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Nearly seven years ago, on the swimming pool bleachers at the local Y, I happened to sit next to Lexi Logan. Above the echoing din of kids splashing, I discovered that although she was trained as a painter, Lexi was interested in branching out into photography. Coincidentally, Dr Kardos and I were interested in branching medicine out into a new media called the internet and were dismayed at the lack of publicly available photos to accompany our blog posts. Lexi and I intersected in the right place at the right time. Since that chance meeting, Lexi has generosity shared dozens of photos with Two Peds in a Pod.

The woman in the photo below, between your Two Peds (Dr. Kardos with the curly hair, Dr. Lai with the straight hair), is our photographer extraordinaire, Lexi Logan. Her work, which you can check out at www.lexilogan.com,  speaks for itself.  Local peeps may want to contact her to take their own family photos.

This Thanksgiving we say thanks to all those parents we’ve ever sat next to on bleachers. All the kid-related information we have learned, from navigating chorus uniforms, bus stop times, best teachers, fun summer camps, and even starting up blogs, has been invaluable.

In particular- thank you, Lexi!

We wish all of our readers a very healthy and happy Thanksgiving,

Dr. Naline  Lai with Dr. Julie Kardos

©2016 Two Peds in a Pod®

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stomach-painThis week Two Peds joined Kelley on her blog Happy Health Kids as she talked about the dreaded phrase, “My belly hurts.”

 

If I crunched the numbers on how often my kids have uttered certain phrases, “my belly hurts,” ranks pretty darn high. So common is this refrain, and typically uneventful the outcome, that there’s a cry-wolf quality to it; I typically point my child towards the pantry or bathroom and go about my day. But sometimes, a stomachache persists, and then figuring out the cause can be like falling into a rabbit hole (and equally unpleasant)….click here to continue

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texting collegeToday , Dr. Lai shares with us the texting guidelines she will be giving to her daughter as she goes away for college (wasn’t kindergarten just yesterday?). We can all learn from this list.

–Dr. Kardos

Text me to share a funny meme.

Text me to wish me a happy birthday and then follow it with a call.

Text me if you are about to go over our shared data plan.

Text me if you are deciding whether to study abroad.

Text me sooner than the day before spring break about your spring break plans.

Text me if you are unhappy about a break-up…even if you forgot to tell me you were going out in the first place.

Text me if you have a cold. I know you know what to do, but it will make us both feel better if I tell you to get good rest and hydrate well.

Text me if you are changing majors…but not before you have a plan for a new major

Text me if you find the essentials of life: “eat, sleep, drink, pee, poop,” difficult. Especially the poop—no one will ever obsess about your bowels like a mother (except maybe a grandmother).

Text me when you are not in class (because I know you will be paying rapt attention to your professors and sucking every last bit of paid knowledge out of their craniums).

Text me sometimes at 1am with the understanding that I will be texting you sometimes at 7 am.

Text me to ask for the phone number of your dentist, but do not ask me to schedule the appointment for you.

Text me if you are feeling 😬 or 😞 or like 💩.

Do not text and ask me to email your professors.

Do not text me to ask about your clothing choices for the day…unless you just want me to say you look beautiful.

Do not text me asking for college housing deadline information; you have the same access to the internet as I do. Plus, you are actually on campus!

Do text me to complain about the 4 loads of laundry you did all Saturday afternoon -it makes me happy to see you can survive on your own- and I promise not to lecture you on how you allowed the laundry to pile up.

And of course, text me out of the blue just to say ❤️

mom

aka Naline Lai, MD

©2016 Two Peds in a Pod®

 

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Teach your child to recognize poison ivy: "leaves of three, let'em be!"

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.

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.  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 not the itch, but the chance of 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, 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.  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

©2016, 2015 Two Peds in a Pod®, updated from 2012

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Time out from summer for a flu update

Time out from summer for a flu update

We interrupt your summer to bring you a Flu vaccine reminder and update.

Although flu (influenza) may be far from your minds, as we enter hot July, pediatricians are already ordering flu vaccines in preparation for Back to School. When the time comes, parents should add “schedule flu vaccine” to their back-to-school list as flu vaccines will arrive in offices as early as late August. Even immunizations given in August will last the entire winter season.

