Two Peds in a Pod®

Don’t roll your eyes at strabismus (lazy eye)

My patient looked up at me. “Do you want to see what I can do?” she asked.

Her father mockingly moaned, ”Oh, no.”

“Pleeease,” persisted the girl, “just once.”

The dad just laughed.

“Watch,” she said proudly as she suddenly rolled her eyeballs back and flipped her eyelids inside out with her fingers.

“Very impressive,” I told her, and snapped a photo.

__________________________

Voluntary eye movements like the one in the photo may be ugly to look at but are not damaging. Nor will the child’s eyes be forever stuck in that position. On the other hand, any involuntary eye movement should be investigated.

In particular, be vigilant for lazy eye (strabismus). In this condition, the eyes are do not align correctly and drift. According to the most recent edition of Nelson Textbook of Pediatrics, lazy eye affects about four percent of children under six years of age and can manifest itself in infancy.

By two months old, your child’s eyes should be able to fix on your face and move together as she watches you. If you notice her eyes cross beyond this age, take her to her doctor. Lazy eyes tend to run in families. The child pictured immediately here has several relatives with lazy eyes.

The cause of most lazy eye is unclear; however some cases are due to a defect in the pathways of the brain and nerves which control eye movement. Occasionally, some types are associated with other medical problems.

Detection of a lazy eye is important because a “lazy” eye can lose vision (amblyopia) from underuse. Treatment for most kids involves covering the good eye and forcing the lazy eye to “do more work” in order to prevent amblyopia. Ophthalmologists (eye surgeons) use techniques such as covering an eye with a patch, prescribing special glasses, or using eye drops to encourage the use of the lazy eye. For some, surgery is needed to fully align the eyes. The earlier treatment starts, the more rapid the response. Unfortunately, after a child is eight years old, treatment is much less effective.

Shortly after the girl showed me her eye rolling talent, a boy in the office showed me another intriguing trick. By inhaling deeply, the boy sucked in one nostril until it flattened without pulling in the other one.

Didn’t take a picture of that one.

Naline Lai, MD with Julie Kardos, MD

September 18, 2010 by twopedsinapod

Of Bracelets and Breast Exams

Move over liveStrong bracelets, move over Silly Bandz. Just when you thought you threw away the your last Oriental Trading Company gadget, here come “I Love Boobies” bracelets. As I see the newest overpriced piece of fashionable rubber dangle from my daughter’s wrist, I sigh at the cost, but console myself that at least the money goes towards breast cancer research. Use the bracelets as a reminder to teach your girls to do monthly breast exams. The American Cancer Society recommends monthly self-breast exams starting at age twenty. However, most pediatricians recommend starting exams earlier. Breasts are full of normal lumps and bumps and your teen or young adult should know her baseline. For directions on conducting a breast exam refer to American College of Obstetrics and Gynecology’s online pamphlet . Yes, even a fashion accessory can turn into a parental teaching point. Now what do jeggings teach kids?

Naline Lai, MD with Julie Kardos, MD

September 14, 2010 by twopedsinapod

Beth

At this time of the Jewish High Holy Days, Dr. Kardos offers us a glimpse into lessons learned as a doctor in training. This is a true story she wrote years after meeting Beth and until now, had only shared with a few close friends.

Tonight starts Yom Kippur and my two youngest children are asleep in their beds. As my oldest sits in the rocker next to my desk reading the last book in the Lord of the Rings series, my husband relaxes playing a computer adventure game. The Jewish High Holy Days are a time for reflection about the past year. But my mind goes back to a Yom Kippur Eve when I was working as a resident in the Pediatric Intensive Care Unit (PICU) as part of my pediatric training.

Residents work through most holidays, even ones they consider important. This night, I wished I had off, but I consoled myself with knowing that I would be off on Thanksgiving. Luckily I was partnered with Amy, the lead physician in the PICU.

The sickest patient that night was twelve-year-old Beth. She had leukemia and had just started chemotherapy. Because her immune system was weak, Beth was very ill with a bacterial infection in her blood. Despite powerful antibiotics, the infection raised havoc in her body. She developed such difficulty breathing that a tube from a mechanical ventilator was placed down her throat to force air into her lungs. Even the comfort of sleep escaped her. Beth was afraid of what was happening to her body. She refused to accept medicine that could help her sleep because she was so afraid that she would never wake up.

