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


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


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


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


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


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


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


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


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


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


Julie Kardos, MD

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When it comes to our children, we want the best that money can buy. However, in these difficult economic times, I want to offer some suggestions from the medical perspective that can save you money without compromising your child’s health or safety.


Don’t buy “Sippy cups.” Just teach your child to drink out of regular open cups. Sippy cups are for parents who don’t like mess-they are not a required developmental stage.  They are actually bad for teeth when they contain juice or milk and they do not aid in child development.


 


Buy generic acetaminophen (brand name = Tylenol), ibuprofen (brand name = Motrin, Advil), diphenhydramine (brand name = Benadryl), allergy medication (brand names Claritin, Zyrtec). If your child’s health care provider prescribes antibiotic such as amoxicillin (for ear infection, Strep throat, sinusitis), ask the pharmacist how much it costs because usually the cost of paying for this commonly prescribed antibiotic out-of-pocket is less than your insurance copay.


 


Accept hand-me-down clothes, shoes, etc. The purpose of shoes is to protect feet. Contrary to what the shoe sales-people tell you, cheap shoes or already-worn shoes will protect feet just as well as expensive, new ones. Just make sure they fit correctly.


 


Don’t buy “sleep positioners” for the crib. Place your newborn to sleep on his back and he will not/cannot roll over. If you need to elevate your baby’s upper body to prevent spit up or to provide comfort from gas, don’t buy a “wedge” but instead put a book under each of the 2 crib legs so the entire crib is elevated. Wedges and positioners are NOT shown to prevent SIDS (Sudden Infant Death Syndrome) and are NOT endorsed by the American Academy of Pediatrics.


 


Make your own baby food and do NOT buy “baby junk food” such as “Puffs” for finger food practice. Instead buy “toasted oats” (brand name = Cheerios) which are low in sugar, contain iron, and are much less expensive. “Stage 3” foods in jars are finger foods so just give your kids what you are serving the rest of the family cut into small bite-sized pieces instead of buying the expensive jars. One exception: do buy the baby cereals (rice, oatmeal, or barley) because they contain more iron than regular oatmeal and babies need the extra iron for their growth.


 


The best toys are ones that can be reconfigured and used again and again. Legos, blocks, crayons/markers/chalk, small cars, dolls, balls come to mind. Avoid one-time only assembly type items, breakables, etc. Have a “toy recycle” party or a pre-Halloween costume recycle party: everyone brings an old costume/toy they would like to trade and everyone leaves with a “new” item (kids don’t care if things are brand new or not, only if you teach them to care will they care). Along these same lines, inexpensive paint can turn a pink “girl’s bike” into her younger brother’s blue “boy bike.”


 


Borrow books from libraries instead of buying them in stores or look for previously owned ones at yard sales, thrift shops, etc.


 


Do not buy endless videos for your child. First of all, despite claims made on the packages, NO video has been shown to advance baby/toddler/child intelligence. In fact, almost all studies show that the more screen time a child logs in, the worse they fare in their language and intellectual development. Also there is some evidence that TV/video viewing in babies can be detrimental to their brain development. Now, as a pediatrician mom, I am not saying that I never sat down and watched Sesame Street with my children (I am a product of the “Sesame Street Generation,” after all). I’m just saying that I recommend using moderation and taking advantage of free offerings on public television instead of spending money on videos. Many libraries also offer free lending of videos if you and your child want occasional “down time” in front of the screen.

Julie Kardos, 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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    I just went through a stack of “mom’s-stuff-stashed-away-when-cleaning-for-a-party-and-forgotten-about” and stumbled on a green three inch by three inch curved piece of plastic.  What was it?  A tres modern chair for the Polly Pockets?  A piece to a bicycle seat? Some treasure from a birthday party? My husband also scratched his head at the unidentifiable object.  I was just about to put it in the “mom’s-unidentifiable-but-probably-useful” pile when it occurred to me what it was….the shield to a potty seat.  The shield sits at the front of a potty chair and is supposed to prevent a little boy’s spray from squirting you in the eye while they are sitting.  This reminded me to warn our readers/listeners who didn’t have a chance to listen to the potty training pod cast to throw the shields away.  They cause more harm than good when an excited little guy tries to jump quickly on and off the potty.   

    Why didn’t I throw mine away?  Who knows.  I have a patient’s family who kept the dried out remains of her belly button cord after it fell off .  After keeping them for thrity years, my own mother recently tried to give me back my twenty baby teeth.   I was going to throw the green piece of plastic away.  Maybe I’ll just keep it and give it to my son when he has his first child…boy, will he be surprised.

Naline Lai, MD

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You just don’t appreciate a picky eater until you have one, ” overheard at Dr. Lai’s dinner table.


 


Picky eaters come in 2 major varieties. One kind is the child who eats the same foods every day and will not vary her diet; for example, cereal, milk, and a banana for breakfast, peanut butter and jelly with milk or juice for lunch, and chicken, rice, and peas for dinner. This diet is nutritionally complete (has fruit, vegetable, protein, dairy, carbohydrate) but is quite “boring” to the parent.


 


            The other kind of picky eater is the child who either leaves out entire food groups, most commonly vegetables or meat, or leaves out meals, such as always eats breakfast but never eats dinner.