For fans of the nasal spray version of the flu vaccine—bad news. Turns out, data from the past 3 years shows the nasal spray is not nearly as effective as the injectable version. The American Academy of Pediatrics  and the American Center for Immunization Practices both recommend giving only the injectable version of flu prevention for protection against influenza.

Nonetheless, for the inconvenience of a pinch, the vaccine is still worthwhile. A total of 77 children died from flu in the US during the 2015-2016 flu season and many more children were hospitalized with flu related complications such as pneumonia and dehydration. Flu is highly contagious and spreads rapidly within households and schools, including daycare centers. People are contagious from flu one day prior to showing any symptoms of flu.

While most people who become sick with the flu survive, they will tell you it is a tough week. In addition to having a high fever that can last 5-7 days, a hacking cough, and runny nose, those stricken will tell you that every part of their bodies hurt. Even the movement of their eyes can hurt. In addition to the physical effects, our high school and college level patients are particularly distraught about the amount of schoolwork they miss while recovering from the flu.

An ounce of prevention is worth a pound of cure, which is why the flu vaccine is so terrific. There is no “cure” for the flu- you have to let your body fight it out. Unfortunately antiviral medications such as oseltamivir at best shorten the duration of flu symptoms by about one day. Flu vaccines work by jump starting your body’s natural immune system to produce disease fighting cells called antibodies. Vaccines are given yearly because flu virus strains  often morph between flu seasons.

For more Two Peds In a Pod posts about flu and about vaccines in general: How to tell the difference between the common cold and the flu, Fact or Fiction: a flu vaccine quiz, Getting back to basics: how vaccines work.

OK, now back to your summer fun!

Julie Kardos, MD and Naline Lai, MD

©2016 Two Peds in a Pod®

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Note that the hot tub folliculitis rash is worse under the area of the swimming suit at the top of the thigh.

Note that the hot tub folliculitis rash is worse under the area of the swimming suit at the top of the thigh.

 

From the start, a family I know was suspicious of the hot tub sanitation at the resort where they recently stayed. As time went by, even though the water looked clear, the hot tub seemed less chlorinated, and the water more tepid. They dubbed the tub “the scuz tub.” After their return, one of the kids broke out in the rash of hot tub folliculitis pictured above. You could say, they figured out just what the “scuz wuz”. 

 Hot tub folliculitis is a skin rash caused by a bacteria called pseudomonas aeruginosa. The rash appears a day or two after soaking in a hot tub. A light pink bump appears around hair follicles (hence the name). As you can see in this photo, the rash is typically worse on areas of skin where bacteria was trapped under a swimming suit. The rash can cover all body surfaces, including the face, if your child dunked his head under water.
 
The rash can be slightly itchy but is not usually painful. No other symptoms develop such as fever or sore throat. The rash is not contagious, but often other people who swam in the same hot tub also break out.
 
Treatment is to wait it out. Typically by one to two weeks, provided your child does not go back into the hot tub, the rash resolves on its own. If your child feels very itchy, you can treat her with oral diphenhydramine (brand name Benedryl). Rarely, just like mosquito bites, the rash can become infected with other bacteria if your child scratches too much.
 
Pseudomonas thrives in warm wet places. In fact, it’s the same bacteria that causes “swimmer’s ear.” Tight control of chlorine and acid content of the hot tub water limit the growth of the bacteria. Unfortunately, you cannot tell the pseudomonas content of water just by eyeing it.
 
May you bring back a better souvenir than this family did on your next vacation.
Julie Kardos, MD and Naline Lai, MD

©2012, 2016 Two Peds in a Pod®

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elephant nose

This Mother’s Day, we honor Dr. Kardos’s mom, who passed earlier this year.

Dr. Kardos and I had been planning a post on nasal congestion in kids, but because we couldn’t have said it any better, we share a poem that Dr. Kardos’s mom wrote on this topic.

–Drs. Lai and Kardos

 

Runny Noses

 

My grandsons seem always to have runny noses;

They drip from their noses and land on their toeses;

One kid especially, his name is Aaron,

Will hug you so tight that what’s runnin’ you’re sharin’.

 

Alex will wipe with the back of his hand;

His runs in the house, on the beach, on the sand.

Jacob is older and he’ll use a tissue,

So his runny nose is not much of an issue.

 

In case they have colds, I hand each one a sweater,

But wearing a sweater does not make things better.

