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dried chapped hands

Raw hands- recognize your kid?

Even when it isn’t flu season, we pediatricians wash our hands about sixty times a day, maybe more. This frequent washing, in combination with cold winter air, leads to chapped hands. Here are the hands of a patient. Do your children’s hands look like these?

To prevent dry hands:

Don’t stop washing your hands, but do use a moisturizer afterwards. Also use warm but not hot water. Hot water removes protective oils from skin.
• According to the American Academy of Dermatology, hand sanitizer can prevent the drying that accompanies frequent hand washing. However, we can tell you from experience that once your hands are already chapped and cracked, the alcohol content in the sanitizers stings sensitive skin. So if your child’s hands are already chapped, stick with water and soap.
Wear gloves or mittens as much as possible outside 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. Having difficulty convincing your child to wear gloves? Point out that refrigerators are kept around 40 degrees Fahrenheit or below. Tell your kids that if they wouldn’t sit inside a refrigerator without layers, then it would be wise to wear gloves.
• Before exposure to any possible irritants such as the chlorine in a swimming pool, protect the hands by layering heavy lotion (e.g. Eucerin cream) or petroleum based product (e.g. Vaseline or Aquaphor) over the skin.

To rescue dry hands:

• Prior to bedtime, 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 up to a week. 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. Keep his nails trimmed to avoid further damage from scratching.
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 smearing glue on your hands and then peeling off the dried glue? It’s not so fun when your skin really is peeling.

Naline Lai, MD and Julie Kardos, MD
© 2009, 2015, 2018 Two Peds in a Pod®

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flu symptoms

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

Headlines remind us daily that the US is officially in the midst of flu season. We are also in the midst of a really yucky cold season. We have seen numerous kids in our offices with bad colds and others with flu.

Parents ask us every day how they can tell if their child has the flu or just a common cold. While no method is fool proof, here are some typical differences:

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

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

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

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

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

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

Fortunately, a vaccine against the flu is available for all kids over 6 months old (unfortunately, the vaccine isn’t effective in younger babies). This flu vaccine can prevent the misery of the flu. In addition, vaccines against influenza save lives by preventing flu-related complications such as pneumonia, encephalitis (brain infection), and severe dehydration. Even though we are starting to see a lot of flu, it is not too late to get the flu vaccine for your child, so please schedule a flu vaccine ASAP if your child has not yet received one for this season. Parents and caregivers should also immunize themselves- we all know how well a household functions when Mom or Dad have the flu… not very well! Sadly there have been 20 children so far this flu season who died from the flu. In past years many flu deaths were in kids who did not receive the flu vaccine, so please vaccinate your children against the flu if you have not already.

Be sure to read our article on ways to prevent colds and flu. As pediatricians, we remind you to WASH HANDS, make sure your child eats healthy, gets enough sleep, and avoid crowds, when possible. As moms, we add that you might want to cook up a pot of good old-fashioned chicken soup to have on hand in case illness strikes your family.

Julie Kardos, MD and Naline Lai, MD

©2018 Two Peds in a Pod®

 

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Olga Pasick, mom of a teen who died of meningococcal disease, shares her personal experience and information about the updated guidelines. 

I wish I had known the importance of vaccination for meningococcal disease before it was too late for my son. Back in September of 2004, David was a happy, healthy 13 year old, who came down with flu-like symptoms one evening. He first felt cold, then spiked a high fever, and vomited throughout the night. In the morning we called the pediatrician to have him seen. Everything ached, and he needed help getting dressed. That’s when I noticed purplish spots on his chest and arms. I didn’t know how serious that symptom was.

As soon as the doctors saw him, they knew he had meningococcal disease. He was rushed to the ER for a spinal tap and treatment. Unfortunately, the disease spread quickly and his organs failed. David died within 24 hours of first developing those flu-like symptoms from a potentially vaccine-preventable disease. Unbelievable… and heartbreaking.

Meningococcal disease is spread through respiratory droplets, such as coughing or sneezing, or through direct contact with an infected person, such as kissing. About 1 in 10 people are carriers, and don’t even know it. It doesn’t affect everyone. It is difficult to diagnose because symptoms are similar to the flu, and include high fever, headache, stiff neck, nausea, vomiting, exhaustion, and a blotchy rash. The disease spreads quickly and within hours can cause organ failure, brain damage, amputations of limbs, and death.

