When one of Dr. Lai’s kids was around two years old, she deliberately let go of Dr. Lai’s hand when wading in waist high water. She exclaimed, “Look mommy, I can swim!” But she couldn’t, and as she started to sink, Dr. Lai scooped her up. What if she had taken swim lessons? Would that have been enough to prevent drowning? It may have helped, but that’s not enough. Kids need layers of protection to prevent tragedy in water.

Just in time for summer, we have new evidence about drowning prevention for both young kids and teens. Read on for updated swimming and water safety tips and an offer for free swim competency lessons for older kids.

Who is most at risk for drowning?

Children age 4 years and younger.

Most of these kids drown when parents do not realize kids have access to water. Think bathtubs, buckets, and toilets as well as ponds, puddles, and pools. Drowning is silent. Parents need to always watch their children around any body of water.

Adolescents aged 15-19.

Several factors contribute, including under-estimating risk (strong tides, swimming out too far), overestimation of skills, and substance use. Be sure to discuss rules of swimming with all of your children even if they are strong swimmers, and instruct them never to swim alone or without a lifeguard. Set an example yourself by wearing life jackets while boating and abstain from alcohol consumption. Alcohol contributes to half of all boating accidents in the United States.

Kids with autism.

Like children with other behavioral disabilities, they often wander away from adults without warning.

Children with seizure disorders.

Drowning is the leading cause of accidental death in children with epilepsy. Like ALL children, kids who have seizures should never be left alone for even a second in pools or baths.

Kids with a predisposition to cardiac arrhythmias.

If your family has a history of heart arrhythmias (eg. Long QT, Brugada syndrome, Ventricular tachycardia), unexplained sudden death at a young age, or an unexplained drowning, bring it to your pediatrician’s attention. In your child, let your pediatrician know about any fainting/near fainting episodes, “funny” heart beats, or chest pain.

When should I start swim lessons for my child?

There is no standard recommended age, but evidence suggests that swim lessons, even for kids as young as 1-4 years, can add a level of protection against drowning. Goals of swim lessons include the ability to enter the water, surface, turn around, swim for 25 yards, tread water or float, and to exit the water safely.

Swim lessons should also include real life “what to do in case of an accident” scenarios, such as swimming with clothes on, how to recognize a swimmer in trouble, and how to call for help. They should learn never to swim without adult supervision. Older children, and all adults for that matter, should learn CPR.

There is lack of evidence that swim lessons for babies under one year protects babies. Babies this young have relatively large heads compared to their body size and are incapable of picking up their heads out of the water to breathe if they are submerged. Think of swim “lessons” for babies as a fun, social activity instead of a potentially life-saving class.

Even if your children take swim lessons, THEY ARE NOT DROWN PROOF. Stay within arm’s length of all young children and non-swimmers.

How can I make kids in my backyard pool safer?

Install a fence that is at least 4 feet high around the pool.

The fence should be self-closing and self-latching, and isolates the pool completely from the rest of the yard and the house.

Pool covers and barrier alarms may add another level of protection, but there is no data that demonstrates definitively that they prevent drowning.

The Consumer Product Safety Commission has detailed instructions and information on the latest safety products recommended for home pools.

Always supervise your swimming children.

Adults should be very clear with each other about who is watching the swimmers. Stay at arm’s length of non-swimmers and young swimmers, and refrain from texting, drinking alcohol, reading, socializing, or any other activity that takes your eyes off of your child or could shift attention away from kids in the water. When kids drown, they drown silently, so you will likely not hear trouble.

Non-swimmers and small children should wear life jackets, even in your own pool, for maximum water safety. Inflatables are not substitutes. Look for US Coast Guard approved jackets.

It bears repeating: most drownings occur when parents had no idea that their child had access to water.

A few years ago, Dr. Lai’s toddler-aged neighbor waddled over to the ice bucket at a Fourth of July party. Toddlers have big pumpkin shaped heads and before Dr. Lai could blink an eye, her neighbor tumbled into the water head first. Luckily Dr. Lai’s husband was standing next to the bucket and pulled the toddler out.

As this case shows, you can’t let your guard down, even if no pool or large body of water is in sight.

Small, blow-up backyard pools are the same as bath tubs in terms of drowning risk, so never leave kids unattended around these pools. Stay at arm’s length of your babies and toddlers when they play in these pools.

Additionally, never leave kids unattended, even briefly, in the bathtub.

We’re going to the beach- can my baby go swimming in the ocean? How about a pool?

