.  Better to convey optimism than anxiety. 
  • Take your child and place her into the arms of a loving adult- do not leave her alone in the middle of a room.
  • Do not linger.  Prolonging any tears, only prolongs tears. The faster you leave, the faster happiness will start.
  • It’s ok to go back and spy on them to reassure yourself that they have stopped crying- just don’t let them see you.

Now with that all being said, kick back late at night, after all the school forms have been put away.  Whether your child is off to college, off to daycare or off to kindergarten, take out a glass of wine and listen to the letter I wrote for one of my own children years ago…


My Child,


As we sit, the night before kindergarten, your toes peeking out from under the comforter, I notice that your toes are not so little anymore. 


Tomorrow those toes will step up onto to the bus and carry you away from me.   Another step towards independence.   Another step to a place where I can protect you less.  But I do notice that those toes have feet and legs which are getting stronger.   You’re not as wobbly as you used to be.  Each time you take a step you seem to go farther and farther. 


I  trust that you will remember what I’ve taught you.  Look both ways before you cross the street, chose friends who are nice to you, and whatever happens don’t eat yellow snow.   I also trust that there are other eyes and hearts who will watch and guide you. 


But that won’t stop me from worrying about each step you take. 


Won’t stop me from holding my breath­. 


Just like when you first started to walk, I’ll always worry when you falter. 


I smile because I know you’ll hop up onto the bus tomorrow, proud as punch, laughing and disappearing in a sea of waving hands.  I just hope that at some point, those independent feet will proudly walk back and stand beside me.   


Maybe it will be when you first gaze into your newborn’s eyes, or maybe it will be when your child climbs onto the bus. 


Until then,


I hold my breath each time you take a step.


Love,
Mommy


Naline Lai, MD

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Ouch! Stung on the scalp.


Ouch! Stung on the hand.


Ouch! Stung on the leg.


Ouch! Ouch! Stung TWICE on the lips.


Those nasty, nasty hornets.  During the hot days of August, they become more and more territorial and attack anything near their nests.  Today, in my yard, hornets mercilessly chased and attacked a fourth grader named Dan.  As everyone knows, you’d rather have something happen to yourself than have something negative happen to a child who is under “your watch.” As I rolled out the Slip and Slide, I was relieved not to see any wasps hovering above nests buried in the lawn.  I was also falsely reassured by the fact that our lawn had been recently mowed.  I reasoned that anything lurking would have already attacked a lawn mower.  Unfortunately, I failed to see the basketball sized grey wasp nest dangling insidiously above our heads in a tree.  So, when a wayward ball shook the tree, the hornets found Dan.


What will you do in the same  situation?


Assess the airway- signs of impending airway compromise include hoarseness, wheezing (whistle like sounds on inhalation or expiration), difficulty swallowing, and inability to talk.  Ask if the child feels swelling, itchiness or burning (like hot peppers) in his or her mouth/throat.  Watch for labored breathing.  If you see the child’s ribs jut out with each breath, the child is struggling to pull air into his/her body.    If you have Epinephrine (Epi-Pen or Twin Jet)  inject  immediately- if you have to, you can inject  through clothing.  Call 911 immediately. 


Calm the panic- being chased by a hornet is frightening and the child is more agitated  over the disruption to his/her sense of security than over the pain of the sting.  Use pain control /self calming techniques such as having the child breath slowly in through the nose and out through the mouth.  Distract the child by having them “squeeze out” the pain out by squeezing your hand.


If the child was stung by a honey bee, if seen, scrape the stinger out with your fingernail or a credit card.  Do not squeeze or pull with tweezers to avoid injecting any remaining venom into the site.   Hornets, and other kinds of wasps, do not leave their stingers behind.  Hence the reason they can sting multiple times.


Relieve pain by administering Ibuprofen (Motrin,Advil) or Acetaminophen (Tylenol).


As  you would with any break in the skin, to prevent infection, wash the affected areas with mild soap and water.


Decrease the swelling.  Histamine produces redness, swelling and itch.  Counter any histamine release with an antihistamine such as Diphenhydramine (Benadryl).  Any antihistamine will be helpful, but generally the older ones like Diphenhydramine, tend to work the best in these instances.  Unfortunately, sleepiness is common side effect.