The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend meningococcal vaccination for all 11-18 year olds. The newest recommendation is for permissive use (recommended on a case by case basis) of a type of meningococcal  vaccine called meningococcal serotype B. The serotype B vaccine is for ages 16-23, with a preferred age of 16-18. This recommendation joins the long-standing recommendation that all adolescents get meningococcal A, C, W and Y vaccine (this one vaccine protects against these four serotypes) at age 11-12 with a booster dose at 16. The newer serotype B vaccine is particularly important for older adolescents and young adults because it is the most common cause of meningococcal disease in this age group. No vaccine is 100% effective, but it is the best preventative measure we can take.

Because of my experience, I became a member of the National Meningitis Association’s (NMA) Moms on Meningitis (M.O.M.s) program. We are a coalition of more than 50 mothers from across the country whose children’s lives were drastically affected by this disease, and are dedicated to supporting meningococcal prevention.

Visit the NMA website for more information and to view powerful personal stories of those affected.  Talk to your doctor about vaccination. It could save a life. How I wish those recommendations were in place years ago.

Olga Pasick
Wall, New Jersey

Note: In the United States, you may know the meningococcal A, C, W and Y vaccine as either  Menactra® or Menveo®. The serogroup B meningococcal vaccine you may recognize as either Bexsero® or  Trumenba®.

©2017, updated from 2011, Two Peds in a Pod®

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runny nose

Ben’s runny nose, as depicted by Ben

The good news is that there was only a smattering of influenza (flu) cases across the United States over the summer. The great news is that according to the Centers for Disease Control, most of the detected strains are covered in this year’s vaccine.

If you’re still hesitant to vaccinate your family, let’s talk frankly about some myths we sometimes hear about flu vaccines:

If my friend’s child has flu symptoms, I’ll just avoid their house to avoid catching the flu
False. According to the CDC , you are infectious the day before symptoms show up. So it is TOO LATE to avoid only those already sick.

My family never gets the flu so it’s not necessary to get the vaccine.
False and dangerous. Saying “My child and I have never had the flu so we don’t need the flu vaccine” is like saying, “I’ve never a car accident so I won’t wear my seat belt.”

I got the flu shot last year and then I got sick. So the flu shot must have made me sick.
Our condolences. True, you were sick. But this statement is False, because the illness was not caused by the flu vaccine. Vaccines are not real germs, so you can’t “get” a disease from the vaccine. But to your body, vaccine proteins appear very similar to real germs and your immune system will respond by making protection against the fake vaccine germ. When the real germ comes along, pow, your body already has the protection to fend off the real disease.

It is important to realize that the vaccine takes about 2 weeks to take effect in your body, so if you were unlucky enough to be exposed to someone with the flu and then got the vaccine the next day, you still have a good chance of coming down with the flu: the vaccine will not have had a chance to work yet.

Please know, however, there is a chance that for a couple days after a vaccine, you will ache and have a mild fever. The reason? Your immune system is simply revving up. But no, the flu vaccine does not give you the flu.

No one dies from the flu anymore, do they? Flu is just not that dangerous, so my child does not need a flu shot. I will just take my chances with flu.                                                                              False! A total of 107 influenza-associated pediatric deaths were reported for the 2016-2017 season. In past seasons up to 90% of children who died from flu did not receive a flu vaccine. So please, vaccinate yourself and your children.

The vaccine coverage is awful.
Not the case this year. On the other hand, even if coverage was spotty, look at it this way— if half of the flu out there was covered, that’s a lot fewer people that won’t give your kid the flu.

Naline Lai, MD and Julie Kardos, MD

©2017 Two Peds in a Pod®

rev Oct. 10, 2017 see comments

 

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AAP NCE

In front of “The Bean” in Chicago

We’re back from the American Academy of Pediatrics National Conference and Exhibition  in Chicago—sharing with you some tidbits from the forefront of pediatrics:

New high blood pressure guidelines are here. Starting at age 3 years, children should have their blood pressure checked annually, more often if they have certain medical conditions such as diabetes or kidney disease. The cutoff for “high blood pressure” has been lowered so more and more, you may notice your pediatrician scrutinizing your child’s blood pressure.