Most pools, oceans, and lakes are much colder than bath water. Babies feel colder more quickly than adults. Remember your own parent telling you to come out of a pool because your lips were blue? Limit a baby’s exposure to cold water accordingly.

Chlorine will not hurt babies, but it can dry out skin. Apply moisturizer after swimming if your child’s skin gets dry.

Salt water is safe for babies and kids to swim in.

Young kids try to drink the water they swim in. Don’t let them. It’s not just your nephew who pees through his swim diaper that you need to worry about. Unfortunately, chlorine and salt fail to kill all viruses, bacteria, and parasites that might lurk in swimming water.

If your child swims outside, remember that sunburns occur more easily because sunlight reflects off the water. Apply sunscreen liberally before and after swimming, even if the sunscreen label says “waterproof.” Better yet, try to keep that baby hat on and have your child wear a sun protective shirt.

Can you suggest more ways my kids can play with water?

Water tables (which can double as sand tables in the spring, leaf tables in the fall and indoor snow tables in the winter) allow young toddlers to stand and play with toys in very shallow water.

Fill a bunch of different sized stacking cups with water for kids to pour, dump, or perhaps to mix with rocks, dirt, or leaves.

Simple squirt bottles are great fun. When Dr. Kardos’s twins were little they spent large amounts of time “watering” every plant, bush, flower, and blade of grass in the yard.

Transform chalk drawings into masterpieces by adding water.

Wet down your walkway and blow bubbles onto the cement – they will cling onto the walkway for a long period of time.

Local Parents: Do you live in Bucks County, PA? Has your child graduated from first grade? Do they know how to swim? The Y of Bucks County, in conjunction with the Children’s Hospital of Philadelphia, is offering free swim lessons for kids past first grade to achieve basic water skills competency. For more information on obtaining a voucher, email us at twopedsinapod@gmail.com.

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

Whenever we look at the child product recall lists from The Consumer Protection Safety Commission (CPSC), it never fails to amaze us that even big brand names crop up in product recalls for children. Ironically, most are not new-fangled products. Bouncer seats, high chairs, rattles, and bicycle helmets are often amongst the recalls. We figure after decades of baby product manufacturing, designers and production managers would understand what constitutes a potential hazard for kids.

We urge you to scrutinize the kid merchandise in your house and identify the potential hazards before your child ends up as the reason a product is on the CPSC list. In fact, you might have already missed a recall on your older products. According to kidsindanger.org, child product recalls occur a couple of times a week, but when a baby product is recalled, only 10-30 percent are ever retrieved. Because recalls occur AFTER injury or death occurs, it is better if parents assess the safety of child products before a recall.

Here are some common reasons for recalls:

Products fail to adhere to the American Academy of Pediatrics safe sleep guidelines. We know parents of crying young infants are often desperate to get some sleep themselves, but many sleep products are not studied. If it seems too good to be true, it probably isn’t. Infants are not ready developmentally to sleep through the night, so any product that promises to help your infant sleep through the night is, by definition, problematic. An example is the Rock ‘n Play sleeper which was recently recalled. The soft squishy inclined cradles clearly did not adhere to the safe sleep guidelines, but often we heard a parent say, ”But that’s the only place they will sleep.” Unfortunately, this recall does not undo the deaths of the 32 reported babies who died in the sleeper. In the wake of the recall, other companies who make similar sleepers are also recalling their products.

We cringe every time a family tells us they are using a new fangled piece of wrap-around-baby sleep gear or sleeping contraption, because
most involve soft surfaces (not advised), inclined surfaces (not advised) or things-in-the-crib-other-than-your-baby (also not advised).

Choking hazards: Babies and toddlers explore the world by mouthing objects. So drop on your hands and knees and see the world from their perspective. And don’t assume your kid has reached an age when “they should know better.” Ever wonder why many Monopoly game pieces go missing? Or why so many kids visit Emergency Departments after swallowing coins? In the past twenty years, the number of children visiting U.S. emergency rooms for swallowing objects doubled. Anything that can fit into a toilet paper tube (2.5 inches in diameter) is considered a choking hazard. Be aware that the toy may be too large to choke on, but a piece that breaks off may be small enough to choke on. Some great example of poorly thought-out products are teething necklaces made of beads strung together and decorative buttons on baby socks.