To decrease overall swelling elevate the affected area.


A topical steroid like hydrocortisone 1% will also help the itch and counter some of the swelling. 


And don’t forget, ice, ice and more ice.  Fifteen minutes of indirect ice on and fifteen minutes off.


Even if the child’s airway is okay, if the child is particularly swollen, or has numerous bites, a pediatrician may elect to add oral steroids to the child’s treatment


It is almost midnight as I write this blog post.  Now that I know all of my kids are safely tucked in their beds, and I know that Dan is fine, I turn my mind to one final matter:  Hornets beware – I know that at night you return to your nest.  My husband is going outside now with a can of insecticide.   Never, never mess with the mother bear…at least on my watch.


Naline Lai, MD

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Recently I received a phone call from a mom whose six-year-old son was afraid to go to sleep at night. For the past two months the child insisted on falling asleep in the parents’ room while holding one parent’s hand, and if the parent carried him to his room after he finally fell asleep, he would wake up every few hours to return to their room. No one was getting good sleep. In addition, his mom was concerned that he often seemed angry during the day.


Turns out that two months ago the boy’s grandfather died. The boy and his toddler-aged sister had attended the grandfather’s funeral and at the viewing his younger sister, upon seeing her dead grandfather in the coffin, kept saying, “Grandpa, wake up, you are missing your party! Why can’t Grandpa wake up?”


When children are confronted with the death of a family member, friend, or pet, it is very important to never refer to death as “sleeping. Children are very literal and so it is better to say something like, “When people are dead, their bodies do not work, they do not breathe or move,” but do NOT use any sleep analogy. This can cause them to be afraid to fall asleep and not be able to wake up.


This child’s mom was concerned that her son “seemed angry a lot of the time” and was difficult to get along with. This behavior change is very normal and was occurring for two reasons:


1)   When children feel sad, they often appear angry. The child is still mourning the loss of his grandfather. In addition, his parents also are grieving and children perceive their parents’ moods. The child misses his grandfather and it is normal for him to feel sad about this. Children often express sadness with anger, so the parents need to be sensitive to this.


2)   When children are sleep deprived, they become short tempered. This child was staying up until midnight or later before falling asleep in the parents’ room, waking up in the middle of the night, and waking up at 7:00 am for school. School aged children need on average about 9-10 hours of sleep or more to function optimally.


I advised the mom to have a casual conversation during the daytime about death. She could start by saying something like, “You know, I was thinking about Grandpa’s funeral. Remember how your sister kept saying “wake up, grandpa?” I wanted to make sure that you knew that Grandpa was not asleep. He was dead and his body wasn’t working anymore.” Then wait and see if he asked any more questions. If he asked why he died, the parent should give a simple but truthful answer. In this case, Grandpa had cancer, so parents could say, “he had an illness that his body was too old and weak to fight off.” It is also fine for the parent to say, “I am sad because I miss Grandpa.” Again, answer questions if they come up but be very concrete and simple in your answer. If the child says, “What if I get sick? Will I die?” the parent could answer, “No, you are young and strong.”


The other important part of helping this child is getting back to good sleep habits. (I refer you to our forthcoming podcasts on sleep for baseline good bedtime habits.) This child may have been afraid of dying in his sleep or just may have developed a bad association with sleep. He clearly associated his parents with safety. I recommended that a parent sit on his bed in his room until he fell asleep. The bedtime would be moved about 15 minutes earlier each night until they arrived at a more appropriate bedtime. They were to tell the child that they would not leave until he fell asleep. If he awoke during the night and came into their room or called out for his parents, one of them was to sit on his bed again until he fell asleep. The parent was not to talk or interact during this time of falling asleep. The goal was to create a positive, safe association with falling asleep.


After a few days of the child falling asleep within about 15 minutes of sitting on his bed, tell him that the new rule is that one parent would sit NEXT to his bed until he falls asleep. Keep repeating this and wean farther away every few days (ie sit in the middle of his room, sit in the doorway, etc) until he is able to fall asleep on his own. Remember to give lots of praise the next day, small tangible rewards are okay for each accomplishment. 


By acknowledging his grief and also by using behavior changes to help restore good sleep at night, this child’s daytime anger gradually resolved.


Julie Kardos, MD

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