Allergic to dust? That’s the answer I’m seeking;

But while I keep dusting, their noses keep leaking.

 

They eat well and sleep well and play hard all day

In spite of their dripping that won’t go away.

So I’ve come to conclude, and I’m happy to say

That the noses of kids prob’ly just come that way.

 

by Felice Kardos (1943-2016)

 

 

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sunburn

An inadvertent sunburn tattoo

I was greatly relieved recently when my teen arrived back from a music department trip to Disney without a sunburn. I had pictured a bright red cherry tomato coming off the plane. For those of us stuck in the middle of an East Coast perpetual rain cloud, it’s hard to believe that anyone outside of the South needs to worry about sunscreen. But soon enough, you will be scratching your head in a pharmacy aisle asking yourselves these questions:

What is SPF? 

  • SPF stands for Sun Protection Factor. SPF gives you an idea of how long it may take you to burn. SPF of 15 means you will take 15 times longer to burn without sunscreen.  If you would burn after one minute in the sun, that’s only 15 minutes of protection!
  • The American Academy of Pediatrics recommends applying a minimum of SPF 15 to children, while the American Academy of Dermatology recommends a minimum of SPF 30. We both apply sunscreen with SPF 30 to our own kids (mom hint: the high SPF sunscreens tend to be watery). 
  • Apply all sunscreen liberally and often– at least every two hours. More important than the SPF is how often you reapply the sunscreen. All sunscreen will slide off of a sweaty, wet kid. Even if the label says “waterproof,” reapply after swimming.
  • Watch out for sunlight reflecting off water as well as sunburning on cool days. One pediatrician mom I know was aghast at seeing signs posted at her kid’s school reminding parents to apply sun screen “because it will be in the 80’s.”  Kids burn on 60 degree days too. Lower temperatures do not necessarily mean less UV light.

Why does the bottle of sunscreen say to “ask the doctor” about applying sunscreen to babies under 6 months of age?

  • Sunscreens were not safety-tested in babies younger than 6 months of age, so the old advice was not to use sunscreen under this age. The latest American Academy of Pediatrics recommendation is that it is more prudent to avoid sunburn in this young age group than to worry about possible problems from sunscreen. While shade and clothing are the best defenses against sun damage, you can also use sunscreen on exposed body areas.
  • Clothing helps to block out sunlight. In general, tighter weaves protect better than loose weaves. Expensive “sun-protective clothing” is not always better—  a study from 2014 suggests regular clothing may be as protective.
  • Hats help prevent burns as well.
  • Remember that babies burn more easily than older kids.

Which brand of sunscreen is best for babies and kids?

  • Although clothing and shade block harmful rays the best, no one brand of sunscreen is better for children than another. We both tell our patients to apply a “test patch” the size of a quarter to an arm or leg of your baby and wait a few hours. If no rash appears, then use the sunscreen on whatever body parts you can’t keep covered by clothing. Look for UVA and UVB protection. More expensive does not always mean “better” and SPF above 50, according to the American Academy of Dermatology, has not been proven to be more effective than 50.

What do we know about the ingredients in sunscreen such as oxybenzone? In the United States sunscreen ingredients are considered medications and are regulated by the FDA. Oxybenzone is one of the oldest broad-spectrum (UVA and UVB) sunscreens, and was approved by the FDA in 1978. Oxybenzone’s main side effect is that it can cause allergic reactions of the skin. Recently, some people question whether oxybenzone can be a hormone disrupter and have questioned the use of oxybenzone. At this point, no hormonal disturbances have been clearly found in humans and the American Academy of Dermatology continues to support the use of oxybenzone.

Sunscreens made with zinc oxide and titanium dioxide (the white stuff on a lifeguard’s nose) have not garnered any questions nor sparked any debate about safety. Interestingly, zinc oxide is not only an effective sunscreen but also you will recognize it as the main ingredient in many newborn diaper rash creams.

Any info about the popular sprays?  For spray formulations of any type of sunscreen, many doctors are concerned that any aerosolized oily substance will irritate the lungs and are looking into long term effects now. Avoid spraying sun screen near a child’s head to avoid inhalation. Also with the spray, some dermatologists worry that people might not be as thorough when they apply a spray as when they apply a cream.

