A thrilling moment in the office is when a mom of a patient shares with me that she is pregnant again. I say, “Wonderful!” What better gift to give your firstborn than a sibling! And I love being a part of good news! As an older sister myself, as a mother of three children, and as a pediatrician, I know the net result of adding another child to the family is positively fabulous.


Although the news is good, sometimes parents are anxious about how to prepare their firstborns for the birth of their younger sibling. Here is what I usually suggest:

For most kids under the age of three to four years, time literally has no meaning.  At best, everything in the past occurred yesterday, and everything in the future will occur tomorrow. So in general, there is no magic moment to announce a forthcoming new baby. A few weeks ahead of time, simply start talking about “when a baby comes to live with us.”  Don’t expect your child to really believe you until you walk into the house with the baby. And don’t be surprised if your firstborn asks, “When is it leaving?” Kids this age do not understand the idea of “forever” or “permanent.”

Parents often feel guilty about bringing a second baby into the home. They worry they will not have as much time for their firstborn.  Well, here’s one secret. Newborns aren’t all that demanding. Unlike with your first born, you will never  have the time or urge to stare endlessly at your second born while she sleeps.  But, the second time around you will realize that feeding, changing, and washing a newborn take up relatively little time. Your firstborn will likely continue to be the center of attention. She is, after all, much more interesting now that she can pretend and play simple games. Believe me when I tell you that you CAN play Candyland and breastfeed an infant at the same time. You CAN burp an infant while reading aloud to a toddler. You CAN change a diaper WHILE pretending you and your toddler are wild jungle animals. You CAN make a bottle while telling a terrifically exciting story to your toddler.

A word about visitors and gifts: the best part of a gift, to a toddler, is opening it, NOT what’s in it. So don’t worry about trying to make sure your older child gets a gift for every gift the new baby gets.  Just allow your toddler to open all the baby’s gifts (if she wants to) because “babies don’t know how to open presents, but big kids do!” Also, newborns don’t care who holds them so visitors are a perfect chance to hand off the baby and get on the floor and play with your toddler. To a toddler, parents are the most important and interesting people in the world.  Even if ten people walk in to visit the baby, your toddler will not be jealous if YOU are the one playing with her.

By three years old, kids understand taking turns. In addition to the above tips, if your eldest asks why you need to hold/feed/care for the baby “so much,” just explain that it’s the baby’s turn. Then reinforce how glad you are that your eldest is able to talk, feed herself, play with toys, and maybe use the potty.  Remind her that her ability to be independent make her more similar to Mommy and Daddy than to a baby.

Finally, realize whether your firstborn embraces her younger sibling with open arms or pretends that the new baby does not exist, you will have plenty of love to go around . Your  heart is big enough for everyone.  Dr. Lai tucks each of her three children in at night with the words, “I love you more than anyone in the universe.”

Truth be told, no one will make your younger child laugh as loud and long as her older sibling. Also, older babies are much more interesting than newborns. Even “luke warm” older siblings will warm up as time progresses and the baby becomes more interactive.

In the meantime, tell lots of “when you were a baby” stories to your older child. Toddlers are egocentric (they all think the world revolves around them) and they will LOVE being the main character in your stories. Bring out baby pictures and videos of your firstborn to share. Be sure to point out how far she has come and all the great things she can do now as a big kid.

I end with a personal story:

When I was pregnant with twins, many of our friends commented to us about our firstborn son, “Boy, you are really going to rock his world.”

HIS world, I would think to myself. How about OUR world?

In order to prepare him for his transition from “only child”to “big brother” we emphasized to our son (who was three at the time) that most older brothers get only ONE baby. Our son would be getting TWO babies! He was excited about having two instead of one. For years afterwards, whenever he heard about a pregnant aunt, friend, or neighbor, his first question was always, “Oh, how many babies is she having?”

Out of the mouths of babes….

Julie Kardos, MD
©2009 Two Peds in a Pod

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The moment is here, your web cam is on and you beam your toddler’s first steps to hundreds of relatives.  But what comes after this highly anticipated moment?  Your toddler’s walking gait looks more like Frankenstein’s than that of an Olympic athlete.  Deborah Stack, who holds Masters and Doctoral Degrees in Physical Therapy from Thomas Jefferson University, joins us today to tell us what to expect next from your little Frankenstein.