That night, despite her incredibly ill state, she got her period. Usually when a girl’s body is stressed, the body preserves all blood and the periods stop. But hers came, and because her blood cells were so abnormal from a toxic combination of infection, chemotherapy, and leukemia, she began bleeding to death. We transfused her with bag after bag of blood to keep her alive.

In the middle of the night, Beth’s blood pressure suddenly plummeted so we added even more medication. Because my mentor Amy was not certain that Beth would survive the night, we called her family at the hotel near the hospital where they were staying and told them come to Beth’s side. And through it all, Beth refused to sleep. Her eyes always opened in terror whenever we approached her bed. Her face was gray. Her chest rose and fell to the rhythm of the mechanical ventilator, and you could smell the fear all around her.

I stood with Amy just outside Beth’s room as Amy reviewed a checklist for Beth’s care. It went something like: “Ok, we just called blood bank for more blood; we called her family; we called the lab; we called the pharmacy. We are currently attending to all of her problems, we now just have to wait for her body to respond.” She paused,” But you know what?”

“What?” I asked her.

“We need to address her spiritual needs as well. Do we know what religion her family is? They may want a clergy member with them.”

I was startled. In the midst of all the tubes and wires of technology, Amy remembered to summon the human factor in medicine. We looked in her medical chart under “religious preference” and there it was: Jewish.

“Amy,” I said, “of all nights. Tonight is Yom Kippur…the holiest night of the Jewish year.”

I knew that the hospital had a Rabbi “on call” just like they had priests, nuns, ministers, and other spiritual leaders. But that night I was sure that every rabbi in Philadelphia would be at synagogue for Kol Nidre, the declaration chanted at the beginning of the Yom Kippur evening service. We were unlikely to track down a Rabbi.

Despite this, we asked her mother if they wanted us to call a Rabbi for them. She shook her head no. I remember feeling relieved, then guilty that I felt relieved. Amy left to check on another patient. Beth’s mom, dad, and older sister stood together watching Beth. Her sister’s hand lay on her mother’s arm. Her mother’s eyes darted from me to Beth to the mechanical ventilator next to the bed. Beth’s eyes were closed and it was difficult to know if she even knew we were there.

Her family walked out into the hall to talk. Beth at that moment opened her eyes and started tapping on the bed with her foot to get my attention. She couldn’t talk because of the tube down her throat and her hands were taped down with IVs. Yet she reached out with one hand as best she could.

I walked close to her bed so she could touch me and I asked, what is it, Beth?

Her lips formed the words around the breathing tube very deliberately, her body tensing. “Am I going to die?”

All in a split second I am thinking to myself: How do I know/it could very well happen/how can I lie to her/how can I tell her the truth of what I fear could very well happen/how am I going to answer this child?

What I answered was, “Not tonight, Beth.”

She relaxed into her pillow but kept her eyes on mine. I waited to see if she would say anything else, but the effort to ask that one question had exhausted her. I stood, holding her hand, until her family came back into the room. Her eyes followed them to her bed and I left so they could be together.

Beth did survive the night and in fact survived a month in the PICU. She became well enough to be transferred to a regular hospital floor. By this time I was working in a different part of the hospital, but one of the oncologists pointed her out to me.

I don’t know what happened to her in the long term.

So now I tell my oldest child it’s time for him to stop reading and go to sleep, and I walk him to his room to say goodnight. My husband and I decide what time we’ll attend Yom Kippur services tomorrow. Part of me feels joined with Jews everywhere who will also be spending the next day reflecting, praying and celebrating a new year. But mostly, like every year at this time, I remember the sounds and the smells and the fear in the PICU where sickness doesn’t care who your God is or what your intentions are. I remember Amy caring enough to think about a dying child’s family religion, and always, I remember Beth.

Julie Kardos, MD
© 2010 Two Peds in a Pod℠

September 11, 2010 by twopedsinapod

Stopping a bully: Talk, Walk, Squawk and Support

Can you identify your child in any of these scenarios?

-Your second grader comes off the school bus crying because another student was teasing him the entire ride home about his new glasses.

-Your fifth grader was punched on the school yard by a sixth grader and none of the playground teachers saw it happen. Your child’s friend shoved the older child off your child before more damage was done.