Ingestion hazards:

• Magnets might be a fun toy, yet they can stick together after a kid swallows them and erode through any piece of gut trapped between them. In fact, even when a parent is fairly certain that their child ate only one single magnet, we pediatricians know that because magnets can be so dangerous, we will check an X-ray, just in case there are more. After all, even an older kid is sometimes too embarrassed to fess up on the number swallowed.
• Batteries can corrode through the lining of the intestines, constituting an emergency. Check to make sure all battery backings are secure. Particularly problematic are button batteries. They are tiny and easily swallowed.
• Brightly painted wooden toys are beautiful, but they may contain lead paint. So can kid jewelry. Lead poisoning occurs usually through eating or drinking contaminated objects such as lead containing paint or paint chips. Be aware of old toys (think antique doll houses) made prior to 1978 (when lead was taken out of paint in the US), toys manufactured in China or other Pacific Rim countries, or imported candies from Mexico. If you are wondering about possible lead exposure, ask your child’s doctor to test your child for lead exposure with a simple blood test. Avoid purchasing home lead kits because they can be inaccurate.

Head entrapment hazards: Infant heads and toddler heads can get wedged. Be aware that slates on a crib need to be no more than 2 ⅜ inches apart, or no bigger than the diameter of a soda can. Beware of baby carriers or high chairs that could allow babies to slip through.

Fall hazard: Check to see all buckles are secure and unlikely to catapult your child out of the restraint. Baby carriers and strollers, especially the jogging ones, seem to crop up often in recalls.

For general guidelines for baby proofing click here.

Sign up for child product recall alerts through the CPSC, the American Academy of Pediatrics,  or kidsindanger.org. Help other families by reporting product concerns to CPSC.

Dr. Lai tells this tale: Years ago, my first child’s crib came with plastic clips which held up her mattress. As my husband and I assembled the crib, a few of the clips snapped and broke. By my second child, even more clips broke apart. By my third child, the crib clips were recalled.

Perhaps we should have been suspicious the first time.

Naline Lai, MD and Julie Kardos, MD
©2019 Two Peds in a Pod®

Does your child have an earache?

In the aftermath of flu and croup season, we are diagnosing a fair share of ear infections. But not all earaches are due to ear infections.

Read our post about ear pain and what to do about it.

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

Wondering how to burp a baby? We decided that words just didn’t convey what to do. So we introduce baby Emma in her first, and our first, how-to-video.

Any other video requests, send them our way.

[youtube https://www.youtube.com/watch?v=XvI5YcGkwSU?feature=oembed&w=1080&h=608]

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

“I think we just hit the four month sleep regression. My baby used to sleep better, and now at four months, she is waking up every hour! What happened?”

Sound familiar?

The term “four month sleep regression” did not appear on Google searches in the United States until 2006 and has been on the rise ever since.
It is not clear how the term came about. After all, babies existed well before 2006. Oddly, most of the search requests come from the state of California. Unfortunately, the term sleep regression has put many a parent into a panic. Do not worry. Sleep is not a developmental milestone, you do not need to move from California, and your baby is not regressing. Rather, your baby is changing. Just like eating and poop patterns change, sleep patterns also change.

Sleep in the beginning

In the beginning… there is newborn sleep. Newborns can fall asleep anywhere at any time: while feeding, in a stroller, on your chest, in your arms, in the car or on the floor. Sometimes they sleep for minutes, sometimes they sleep for a few hours.

For the first three months, babies are in a feeding frenzy mode. Babies this age gain about one ounce per day (a huge feat) so therefore they eat to sustain growth. So they eat, and eat, at a pace of every one and one-half to three hours. They are hungry buttheir bellies are small, so they must eat frequently. Sometimes they cluster feed every hour. Because they spend so much time feeding, chances are they often fall asleep while sucking either a breast or a bottle. Some babies, by the end of the third month, are sleeping longer at night and making up for missed feedings during the day.

The plot thickens…

Between three and four months, babies slow in the pace of their growth. From three to six months they gain only about one-half an ounce per day. Because they are not quite so ravenous and because their bellies are bigger now, they can wait longer between feedings. You will notice that a more discernible pattern to their day emerges and you can now tell the difference between “hungry” and “tired” cries.

Another change occurs around four months. You will notice that when your baby is hungry, they get excited when they either hear or see you preparing a bottle or positioning to breastfeed. They become AWARE that a feeding is about to happen and recognize events that immediately precede a meal.

That same awareness occurs around sleep. When she feels sleepy, your baby becomes aware of events that lead up to sleep. If that event is eating, then she will believe that EATING precedes SLEEPING. If that event is rocking with a parent to sleep or laying in a parent’s arms, then they learn that rocking or being held is the key to falling asleep.

The final piece of the puzzle

This increased awareness of sleep associations is likely the origin of the four month sleep regression. You see that the 4 month sleep regression actually is not a regression, but rather an AWARENESS of how to fall asleep. If you always put your baby down in the crib when tired, they will learn that resting in a crib is how to fall asleep. If you play music and put the baby in the crib, the baby will expect music and a crib to fall asleep. And if you always feed your baby to sleep, then feeding becomes the key to falling asleep.