Naline Lai, MD and Julie Kardos, MD

_____________________________________________________________

I remember looking at my 16-month-old son and telling him, “You need to learn to walk before your new brother or sister is born.” I did not relish the idea of simultaneously carrying two children.   But even after my second was born, I still did a lot of carrying.  We all focus on our children’s first steps, but mature walking does not occur immediately.  

Toddlerhood officially begins when a child takes his first steps, around 12-15 months, and ends with a mature walking pattern around age three years.  But what happens in between?  Look for your child to begin taking steps with his feet closer together. His hands progress from being held out to the side near the shoulders to a relaxed position lowered at his sides as he moves.  Children will also begin to be able to walk on a wider variety of surfaces such carpet, grass, sand and inclines.  They will learn to walk sideways and backwards as well as maneuver around and over toys in their path.  Initially your child will probably walk on his toes or with his whole foot hitting the ground at the same time and his feet as wide apart as his shoulders or even more.  By age three, most children will walk with their feet just a few inches apart and a “heel-toe” gait, meaning their heel will hit first and then they will shift their weight forward to the big toe before lifting it for the next step.  Skills such as running and jumping occur at varying times during toddlerhood.  

Taking a walk is a great way to help your child develop his gait. But don’t restrict him to staying on the path!  Try walking on grass, playground surfaces, sand boxes, and snow.  Once your child can walk on level surfaces, try walking up and down hills and then across them.  Decrease your support as he gains confidence.  At the playground, climbing is a great way for toddlers to strengthen their muscles, as well as to develop balance and spatial awareness.

This holiday season, save the shipping boxes.  Stepping in and out of low boxes is a great way to practice balance and will provide hours of fun during the upcoming holiday festivities.

These tips will help you enjoy your child’s “next steps” as much as his first ones.

Deborah Stack, PT, DPT, PCS

www.buckscountypeds.com
© 2009 Two Peds in a Pod

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A friend of mine who has no children commented to me that many people tell him, “You just can’t know happiness until you have children of your own.” However, I know several adults who are very happy people and who have made a conscious decision to not have children. So I would actually amend the above adage to: “You just can’t know WORRY until you have children of your own.”


Especially in winter, many illnesses circulate. All these sick kids make for many worried parents. Some questions that I answer many times a day in the office are: “Okay, Doc, you just told me that my child is handling her illness right now, but how will I know if she is getting worse? When do I need to worry?”


Here is what I tell my patients’ parents:


First and foremost, trust your parent instincts that something is wrong.


Think about these THREE MAIN SYSTEMS: breathing, thinking, and drinking/peeing.


Breathing:


Normally, breathing is easy to do. It is so easy, in fact, that if you take off your child’s shirt and watch her breathe, it can be hard to see that she is breathing. You should try this while your child is healthy. Normal breathing does not involve effort. It does not involve the chest muscles.


If your child has pneumonia, bad asthma, bronchitis, or any other condition that causes respiratory distress, breathing becomes hard. It becomes faster than baseline. It involves chest muscles moving so it looks like ribs are sticking out with every breath. The chest itself moves a lot. Kids’ bellies may also move in and out. Nostrils flare in attempt to get more oxygen. Sometimes kids make a grunting sound at the end of each breath because they are having difficulty pushing the air out of their lungs before taking another breath in. Also, instead of a normal pink color, your child’s lips can have a blue or pale color. Pink is good, blue or pale is bad. Children old enough to talk may actually have difficulty talking because they are short of breath. Any of the above signs tell you that your child needs medical attention.


Thinking:


This refers to mental or emotional state. Normally, children recognize their parents and are comforted by their presence. They are easy to console by being held, rocked, massaged, etc. They know where they are, and they make sense when they talk.


Change in mental state, whether it comes from lack of oxygen/shortness of breath, pain, or severe infection, results in a child who is inconsolable. She may not recognize her parents or know where she is. Instead of calming, she may scream louder when rocked. She may seem disoriented or just too lethargic/difficult to arouse. Being very combative can also be a sign of not getting enough oxygen. In a baby, extreme pain can cause all these signs as well.