Can I use last year’s sunscreen? Most sunscreens have expiration dates, as long as your bottle hasn’t expired, then it should be effective. In general, sunscreens are designed to last about three years before they expire.

Remember when we used to call sunscreen lotion “suntan lotion,” and when tolerating red, blistering shoulders was considered a small price to pay for a tan? Live and learn.

Naline Lai, MD and Julie Kardos
Two Peds in a Pod® rev ©2016 , 2015 

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allergy medications kidsallergy medications kidsallergy medications kids

Lately, whenever I take my dog for her walk, she sneezes as soon as we get outside. I find it  interesting that my vet says I can give her Claritin—the same dose that I take for my own seasonal allergies. Must be time to repost our allergy medicine post featuring Dr. Lai’s poem.

–Drs. Kardos and Lai

The Quest for the Best  (antihistamine)

Junior’s nose is starting to twitch
His nose and his eyes are starting to itch.
 As those boogies flow
, you ask oh why, oh why can’t he learn to blow? 
 It’s nice to finally see the sun
But the influx of pollen is no fun. 
Up at night, he’s had no rest,
But which antihistamine is the best?

It’s a riddle with a straight forward answer. The best antihistamine, or “allergy medicine” is the one which works best for your child with the fewest side effects. Overall, I don’t find much of a difference between how well one antihistamine works versus another for my patients. However, I do find a big difference in side effects.

Oral antihistamines differ mostly by how long they last, how well they help the itchiness, and their side effect profile.  During an allergic reaction, antihistamines block one of the agents responsible for producing swelling and secretions in your child’s body, called histamine. Prescription antihistamines are not necessarily “stronger.” In fact, at this point there are very few prescription antihistamines. Most of what you see over-the-counter was by prescription only just a few years ago. And unlike some medications, the recommended dosage over-the-counter is the same as what we used to give when we wrote prescriptions for them.

The oldest category, the first generation antihistamines work well at drying up nasal secretions and stopping itchiness but don’t tend to last as long and often make kids very sleepy.  Diphendydramine (brand name Benadryl) is the best known medicine in this category.  It lasts only about six hours and can make people so tired that it is the main ingredient for many over-the-counter adult sleep aids.  Occasionally, kids become “hyper” and are unable to sleep after taking this medicine. Another first generation antihistamine is Clemastine (eg.brand name Tavist).

The newer second generation antihistamines cause less sedation and are conveniently dosed only once a day. Loratadine (eg. brand name Alavert, Claritin) is biochemically more removed from diphenhydramine than Cetirizine (eg. brand Zyrtec) and runs a slightly less risk of sleepiness. However, Cetirizine tends to be a better at stopping itchiness.
Now over-the-counter, fexofenadine (eg brand name Allegra) is a third generation antihistamine.  Theoretically, because a third generation antihistamine is chemically the farthest removed from a first generation antihistamine, it causes the least amount of sedation. The jury is still out.

If you find your child’s allergies are breaking through oral antihistamines, discuss adding a different category of oral allergy medication, eye drops or nasal sprays with your pediatrician.
Because of decongestant side effects in children, avoid using an antihistamine and decongestant mix (often, first generation antihistamines such as brompheniramine are combined in this fashion).

Back to our antihistamine poem:

Too many choices, some make kids tired,
Paradoxically, some make them wired. 
Maybe while watering flowers with a hose,
I’ll just turn the nozzle and wash his nose. 

Naline Lai, MD with Julie Kardos, MD

©2016 Two Peds in a Pod®

Updated  from the original  post April 10, 2011

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lyme rash photo

The classic bullseye rash of Lyme

 

Our infectious disease colleagues warn us that this year, winter in the Northeast United States was not cold enough for long enough to kill off as many ticks as usual. Thus, we folks in Pennsylvania are in for a more burdensome Lyme disease season. We’ve already had children come  to our office this spring with concerns of tick bites, so here’s an update on Lyme disease:

Lyme disease is spread to people by blacklegged ticks. Take heart- even in areas where a high percentage of blacklegged ticks carry the bacteria that causes Lyme disease, the risk of getting Lyme from any one infected tick is low. Niney-nine percent of the little critters DON’T carry Lyme disease… but there are an awful lot of ticks out there. Blacklegged ticks are tiny and easy to miss on ourselves and our kids. In the spring, the ticks are in a baby stage (nymph) and can be as small as a poppy seed or sesame seed. In order to spread disease, the tick has to be attached and feeding on human blood for more than 36 hours, and engorged.