           


            My own children range from the One Who Tries Anything to the One Who Refuses Everything (these are my twins!). My oldest child lived on cheerios and peanut butter and jelly for about two years and now eats crab legs and bulgur wheat and other various foods. My point: I know where you’re coming from, I feel your frustration, and I will give you advice that works as well as optimism and a new way of thinking about feeding your children.


 


            Fortunately, from a medical point of view, toddler/child nutrition needs to be complete as you look over several days, not just one meal. For example, if every 3 days your child has eaten some fruit, some vegetables, some protein, some dairy, and some complex carbohydrates, then nutritional needs are met and your child will thrive!


 


Twelve ways to outwit, outplay, and outlast picky eaters


 


1)      Never let them know you care about what they eat. If you struggle with your child about eating, she will not eat and you will continue to feel bad about her not eating. Talk about the day, not about the food on the table. You want your child to eat for the simple reason that she feels hungry, not to please you or anyone else, and not because she feels glad or mad or sad or because of what you the parent will feel if she eats or doesn’t eat. Along these lines, NEVER cook a “special meal” for your toddler. I can guarantee that when they know how desperately you want them to eat your cooking, they will refuse it.


2)      Let them help cook. Even young children can wash vegetables and fruit, arrange food on platters, and mix, pour, and sprinkle ingredients. Older kids can read recipes out loud for you and measure ingredients. Kids are more apt to taste what they help create.


3)      Let them dip their food into salad dressing, apple sauce, ketchup etc., which can make their food more appealing or interesting to eat.


4)      Let them pick their own food. Whether you grow your own foods, visit a farm or just let your kids help you in the supermarket, kids often get a kick out of tasting what they pick.


5)      Hide more nutritious food in the foods they already like (without them knowing). For example, carefully mix vegetables into meatballs or meatloaf or into macaroni and cheese. Let me know if you want my recipe for zucchini chocolate chip muffins or Magic Soup.


6)      Offer them foods that you don’t like—THEY might like it. Here’s an example: my children were decorating Easter eggs with Dr. Lai’s children. My kids asked if they could eat their decorated hard boiled eggs. Now, hard boiled eggs are one of the few foods that I do NOT like. I don’t like their smell, their texture, and I really don’t like the way they taste. Yet, all three of my kids, including my pickiest, loved those hard boiled eggs dipped in a little bit of salt. Go figure. Now I have an inexpensive, easy, healthy protein source to offer even though I can’t stand the way my kitchen smells when I cook them… but hey, if my kids actually will EAT them…


7)      Continue to offer foods even if they are refused. Don’t force feed; just have them on the table. It could take 20 -30 exposures before your kids might try them so don’t despair.


8)      Hunger is the best sauce. Do not offer junk food as snacks. Pretzels, crackers, cookies, candy, and chips have NO nutritional value yet fill up small bellies quickly. Do not waste precious stomach space with junk because your insightful child will HOLD OUT for the junk and refuse good nutrition if they know they can fill up on snacks later. Along these lines, never bribe food for food. Chances are, if you bribe eating vegetables with dessert, all the focus will be on the dessert and a tantrum will follow. You and your child will have belly aches from stress, not full bellies


9)      It is okay to repeat similar meals day after day as long as they are nutritious. We might like variety as grownups but most toddlers and young kids prefer sameness and predictability.


10)  Turn off the TV. Trust me and trust numerous scientific behavioral studies on this, while it sometimes works in the short term, it never works in the long term. In addition, watching TV during meals is antisocial and promotes obesity.


11)  Do not become a “short order” chef. If you do, your child will take advantage of you. Also see rule #8. When your child says, I don’t want this dinner/lunch/breakfast, I want something else,” you say “The meal is on the table.” One variation of this that works in some families is to have one back up meal that is the same every day and for every meal and must be completely non-cook and nutritious, for example, a very low sugar cereal and milk, peanut butter and jelly sandwich, etc, that you agree to serve if your child does not want to eat what the rest of the family is eating.


12)   You can give your child a pediatric multivitamin. This tactic is not “giving up” nor is it cheating, and it can give the Parent as Provider of Nutrients peace of mind. You can either give a multivitamin every day or just on the days that you are convinced that your child has eaten nothing.


 


And if all else fails, just remember someday, your child will probably become a parent of a picky eater too, and she will consult ask you how to cope. You’ll be able to tell her what worked for you when she was a picky eater. 

Julie Kardos, MD with Naline Lai, MD



                 

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My husband and I finally saw the Star Trek movie the other night, and as I write our first blog entry for Two Peds in a Pod I feel like I am aboard the USS Enterprise taking off from the space station for the first time, to “explore all aspects of child care, to boldly go where this pediatrician has never gone before,” namely, cyberspace. 

After all, I spend my work days in my pediatric office seeing patients and interacting with parents directly. The internet was born while I was in medical school and because I was so busy studying, then working and raising a family, cyberspace remains mostly foreign territory to me. However, I realize that the huge majority of my patients’ families turn to the internet for all sorts of information, including medical advice.  Unfortunately, medical advice in cyberspace is often shady, inaccurate, or incomplete.

Dr. Lai and I hope to give you easily accessible, accurate pediatric information in the form of podcasts for those who are auditory learners and blogs for those who prefer written material.

We will address the everyday questions that we hear from parents in our practices and we welcome your suggestions. Please email us at twopedsinapod@gmail.com to suggest future blog and podcast content. We promise to keep our podcasts and blog entries brief so we can give you maximum information with your time constraints in mind.

Thank you for being a part of our maiden voyage.

Julie Kardos, MD

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