We’ve noticed many more over-use injuries from kids who play the same sport year round. We were reminded that most professional athletes played multiple sports in high school and some even up through college. Specialization in a particular sport leads to more injuries,  burnout, depression, and anxiety.  If you feel that sports rule your child’s life, remember this good rule of thumb: for high school kids, keep training under 16 hours a week. For the younger kids, keep the total number of hours per week playing organized sports under an hour per week for each year of age.  For example, an 8 year old should spend no more than 8 hours per week playing organized sports.

Probiotics are ubiquitous these days, but are they helpful? In viral diarrhea, probiotics can be mildly helpful, and may shorten the duration of diarrhea by about a day.  Probiotic therapy is showing promise for treating colic, but not for treating eczema. For more information see the International Scientific Association of Probiotics and Prebiotics.

If your child scalds himself, put the burn under COLD running tap water for 20 minutes to stop further injury. This treatment is effective for up to 3 hours after a burn.

A cautionary word about herbs: Know that herbs are not regulated by the FDA (Food and Drug Administration). Companies that supply herbs are under no obligation to show that the product works. Additionally, the company that sells the herb does not have to show that the herb is safe or effective, and cannot claim that the product can cure or prevent anything. Additionally there are no manufacturing standards to adhere to, which means you do not know how much herb or for that matter, any other contaminants, are in the herbs that you buy.

Julie Kardos, MD and Naline Lai, MD

©2017 Two Peds in a Pod®

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router safety

At college drop off last week, my  husband noticed an object that looked suspiciously like a router in our kid’s dorm room. Vaguely aware that routers emit some sort of radiation,  I turned to environmental medicine expert Dr. Alan Woolf for information, here is what he shared: 

Q: My daughter has a wireless router within 2 feet of where she sleeps. Is this a problem?

A: The answer to the question is unfortunately not a straightforward ‘no problem’. Routers are one of a number of devices, including tablets, cell phones, and cell towers, that give off electromagnetic radiation (EMR) or radiofrequency radiation (RFR). In 2013 more than 6.8 billion mobile phones were registered.

Animal studies of EMR/RFR shows some biological effects, but it is uncertain whether these are applicable to humans. Human studies (and there have been many) have been either inconclusive or negative and are frequently confounded by problems with their design. However one well-controlled, blinded 2015 study of 31 adult females (average age: 26 years) holding 3G mobile phones near their heads for 15 minutes showed evidence of changes in their brain waves on EEG. Whether these changes were long-lasting or of any health import are unanswered questions. The International Agency for Research on Cancer (IARC), part of the United Nations’ World Health Organization, said in June 2011 that a family of frequencies that includes mobile-phone emissions is “possibly carcinogenic to humans.”

Federal agencies, such as the NIOSH, FCC and FDA, have set safety standards for mobile phones, routers, cell towers, etc. that are inclusive of safety factors for EMR/RFR emissions for humans; no commercial devices can be sold in the U.S. that do not comply with such standards. RFR energy levels from Wi-Fi equipment in all areas accessible to the general public, including school settings, are required to meet Federal exposure guidelines. The limits specified in the guidelines are based on an ongoing review of thousands of published scientific studies on the health impacts of RFR energy. Levels of RFR energy emitted from Wi-Fi equipment are typically well below these exposure limits. As long as exposure is below these established limits, there is no convincing scientific evidence that emissions from this equipment are dangerous to schoolchildren or to adults. There is no scientific evidence of long-term or cumulative health effects of RFR in children.

Wireless routers in commercial use are very low energy devices and are not a safety concern. Still, It seems prudent to keep some distance away from EMR/RFR emitters when chronic exposure is likely. The strength (and therefore dose) of EMR/RFR is exponentially inversely proportional to distance from the emission. Apple Inc. itself recommends, for example, that mobile phones be held at least 5/8 inch away from the body, or that Bluetooth-type headphone devices be used to keep the head away from the phone emitter.

In reality, EMR/RFR waves are all around us (just see what happens when your cell phone is ‘searching’ for a signal–sometimes it finds half a dozen or more in your vicinity). Unfortunately the medical safety science has not kept up with advances in the technology and so there continue to be uncertainty and unanswered health questions concerning their safety.