-Your ninth grader keeps missing the school bus so you have to drive her to school. When she comes home from school she uses the bathroom immediately. You find out she avoids the bus and the school bathroom because verbal abuse occurs in both places.

Whatever your child’s age, when you realize he or she is being bullied you will be outraged. In fact you might be tempted to retaliate against the bully yourself. However, here are more appropriate ways to help your child.

Bullying should never be tolerated. Teach your child how to directly deal with a bully, but be quick to talk also to the adult supervising your child when the bullying occurs. Your child should always feel safe in school, day camp, on a sports team, or any other adult-supervised activity.

Bullies are always in a position of power over their victims; either they are physically larger, older, or more socially popular. Teach your child first to try a strong verbal response (talk) such as “STOP talking to me that way!” or “Don’t DO that to me!” Speaking strongly and looking the bully in the eye may take away some of the bully’s power as well as attract attention of nearby peers or adults who can help your child.

Teach your child to walk away from a fight. Tell him to keep on walking toward a teacher, a classroom, a peer, or anyone else who can offer safety from a bully. Train him to breathe deeply/ignore/de-escalate situations to diffuse a bully’s anger.

Have your child tell a teacher, camp counselor, coach, or other supervising adult about the abuse (squawk) as soon as it occurs. Always encourage your children to talk to you as well. Remember at home to ask your child questions such as “How is school,” “How are your friends,” “Do you know any kids who are being bullied?,” and “Are YOU being bullied?”

If your child says he is angry at a friend or a classmate, be sure to ask questions that encourage your child to elaborate, such as “Oh, what happened?” or “Did something happen between you?” Listen carefully to his response. He may be taking out his anger at a bully on his own friends. This response is in retaliation for his friend’s failure to protect him from a bully. Also, is your child becoming more reluctant to attend school, “missing” the bus more often and thus requiring a ride, or acting angry or sad more often? Kids who are victims of bullying can act like this.

In school, once you are aware that your child is a victim, talk not only to your child about how she should handle a bully but also alert your child’s teacher and/or school principal about the situation (support). You should tell them in your child’s words what happened, what was said, and be clear that you are asking for more supervision so that the bully has less access to your child. Ask for more supervision during times when there is usually less adult presence such as in the lunchroom or on the schoolyard. Your school may already have a “no bullying” policy. Often, the aggressor gets the heavier consequence in the event of a conflict. Again, children have a right to feel safe in school.

Restore your child’s self-confidence. Bullies pick on kids who are smaller and weaker than they are, physically as well as psychologically. So your child has more positive experiences with kids who do not bully, encourage your child to invite friends over to your home or host a fun group activity (kickball game in your backyard, show a movie/supply popcorn, etc.). Do family activities and show your child that you enjoy spending time with him. Enroll your child in activities that increase his self esteem such as karate, sports, or music lessons. A child who feels good about himself “walks taller” and is less likely to attract a bully.

As a parent, you might read this post and think, “Yes, but I’d rather just teach my child to take revenge.” Unfortunately, escalating the situation only breeds anger and in fact may get your child into trouble. Rather than “hate” the bully, help your child see that a bully deep down feels insecure. A bully resorts to making himself feel better by making others feel bad. Teach your child to pity the bully. With your guidance, your child will project self-confidence and a bully will never, ever, be able to touch him.

Julie Kardos, MD with Naline Lai, MD
© 2010 Two Peds in a Pod℠

September 7, 2010 by

Evaluating Vaccine Sites on the Internet

A concerned parent wrote to us:

Can you please read this and comment?www.thinktwice. com.
I’m terrified to vaccinate due to sites like these. There seems to be many horrifying stories out there to what happens to kids after getting vaccines. If the chance of them getting these diseases is small, is it worth taking the risk of them suffering these near death or death experiences?

Here is our response:

Dear Concerned,

We looked at the web site you sent to us. When evaluating the merit of information that you read on the internet, it is important to know the source of the information. The thinktwice site has an easy to read disclaimer. To highlight: the founders of the site explain that they are NOT medical professionals and that they do NOT give medical advice. They refer their readers to “licensed medical professionals” for medical advice. In addition, they acknowledge that their site is NOT endorsed by the American Academy of Pediatrics (AAP), the Food and Drug Administration (FDA), or the US Center for Disease Control (CDC). In fact, they refer their readers to these organizations for vaccine information and advice. They post “information” that will certainly cause a stir on the internet but actually defer to well established medical experts at the AAP, the CDC, and the FDA for definitive advice about vaccines. If you investigate those sites, you would find that all of the organizations actually endorse the use of vaccines.