Unlike when they were newborns, if you always put your four-month-old baby in the crib AFTER they fall asleep, they will eventually sense that something is different, and they will wake up. Imagine if you fall asleep in your bed and then wake up to find yourself on the front lawn. You will think to yourself, “WHAT ON EARTH JUST HAPPENED?” Then you will stomp back into the house and find your bed in order to go back to sleep.

If your baby falls asleep breastfeeding, and then you put them down in a crib, your baby may realize that the breast is no longer there. The realization will jolt them out of sleep (WHAT ON EARTH JUST HAPPENED?) and they will cry until you comply with your baby’s demand to breastfeed in order to fall back asleep. All understandable.

The solution: how to overcome the four month sleep regression

Herein lies the key to overcoming the four month sleep regression. Teach your baby that she wants to be in the CRIB to fall asleep. Now is the time to change up the bedtime routine so it ends with your baby in the crib AWAKE and then your baby will fall asleep on her own in the crib. Then, if she wakes up later in the night, she will think to herself: “Ok, I am in the crib, just where I was before. I am still tired and will go back to sleep now.” Same at nap time. When your baby gets drowsy, put her in her crib. It is not necessary to feed her first.

We do not advocate letting your baby “cry it out” yet— four months is too young. Developmentally, a four-month-old does not understand cause and effect. Anytime you show up, it’s a happy surprise. They do not realize that they have the power to “make you come.” However, you can allow for a bit of crying (say, five minutes maximum) because some babies need to unwind before they fall asleep. Remember, if you last fed your four-month-old within the hour, they are not hungry. They are just fussy. Do you remember stomping your foot as a child, rubbing your eyes and crying to your parents, “I am not tired! I do not want to go to bed now.”

If, however, your baby is not showing signs of self-soothing after a couple minutes, then go to them and pat them gently or pick them up for a cuddle. But, as soon as they calm down, put them back into the crib so they can learn to fall asleep in the crib, not on you. Allow them to learn that their crib is coming when they are tired, just as they learn that a breast or bottle is coming when they are hungry.

Once babies learn to fall asleep in the crib, many night time awakenings just stop happening. Keep in mind, most four-month-olds do not sleep for eight hour stretches overnight. Many still wake up once or twice to feed. Keep the feedings brief, and put your baby back into the crib BEFORE they drift off to sleep. Also, many babies are ready for additional solid food at this point. Discuss with your pediatrician if it’s time to give solid sustenance during the day along with liquids.

A parenting truth

The bottom line? The four month sleep regression is not a regression. Rather, it’s a sign of your baby’s emerging awareness of her environment and her readiness to learn how to fall asleep.

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

Dr. Kardos’s fourth child wears her coat without fuss in cold weather.

Now that the weather has turned “freezy,” parents ask us how to dress their baby (and big kids) for cold weather. Even Dr. Kardos’s teenaged kids allow her to  thrust winter coats on them as they head out to the bus stop. Wondering how to know if your baby, toddler, or older child are dressed correctly for the weather? Read our post on this topic.

Stay warm!

Naline Lai, MD and Julie Kardos, MD
©2019 Two Peds in a Pod®

Unfortunately, it is sick season. Fortunately, we have a great post to help you know when you need to call the doctor about your child’s illness. 

Julie Kardos, MD and Naline Lai, MD

©2018 Two Peds in a Pod®

Fight the flu! Vaccinate!

It’s time for your child’s yearly flu vaccine!

Why get the flu shot? Vaccinate against influenza (the flu) not only to avoid missed school days, but also to avoid hospitalizations and death. Last year in the USA, 172 children died from flu. You may not have heard about these fatalities because more sensational news tends to overshadow news about illness. We wish the news would inform that the vast majority of kids who died from flu had not received the flu vaccine. In addition, about half of the children who died from the flu were previously healthy and without underlying medical problems. Excluding the 2009 flu pandemic (H1N1), last year’s flu deaths represents “the highest reported since influenza-associated pediatric mortality became a nationally notifiable condition in 2004.” Kids younger than 5 years old have the highest flu complication rate of all children, so even if they do not yet attend daycare or school, bring your little ones in for a flu vaccine. Vaccinate your school-aged kids as well, for they spread the flu to more folks than any other age group.