Alan Woolf, MD, MPH

©2017 Two Peds in a Pod®

We thank Dr. Woolf for his insight, and Dr. Lai is happy to report that her daughter gets great wi-fi reception. Alan Woolf, MD, MPH is Professor of Pediatrics, Harvard Medical School (HMS), attending physician at Boston Children’s Hospital (BCH) and has authored over 250 original reports, scientific reviews, chapters, and other publications, many of them on topics concerning children’s poisoning and toxic environmental exposures. Among other accolades he is a past-president of the American Association of Poison Control Centers (AAPCC), and immediate past-president of the American Academy of Clinical Toxicology (AACT). Dr. Woolf has also served as external consultant to the World Health Organization’s International Program in Chemical Safety and as a member of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances, EPA. He was recently chosen as a member of the General Hospital & Personal Use Device Panel of the Food & Drug Administration (FDA) and also serves as a consultant to the Medical Devices Advisory Committee of the Center for Devices and Radiological Health of the FDA.

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flu vaccine update

“What? The flu vaccine again? We JUST got it,” our kids groaned when we told them it was time to get their flu vaccines. In fact, they “just got it” a year ago, which we pointed out to them. Read on to see updates on this year’s flu vaccine and why it  should be on your child’s back to school to do list. 

This year’s flu vaccine is slightly different from last year’s– it’s been changed to cover a different strain of circulating H1N1 influenza. Several flu vaccines have been FDA approved for this year’s flu season and all of them will give similar protection for your child. Make sure your child receives a flu shot and NOT the FluMist/spray-in-the-nose kind of vaccine. Unfortunately for those who are needle phobic, the FluMist has not been shown to be effective and therefore, while still licensed, is NOT recommended for use this year.

The flu vaccine is recommended for all kids six months of age and older, with very few exceptions. Even pregnant moms safely can receive the flu vaccine.

Too early for flu vaccine? Nope! Older adults might lose some immunity if vaccinated “too soon” in the season, but this observation is not born out in kids. The threat of incomplete or forgotten vaccine outweighs theoretical risk of delaying flu vaccine (even for older adults), so best to get it now.

In case you forgot, the flu is a week of misery, consisting of high fevers, cough and other respiratory symptoms, body aches, and headaches. Younger kids are prone to some diarrhea or vomiting or both along with these bad cold symptoms. The flu can cause dehydration and pneumonia, and sometimes death, even in previously healthy kids. Simply limiting your child’s exposure to people showing flu symptoms is not an effective way of preventing illness because people are the most contagious right before they show any symptoms.

Booster dose As in previous years, children under nine years of age need a booster dose the first year they receive the vaccine. If your young child should have received a booster dose last year, but missed it, they will receive two doses of this year’s vaccine spaced one month apart (the primary dose plus a booster dose).

This prior post teaches you how to tell if your kid has flu vs “just” a cold. We invite you to read more about this year’s flu vaccine on the Centers for Disease Control website here.

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

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Teach your child to recognize poison ivy: “leaves of three, let’em be!”

Recently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, poison ivy is NOT contagious. You can catch poison ivy ONLY from the plant, not from another person.

Another myth buster: You can not spread poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch:

Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.

Hydrocortisone 1%-  This is a mild topical steroid which decreases inflammation.  We suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day

Calamine lotion – a.k.a. the pink stuff- This is an active ingredient in many of the combination creams.  Apply as many times as you like.

Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti-itch properties.

Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub. Alternatively buy the commercial ones (e.g. Aveeno)

Do not use alcohol or bleach– these items will irritate the rash more than help

The biggest worry with poison ivy rashes is the chance of infection.  Just like with an itchy insect bite, with each scratch, your child is possibly introducing  infection into an open wound.  Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.

However, infections cause pain – if there is pain associated with a poison ivy rash, think infection.  Allergic reactions cause itchiness- if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure to poison ivy.  Infection usually occurs on the 2nd or 3rd day of scratching.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

Naline Lai, MD and Julie Kardos, MD
©2017, 2016, 2015 Two Peds in a Pod®, updated from 2012

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These lucky fish don't have to worry about swimmer's ear... they don't have any ears!