Drinking/peeing:


While this varies somewhat depending on the age of the child, most kids urinate every 3-6 hours or so. Young babies may urinate more frequently than this and some older kids urinate perhaps 2-3 times daily. You should know your child’s baseline. Normal urine reflects a normal state of hydration. If you don’t drink enough, you will urinate less.


If your child has fever, coughing, vomiting, or diarrhea, she will use up fluid in her body faster than her baseline. In order to compensate, she needs to drink more than her baseline amount of liquid to urinate normally. A child will refuse to drink because of severe pain, shortness of breath, or change in mental state, and may go for hours without urinating. This is a problem that needs medical attention. Occasionally a child will urinate much more than usual and this can also be a problem (this can be a sign of new diabetes as well as other problems). Basically any change from baseline urine output is a problem.


A note about fever: any infant 8 weeks of age or younger with fever of 100.4 F or higher, measured rectally, requires immediate medical attention, even if all other systems are good. Babies this young can have fever before any other signs of serious illness such as meningitis, pneumonia, blood infections, etc. and they can fool us by initially appearing well.


In older babies and children, fever is defined as 101 F or higher. Some kids can look quite well even at 104 and others can look quite ill at 101. Fever is a sign that your body’s immune system is working to fight off illness. In addition to fever, it is important to look at breathing, thinking, and hydration state because this will help you determine how quickly your child needs medical attention. A child with a mild runny nose and fever of 103 who can play still play a game with you while drinking her apple juice is less ill than a child with a 101 fever who doesn’t recognize her parents.


To summarize, any deviation from normal breathing, thinking, or drinking/urinating (peeing) is a problem that needs medical attention, even if no fever is present. In addition, any change in the wrong direction (getting worse instead of getting better) is a problem that needs medical attention.


Finally, all parents have PARENT INSTINCT. Trust yourself. Ultimately, if you are wondering if you should seek medical advice, just do it. If parents could just worry every problem away, no one would ever be sick.


Julie Kardos, MD with Naline Lai, MD
© 2009 Two Peds in a Pod

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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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Sudden Infant Death Syndrome, or SIDS, refers to the sudden unexplained death of an infant between the ages of 1-12 months and seems to occur during sleep. We (meaning pediatricians and the rest of the scientific community) still don’t know exactly what causes SIDS, although we do know that some babies seem to be more at risk, such as premature infants and infants of multiple births (twins, triplets, etc).While parents cannot control prematurity and multiple births, parents CAN control other risk factors. 

Here is a summary of ways to reduce the risk of Sudden Infant Death Syndrome (SIDS) as recommended by the American Academy of Pediatrics:

·    Place babies on their backs (supine) to sleep. Do not waste money buying positioners or wedges for the crib because they are not proven to prevent SIDS and are not endorsed by the American Academy of Pediatrics. A newborn cannot roll from back to stomach. If you start out always placing your infant down on his back to sleep, he will stay this way and learn to like to sleep this way. Side sleeping is not as safe as back sleeping.

·    Do not sleep with your baby in a chair, couch, or adult bed. You can take your infant into your bed to nurse/feed but then put him back in his own sleep space.

·    Do not let your infant sleep in a bed with older siblings. Put your baby in his own crib.

·    Put nothing in the crib other than your baby. No stuffed animals, blankets, pillows, etc. Even bumpers are not recommended.

·    Do not smoke in the room where your baby sleeps.

·    Offer a pacifier. This has a protective effect.

·    Breastfeeding has a protective effect.

Some parents admit to us that they place their babies stomach down (prone) to sleep because “the baby sleeps better that way.” Unfortunately, what seems to be easier in the short run isn’t always the best for children in the long run. For the same reason that you should insist your children wear bike helmets and seatbelts, even if they protest at times, you should put your children down on their backs (supine) to sleep as infants. The rate of SIDS in the USA has dropped by over 50% since 1994 after the start of a “Back to Sleep” campaign. This sleep position change has been the single most effective way, to date, of reducing the rate of SIDS. Of course if your child has any rare medical condition that may prevent supine sleep, your child’s doctor should advise you on the safest sleep position for your child.