Does it help to wait to give the vaccine? What if the vaccine wears off before flu season ends?
We wish we could predict just when the flu will hit, but sadly we cannot. Therefore, we urge you to give your children the flu vaccine as soon as your pediatrician has it available. Like all vaccines, it will take about two weeks for the protection against flu to kick in, and you never know when flu will strike your community. Did anyone catch the story about Vanilla Ice quarantined on a plane in New York with sick passengers last week? Turns out flu was on board. Don’t worry about immunity decreasing over time, infectious disease experts would not allow us to give it in early fall if they thought protection wouldn’t last for at least a few months.

If I give my children the flu vaccine every year, why do I have to give it again this year? Even we constantly-exposed-to-germs pediatricians get our flu vaccine yearly. The flu germs morph from year to year so the vaccine also changes.

Why does my younger child need a second dose this year?
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).

Is the nasal spray form back? Or is it only in injectable form?
The nasal spray form of the flu vaccine is back for healthy kids ages 2 years and up. However, this year, it received only a lukewarm reception from the American Academy of Pediatrics. The AAP recommends giving all children aged 6 months and older the flu SHOT, because in past years the intranasal form did not protect against the flu nearly as well as the shot did.

Not only is the nasal spray vaccine not getting a high endorsement, but some kids with asthma and kids with certain immune system problems are not allowed to get the nasal spray form. All kids can get the shot. So, pediatricians will continue to recommend injectable form of flu vaccine this year. However, with the rationale that something is better than nothing, for the severely injection-phobic family, some doctors may elect to give the nasal spray.

In the past, my child did not get the flu vaccine because he is allergic to eggs- did that change?
Even kids with severe egg allergies can get the flu shot safely in their pediatrician’s office. Now we know that allergic reactions to flu vaccine, as with any vaccine, are exceedingly rare.

We visit other people’s homes only if they are not sick. If my child’s friend doesn’t have flu symptoms, doesn’t that mean we can’t catch it from him?
Nope. You are infectious the day before symptoms show up.

Why is it worth it? The coverage is never 100 percent.
Children who get the flu vaccine but then get the flu anyway do not get sick as severely as kids who are unvaccinated. If all kids and adults got flu vaccine, then the chances of YOUR vaccinated child getting flu would be MUCH less. That’s how vaccines work.

Here we have tips on how to help your children if they get the flu.

You can read a comprehensive summary of this year’s flu vaccine recommendations from the Centers for Disease Control here.

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

Car seat safety isn’t just child’s play.

Just in time for families who plan to drive to Labor Day Weekend destinations, the American Academy of Pediatrics updated their car seat safety recommendations.

Families are now encouraged to keep their children rear facing for as long as possible, until they exceed the height or weight limit allowed by their car seat’s manufacturer. This means that some kids who are older than two years will continue to ride backwards. Dr. Lai’s own pip squeaks easily would have ridden backwards until they were three or four years old.

Regardless of age, kids facing backward in a car crash fare better than kids facing forward. A rear facing car seat prevents whip lash by fully supporting a child’s head and neck. A forward facing car seat does not restrain kids’ heads. In a crash, kids’ heads continue to move at the speed of the car until the shoulder harnesses and lap belts restrain their bodies. It makes us wish that grownups could also somehow ride backwards.

Other recommendations remain the same. For example, children can graduate from booster seats when they are 4 ft 9 inches tall and the car’s seat belt fits them properly. You can read about other car safety tips and view a link to children’s airline safety restraints in our 2017 post about car seat safety. In the post you will see a fabulous photo of a child who was saved by her car seat.

Again, no matter the age, as long as they fit, keep your children riding backwards in their car seats.

We’re thrilled that car safety has progressed over the years. Pictured here is Dr. Lai ready to go out in her 1960’s car seat :

Drive Safe!

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

Now that you just read how to drop your kid off at school on the first day, you may be backpack shopping, pondering what to send your child for lunch, and knowing that your child will have difficulty waking up early for school. Never fear! Your Two Peds can help you and your kids get ready for school.

First, make sure your child’s backpack fits correctly and is not too heavy. Our guest blogger, a pediatric physical therapist, provides tips to help lighten the load.

Help your child get back on a school-friendly sleep schedule. If your child is still in summer vacation sleep mode, we provide ways to help get your child’s sleep back on track.

If your child brings lunch to school, you may need some hints on what to pack and how to beware of junk food disguised as healthy food. And this post provides suggestions for healthy snacks.

Need suggestions on how to motivate your child to want to learn? Two former school principals share their wisdom in this post.

Finally, you should know when to keep your child home for illness. This post also contains some surprising truths about when you can send your child back to school during as well as after certain maladies.

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