It makes sense to consult experts in the field for any problem that you have. When researching a health care issue, actresses, political figures, and web site sponsors, while experts in knowing their own children, are not medical professionals. If, for example, we had a car problem, we would consult a mechanic. We would not read testimonials of car owners on the internet to figure out how to fix a car. If we did not trust our mechanic’s recommendation, we would get a second opinion from another car expert.

Doctors are trained to evaluate evidence. We are medical professionals who read all the medical textbooks for you. Pediatricians go to school and train for nearly a quarter of a century before they even begin practicing on their own. We base our medical advice on the pediatric standards set forth by the American Academy of Pediatrics. These standards represent consensus of thousands of pediatricians who dedicate their lives to improving the well being of children. We would never support a practice that causes more harm than good.

If you are moved by testimonials, then you should also read testimonials of parents whose children were not vaccinated and then died or suffered disability from vaccine preventable diseases: http://vaccinateyourbaby.org/why/victims.cfm, http://vaccine.chop.edu. In addition, we encourage you to read our own vaccine posts: How Vaccines Work and Do Vaccines Cause Autism? Please visit the websites we provide in these articles for more information about vaccines.

Experts in pediatrics have evaluated data based on millions of vaccine doses given to millions of children. The evidence shows that the benefits of vaccines outweigh risk of harm. Think of seat belts. You may imagine that your child’s neck may get caught in a seat belt, but you would never let your child go without a seatbelt. The reason is that rather than trust a “feeling” that theoretically the seat belt could cause harm, we know from evidence, data, and experience that seatbelts save lives.

Vaccines are a gift of protection against childhood disease. As moms, both of us vaccinated our own children on time according to the standard schedule. Tragically, the more parents don’t vaccinate, the easier it will be for all of our children to contract these preventable and often deadly disease. Proof of this is California’s current whooping cough epidemic which has killed six infants so far. Most of the illness is breaking out in areas where parents stopped vaccinating their children.

If you are wondering about the merits of a web site, try to cross reference the information with organizations which set medical standards such as The American Academy of Pediatrics, the Centers for Disease Control, and your local Children’s Hospital. And of course, you can always ask your pediatrician.

By asking questions you are being a responsible parent.

Keep on asking.

Julie Kardos, MD with Naline Lai, MD
© 2010 Two Peds in a Pod℠

September 3, 2010 by twopedsinapod

Rotten News: A Salmonella Story

Eeew! Pictured is the raw chicken I left sitting out in a pot for a day (inadvertently, of course). The putrid mess was teaming with germs and amongst them was probably salmonella. This bacteria is in the news because of the thousands of eggs recently recalled for contamination (Centers for Disease Control , New York Times, National Public Radio.)

Non-typhoidal Salmonella usually causes fever and crampy diarrhea. This stomach bug mainly lurks in raw poultry, raw eggs, raw beef, and unpasturized dairy products. Luckily, salmonella does not jump up and attack humans. People are safe from disease as long as they do not eat salmonella-infested food.

In the case of my pot of rotten chicken, the obvious stench warned me that it was inedible. However, salmonella often hides in food and it is difficult to tell what is or is not contaminated. A perfectly fine looking egg may harbor the germ. Even before this outbreak, the Centers for Disease Control estimates in the United States as many as 1 in 50 people are exposed to a contaminated egg each year.

Luckily salmonella is killed by heat and bleach. Even if an egg has salmonella, adequate cooking will destroy the bacteria. Gone are the days when parents can feed kids soft boiled eggs in a silver cup, have kids wipe up with toast the yolk from a sunny-side up egg, or add a raw egg to a milkshake. Instead, cook your hardboiled eggs until the yolks are green and crumble, and tolerate a little crispness to your scrambled eggs. Wash all utensils well. The disinfecting solution used in childcare centers of ¼ cup bleach to 1 gallon water works well to sanitize counters. Do not keep perishable food, even if it is cooked, out at room temperature for more than two hours.