These lucky fish don’t have to worry about swimmer’s ear… they don’t have any ears! –Photo by Dirk Peterson, MD

It’s the type of ear pain that usually creeps up on a school-aged summer camper. One night he may notice discomfort when his ear is against his  pillow. The next night, the pain gets worse. Eventually, even touching the ear is painful. The ear is probably infected, but infected with “the other kind” of ear infection—swimmer’s ear.

Ear infections are divided into two main types: swimmer’s ear (otitis externa) and middle ear infections (otitis media). An understanding of the anatomy of the ear is important to understanding the differences between the two types of infection.  Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. The tunnel is called the external ear canal and the door is called the ear drum.

Swimmer’s ear occurs in the ear canal. Dampness from water, and it can be water from any source- not just the pool, sits in the ear canal and promotes bacterial infection.  

Next, open the door. You will find yourself in a room with a set of three bones. Another closed door lies at the far end.  Look down.  In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a middle ear infection, fluid, such as during a cold, can collect in the room and promote bacterial infection.  Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe, called the eustachian tube,  drains the fluid.  But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected. 

Because a swimmer’s ear infection occurs in the external canal, the hallmark symptom of swimmer’s ear is pain produced by pulling the outside of the ear.  Since middle ear infections occur farther down in the ear, pain is not reproduced by pulling on the outer ear.

Swimmer’s ear is treated topically by your doctor with antibiotic drops.  To avoid dizziness and discomfort when putting drops in, first bring the ear drop medicine up to body temp by holding the bottle in your hand.

Home remedies to prevent swimmer’s ear:

  • After immersion in the water, tilt your child’s head to the side and towel dry what leaks out.
  • Mix rubbing alcohol and vinegar in equal parts. After swimming, place a couple drops in the ear.  Do not put these drops in if there is a hole in your child’s eardrum. 
  • Prior to swimming put a drop of mineral oil or olive oil in each ear. This serves as a barrier protection against the water as well an ear wax softener. Do not put in if there is a hole in your child’s eardrum.

Although it’s tough to remind children to dry their ears well, take heart.  Dr. Lai once spent two hours trying to get a cockroach out of a child’s ear canal.   We  suspect those parents would have been happier if instead, water had gotten into their child’s ear.

Naline Lai, MD and Julie Kardos, MD

©2017 Two Peds in a Pod® 
updated from 2016

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father's day cartoonA few years ago, we asked our dad readers to help us write our Father’s Day post.  We thought you would enjoy hearing from them again. The dads completed this thought: “Before I became a dad, I never thought I’d…”

…Learn to curl hair for cheerleading competitions

 

…BE RESPONSIBLE

 

…Become a stay at home dad AND love it so much after everything I’ve been through!!

 

…Learn all of the names of Thomas The Tank Engine’s friends and the many songs associated with them.

 

…Have a toys r us in my house.

 

…Go food shopping at midnight.

…Make so many pancakes on Sunday mornings.

…Volunteer in a dunk tank and have pie thrown at me.

 

One of our readers summed up his thoughts on becoming a dad:

Since I’ve become a father, nearly seven years and two beautiful daughters later, my life has become a series of jobs that I never thought I would have to tackle. These include:

Beautician: I never thought in a million years that I would be learning how to do pony tails, side pony’s, braids (not that I can braid yet), and painting little finger and toe nails.

Disney Princess Aficionado: At one point in my life I thought I was cool because I knew a lot about beer, how it was made, where it was from, where the best IPA’s were being poured. Now I am “cool” because I know where Mulan lived, and because I know the story about Ariel falling in love with Prince Eric.

Doctor: I am well versed here and can cover almost everything from the simple band-aid application and boo-boo kissing, to the complex answering of why daddy is different and why he gets to go to the bathroom standing up.

Cheerleader: Both of my daughters enjoy participating in sports. It’s been such a great experience to cheer them both on from the side line. I enjoy watching them grow with the sport and gain confidence game after game.

Becoming a father was one of the best choices I have made with my life. I love being a dad, and I look forward to the future dad challenges, good and bad, and being the best mentor I can be.

Thank you to our readers for contributing to this post.

Happy Father’s Day!

Julie Kardos, MD and Naline Lai, MD

©2014, 2017 Two Peds in a Pod®

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