The best way to form good habits is to use them from the beginning. It is perfectly safe to position your newborn on his belly during awake time/ playtime while you are with him. However, if you are putting your baby down to sleep, or if you are putting your baby down and walking away and during this time he might fall asleep, just put your baby down on his back. And remember to tell anyone else who cares for your baby the same instructions, including daycare workers, nannies, and even well-meaning grandparents, because safe sleep advice has changed over the generations.

 

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

 

 

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We noticed Atom 1.0 readers did not pick up the podcast. Try the RSS 2 feed instead.

Let us know about any technical glitches.  We are still very new to cyberspace and appreciate your feedback.  We say in our podcasts, “Right now our recording studio is our kitchen table”…. you should see our computer help desk

Naline Lai, MD and Julie Kardos, 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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Boo (boo-hoo)

A lot of Halloween festivities in our area have been dampened by H1N1 flu.  For all the parents of the boys and ghouls in a similar situation, this picture will make you smile.  It was sent to me by Ben’s mom.  It is flu from the perspective of a kindergarten boy.  The arrow points to Ben’s nose.  Note the huge boogie to nose ratio.  The red represents “boss germs” and the purple ones are the “just plain mean” ones. 

Don’t let the “Boogie” man get your family this Halloween

Naline Lai, MD

© 2009 Two Peds In a Pod

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And speaking of vaccines…

Do you ever wonder how a vaccine works?

To understand how vaccines work, I will give you a brief lesson on the immune system. Trust me, it is interesting. Let me give you an example of me. When I was eight, I had chicken pox. It was a miserable week. I started out with fever and headache, then suffered days of intense body itching from blister-like spots, and ultimately, because I “scratched off” some scabs, ended up with scars. During this time, my immune system cells worked to battle off the chicken pox virus. Immune cells called memory cells also formed. These cells have the unique job of remembering (hence the name “memory cells”) what the chicken pox virus looks like. Then, if ever in my life I was to contact chicken pox again, my memory cells could multiply and fight off the virus WITHOUT MY HAVING TO GET SICK AGAIN WITH CHICKEN POX. So after I was well again, I was able to play with my neighbor even while he suffered with chicken pox.  I even returned to school where other children in my class had chicken pox, but I did not catch chicken pox again. Even now, as a pediatrician, I don’t fear for my own safety when I diagnose a child with chicken pox, because I know I am immune to the disease.

This is an amazing feat, when you think about it.

So enter vaccines. A vaccine contains some material that really closely resembles the actual disease you will protect yourself against. Today’s chicken pox vaccine contains an altered form of chicken pox that is close to but not actually the real thing. However, it is so similar to the real thing that your body’s immune system believes it is, in fact, real chicken pox. Just as in the real disease, your body mounts an immune response, and makes  memory cells that will remember what the disease looks like.  So, if you are exposed to another person with chicken pox, your body will kill off the virus but YOU DON’T GET SICK WITH THE CHICKEN POX. What a beautiful system!

Before chicken pox vaccine, about 100 children per year in the US died from complications of chicken pox disease. Many thousands were hospitalized with secondary pneumonia, skin infections, and even brain damage (encephalitis) from chicken pox disease. Now a shot in the arm can prevent a disease by creating the same kind of immunity that you would have generated from having the disease, only now you have one second of pain from the injection instead of a week of misery and possible permanent disability or death. I call that a Great Deal!

All vaccines operate by this principle: create a safe environment for your immune system to make memory cells against a potentially deadly disease. Then when you are exposed to someone who actually has the disease, you will not “catch” it. Your body will fight the germs, but you do not become sick. If everyone in the world were vaccinated, then the disease itself would eventually be completely eradicated. This happened with small pox, a disease that killed 50 percent of infected people. There is no longer small pox because nearly everyone on earth received the small pox vaccine. Now we do not need to give small pox vaccine because the disease no longer exists. This is a huge vaccine success story.

Friedrich Nietzsche said “What doesn’t kill us makes us stronger.” We pediatricians feel this is unacceptable risk for children. We would rather see your child vaccinated against a disease in order to become immune rather than risking the actual disease in order to become immune.