In areas in the United States where Lyme disease is prevalent (New England and Mid-Atlantic states, upper Midwest states such as Minnesota and Wisconsin, 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 armpits, but can occur anywhere. When my kids were young, I showered them 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. Now that they are older I call through the bathroom door periodically when they shower: “Remember to check for ticks!” Read our post on how to remove ticks from your kids.

“I thought that Lyme is spread by deer ticks and deer are all over my yard.”  Nope, it’s not just Bambi that the ticks love. Actually, there are two main types of blacklegged ticks, Ioxdes Scapularis and Ioxdes Pacificus, which both carry Lyme and feed not only on deer, but on small animals such as mice.  (Fun fact: Ioxdes Scapularis is known as a deer tick or a bear tick.)

Most kids 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 red or pink. It can have some central clearing. The rash typically does not itch or hurt. The key is that the rash expands to more than 5 cm, and can become quite large as seen in the above photo.  This finding is helpful because if you think you are seeing a rash of Lyme disease on your child, you can safely wait a few days before bringing your child to the pediatrician because the rash will continue to grow. The Lyme disease rash does not come and then fade in the same day, and the small (a few millimeters) red bump that forms at the tick site within a day of removing a tick is not the Lyme disease rash. Knowing that a rash has been enlarging over a few days helps us diagnose the disease. Some kids have fever, headache, or muscle aches at the same time that the rash appears.

If your child has primary Lyme disease (enlarging red round rash), the diagnosis is made by a doctor examining your child. Your child does not need blood work because it takes several weeks for a person’s body to make antibodies to the disease, and blood work tests for antibodies against Lyme disease, not actual disease germs. In other words, the test can be negative (normal) when a child does in fact have early Lyme disease.

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- with a few weeks of antibiotics.

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. Your pediatrician needs to see the rash to make the diagnosis. This treatment prevents later complications of the disease. While the disease can progress if no treatment is undertaken, fortunately children do not get “chronic Lyme disease.” 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 you should contact your child’s doctor if it persists for longer.

Later stages of Lyme disease  may be treated with  the same oral antibiotic as for early Lyme but for 3-4 weeks instead of 2-3 weeks. The most common symptom of late stage Lyme disease is arthritis (red, swollen, mildly painful joint) of a large joint such as a knee, hip, or shoulder. Some kids just develop joint swelling without pain and the arthritis can come and go.

For some manifestations, IV antibiotics are used. The longest course of treatment is 4 weeks for any stage. 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. Some adults have lingering symptoms of fatigue and aches years after treatment for Lyme disease. While the cause of the symptoms is not understood, we do know that prolonged courses of antibiotics do not affect symptoms.

For kids eight years old or older, if a blacklegged tick has been attached for well over 36 hours and is clearly engorged, and if you live in an area of high rates of Lyme disease-carrying ticks, your pediatrician may in some instances choose to prescribe a one time dose of the antibiotic doxycycline to prevent Lyme disease. The study that this strategy was based on and a few other criteria that are considered in this situation are described here.* Your pediatrician can discuss the pros and cons of this treatment.

Bug checks and insect repellent. Protect kids with DEET containing insect repellents. The Centers for Disease Control recommends 10 to 30 percent DEET- higher percent stays on longer. Spray on clothing and exposed areas and do not apply to babies under two months of age. Grab your kids and preform daily bug checks- in particular look in crevices where ticks like to hide such as the groin, armpits, between the toes and check the hair. Be suspicious of random scabs. Dr. Lai once had a elementary school patient who had a blacklegged tick in the middle of his forehead. The mother noticed it at breakfast, tried to brush it off,  thought it was a scab and sent the boy to school. Later that day the teacher called saying, “I think your son has a bug on his face.”

Misinformation about this disease abounds, and self proclaimed “Lyme disease experts” play into people’s fears. While pediatricians who practice in Lyme disease endemic areas are usually well versed in Lyme disease, 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, look to the Center for Disease Control website: www.cdc.gov.

Julie Kardos, MD and Naline Lai, MD

©2016 Two Peds in a Pod®, updated from our original post in 2009

*link corrected 4/18/2016

 

 

 

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