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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

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Drs. Kardos and Lai advise parents on what they can do for their tired teen. Although we all enjoyed an hour’s extra sleep this past weekend with the resetting of the clocks, many teens are back to their “usual” sleep deprived state. Listen here to find out how to help reset your teen’s internal clock, and what  to consider when you have a tired teen.


 




Julie Kardos, MD  and 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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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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poisonivyRecently 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.

Also, contrary to popular belief, 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.  I 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.
  • Do not use alcohol or bleach- these items will irritate the rash more than help

The biggest worry with poison ivy rashes is not the itch, but the chance of super-infection.  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, a hallmark of infection is tenderness- if there is pain associated with a poison ivy rash, think infection.  A hallmark of an allergic reaction is 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.  Infection usually occurs on the 2nd or 3rd days.  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

2012 Two Peds in a Pod®

photo updated 6/03/12

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lyme rashAs we are in the middle of Lyme disease season here in the Northeastern United states, I thought I should address Lyme disease. I have diagnosed 8 cases so far this summer, seven in my office and one at a picnic, and what struck me in each case was how relieved the parents were to find out how easy it is to treat the disease when it is diagnosed early. It is important to treat Lyme disease in the early phase because this treatment prevents later manifestations of the illness (arthritis, meningitis, etc.).

 Lyme disease is spread to people by deer ticks. Any one deer tick that you pull off your child has only a 1% chance of transmitting Lyme disease, but the reason so many people get Lyme disease is that there are an awful lot of deer ticks out there.

In areas where Lyme disease is prevalent (New England and Mid-Atlantic states, upper Midwest states, and California), parents should be vigilant about searching their children’s bodies daily for ticks and for the rash of early Lyme disease. Tick bites, and therefore the rash as well, especially like to show up on the head, in belt lines, groins, and axillas (armpits), but can occur anywhere. I shower my kids daily in summer time not just to wash off pool water, sunscreen, and dirt, but also for the opportunity to check them for ticks and rashes.

Most kids do get the classic rash of Lyme disease at the site of a tick bite. The rash most commonly occurs by 1-2 weeks after the tick bite and is round, flat, and typically red. It can have some central clearing. The key is that the rash expands and becomes larger than 5cm. Untreated, it can become quite large as seen in the above photo. The rash does not itch or hurt. This finding is helpful because if you think you are seeing the primary rash of Lyme disease on your child, you can safely wait a day or two before bringing your child to his health care provider because the rash will continue to grow. The Lyme disease rash does not come and then fade in the same day. In fact, the history of a rash that enlarges over a few days is helpful in diagnosing the disease. Some kids have fever, headache, or muscle aches at the same time that the rash appears.

The second phase of Lyme disease occurs if it is not treated in the primary phase. It occurs about one month from the time of tick bite. Children develop a rash that looks like the primary rash but appears in multiple body sites all at once, not just at the site of the tick bite. Each circular lesion of rash looks like the primary rash but typically is smaller. Additional symptoms include fever, body aches, headaches, and fatigue without other viral symptoms such as sore throat, runny nose, and cough. Some kids get the fever but no rash. Some kids get one-sided facial weakness. This stage is called Early Disseminated disease and is treated similarly to the way that Early Lyme disease is treated.

If your child has primary Lyme disease (enlarging red round rash), the diagnosis is made on clinical presentation alone. No blood work is needed because it takes several weeks for a person’s body to make antibodies to the disease, and blood work tests for antibody response. In other words, the test can be negative when a child does have early Lyme disease. Therefore, treatment begins after taking a history and performing a visual diagnosis.

The treatment of early Lyme disease is straightforward. The child takes 2-3 weeks of an antibiotic that is known to treat Lyme disease effectively such as amoxicillin or doxycycline prescribed by your child’s health care provider. This treatment prevents later complications of the disease. While the disease can progress if no treatment is undertaken, in children there is no evidence of “chronic Lyme disease” despite claims to the contrary. Once treatment is started, the rash fades over several days. Sometimes at the beginning of treatment the child experiences chills, aches, or fever for a day or two. This reaction is normal but your child’s health care provider should be contacted if it persists for longer.

If not treated early, then treatment starts when diagnosis is made during later stages of Lyme disease and may include the same oral antibiotic as for early Lyme but for 4 weeks instead of 2-3 weeks. The most common symptom of late stage Lyme disease is arthritis (red, swollen, painful joint) of a large joint such as a knee, hip, shoulder. Some kids just develop joint swelling without pain. The arthritis can come and go. This stage is prevented by early treatment but is also can be treated with antibiotics.

For some manifestations, IV antibiotics are used. The longest course of treatment is 4 weeks for any stage. Again, children do not develop “chronic Lyme” disease. If symptoms persist despite adequate treatment, sometimes one more course of antibiotics is prescribed, but if symptoms continue, the diagnosis should be questioned. No advantage is shown by longer treatments.

Misinformation about this disease abounds, and self proclaimed “Lyme disease experts” play into people’s fears. If you feel that you need another opinion about your child’s Lyme disease, the “expert” that you could consult would be a pediatric infectious disease specialist.

For a more detailed discussion of Lyme disease, I refer you to the Center for Disease Control website: www.cdc.gov.

Julie Kardos, MD with Naline Lai, MD

2009 Two Peds in a Pod, updated 2015

 

 

 

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