Hopefully this blog post answers your questions about how vaccines work. For more details or more in depth explanations, I refer you to the AAP (American Academy of Pediatrics) website www.aap.org, the Children’s Hospital of Philadelphia’s Vaccine Education Center at www.chop.edu,  and the book Vaccines: What You Should Know, by pediatricians Dr. Paul Offit and Dr. Louis Bell.

Julie Kardos, MD and Naline Lai, MD

© 2009 Two Peds In a Pod®

updated 1/18/2015

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Unless your child is getting the flu mist, your child may receive not only the seasonal flu vaccine as an injection this year, but also the H1N1 vaccine as an injection. Here’s how you can take away the sting of any needle:


Set the stage. Your child looks to you for clues on how to act. If mommy and daddy are trembling in the corner of the room, it will be difficult to convince your child that the immunization is “no big deal.”  Do not tell your child days in advance that she will be immunized. The more you perseverate, the more your child will perceive that something terrible is about to happen. Simply announce to your child right before you leave to get the immunization, “We are going to get an immunization to protect you from getting sick.”


 


Do not say “I’m sorry.” Say instead,”Even if this is tough, I am happy that this will protect you.”  


 


Never lie.  If your kid asks “will it hurt?”say “less than if I pinched you.”


 


Watch your word choice. Calling an immunization “a shot” or “a needle” conjures up negative images. In general, avoid negative statements about injected vaccines. I cringe when parents in the office threaten children with,” If you don’t behave, then Dr. Lai will give you a shot.”


 


Remember the mantra, if all is well in the basic areas of eat, sleep, drink, pee, and poop, then any stressor is easier to handle. 


 


Kids talk. Be aware that kids, especially those in kindergarten, like to scare each other with tall tales. Ask your child what they have heard about vaccines. Let children know that Johnny’s experience will not be their experience.


 


The moment is here.


 


You may have heard about a topical cream which numbs up an area of skin. Unfortunately, because the creams anesthetize the surface of the skin and most vaccines go into muscle, I do not find the creams very effective at taking the pain away. 


 


Instead, practice blowing the worries away. Have your child practice breathing slowly in through her nose and blowing out worries through her mouth. For the younger children, bring bubbles or a pin wheel for your child to blow during the immunization. In a pinch, take a piece of the exam paper in the room and have your child blow the paper.


 


The cold pack: holding something very cold can distract your child’s brain from feeling the pain of an injection.


 


“Transfer” the immunization to mommy or daddy.  Have your child squeeze your hand and “take the immunization” for him.


 


Tell your child to count backwards from 10 and it will be over. In reality, it will be over before your child says the number seven.


 


Have as much direct contact with your child as possible. The more surfaces of his body you touch, the less your child’s brain will focus on the injection. Again, this is the distraction principle at work. By touching your child, you are also sending reassuring signals to him. For the younger child, if he is on the table, stay close to his head and hug his arms, or have him on your lap. For the older child and teen, hold their hand. I sometimes see parents of older teens and college students leave the room. Even the big kids may need someone to keep them company.


 


Help hold your child firmly. Holding him will make him feel safe and will  prevent him from  moving during the injection. Movement causes more pain or even injury.


 


After the drama is over. 


Have your older child sit quietly for a moment. As the anxiety and tension suddenly falls away, the body sometimes relaxes too suddenly and a child will start to faint.  This phenomenon seems to happen most often with the six foot tall stoic teenage boys.  We have a saying in my office- The bigger they are, the more likely they are to fall.


 


Compliment your child. Remind them that you will never let anyone really hurt them.


Now a story:


When my middle daughter was two years old, my family trouped into my office for the flu vaccine injection. We all sat calmly in a circle and smiled. 


First, the nurse gave me my immunization. I smiled. My middle daughter smiled.


Second, the nurse gave my husband his immunization. He smiled. My middle daughter smiled.


Then the nurse gave my oldest daughter her immunization. She smiled. My middle daughter smiled.


Then the nurse gave my middle daughter her immunization. She did not smile. She did not cry. Instead, she slugged the nurse with her little fist.  I think the nurse felt more pain than my child.


Someday all immunizations will be beamed painlessly into children via telepathy. Until then, I have no advice on how to take the sting away from the punch of a two year old. 


Naline Lai, MD


© 2009 Two Peds In a Pod

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