A mom once called me frantic because her child had just happily eaten a half-cooked chicken nugget. What if this happens to your child? Don’t panic. Watch for symptoms — the onset of diarrhea from salmonella is usually between 12 to 36 hours after exposure but can occur up to three days later. The diarrhea can last up to 5-7 days. If symptoms occur, the general recommendation is to ride it out. Prevent dehydration by giving plenty of fluids. My simple rule to prevent dehydration is that more must go in than comes out.

According to the American Academy of Pediatric’s 2009 infectious diseases report, antibiotic treatment may be considered for unusually severe symptoms or if your child is at risk for overwhelming infection. People at high risk for overwhelming disease include infants younger than three months old and those with abnormal immune systems (cancer, HIV, Sickle Cell disease, kids taking daily steroids for other illnesses). Using antibiotics in a typical case of salmonella not only promotes general antibiotic resistance, but in fact does not shorten the time frame for the illness. Also, the medication can prolong how long your child carries the germ in his stool.

I ended up tying the chicken up, pot and all, in a plastic grocery bag and throwing out the whole mess. Don’t tell my husband, he is the kind of guy who gets annoyed because I throw out germy sponges on a frequent basis. If he knew, he’d probably want me to at least keep the pot. Yuck.

Naline Lai, MD with Julie Kardos, MD

August 30, 2010 by twopedsinapod

Cry Baby- Why do infants cry?

Why do babies cry? This may seem like a silly question, but sometimes you really want to know why your infant is crying.

Remember, newborns cannot talk. They can’t even smile back at you until around six weeks of age. Why do babies cry? In short, newborns cry to communicate.

Ah, but what is it, exactly, that they try to communicate? Babies cry when they…

– Are tired.

– Are hungry.

– Feel too cold.

– Feel too hot.

– Need to be changed –I never really believed this reason before I had my twins. My firstborn couldn’t have cared less if he was wet and could nap right through a really poopy diaper. Then I had my twins. I was amazed that their crying stopped if I changed the tiniest bit of poop or a wet diaper. Go figure.

– Are bored. Perhaps she is tired of the Mozart you play and prefers some good hard rock music instead. Maybe she wants a car ride or a change of scenery. Try moving her to another room in the house.

– Feel pain. Search for a piece of hair wrapped around a finger or toe and make sure he isn’t out-growing the elastic wrist or ankle band on his clothing.

– Need to be swaddled. Remember a fetus spends the last trimester squished inside of her mom. Discovering her own randomly flailing arms and legs can be disconcerting to a newborn.

– Need to be UN-swaddled. Hey, some like the freedom to flail.

– Need to be rocked/moved. Dr. Lai’s firstborn spent hours tightly wrapped and held by her dad in a nearly upside down position nicknamed “upside-down-hotdog” while he paced all around the living room.

– Check to see if there is a burp stuck inside her belly. Lay her down for a minute and bring her up again to see if you can elicit a burp.

– Does your baby seem gassy? Bicycle his legs while he is on his back. Position him over your shoulder so that his belly presses against you. You’d be gassy too if you couldn’t move very well. The gassy baby is a topic for an entire post- talk to your doctor for other ideas.

– Are sick. Watch for fever, inability to feed normally, labored breathing, diarrhea or vomiting. Check and see if anything is swollen or not moving. Listen to his cry. Is it thin, whimper-like (sick) or is it loud and strong (not sick)? Do not hesitate to check with your pediatrician. Fever in a baby younger than eight weeks old is considered 100.4 degrees F or higher measured rectally. A feverish newborn needs immediate medical attention.

What if you’re certain that the temperature in the room is moderate, you recently changed his diaper, and he ate less than an hour ago?

– Walk outside with your baby- this can be a magic “crying be gone” trick. Fresh air seems to improve a newborn’s mood.

– Offer a pacifier. Try many different shapes of pacifiers. Marinade a pacifier in breast milk or formula to increase the chance your baby will accept it.

– Pick her up, dance with her, or walk around the house with her. You can’t spoil a newborn.

– Try vacuuming. Weird, but it can work like a charm. Place her in a baby frontal backpack or in a sling while cleaning.

– Try another feeding, maybe she’s having a growth spurt.

-When all else fails, try putting her down in her crib in a darkened room. Crying can result from overstimulation. Wait a minute or two. She may self-settle and go to sleep. If not, go get her. The act of rescuing her may stop the wailing.

-If mommy or daddy is crying at this point, call your own mom or dad or call a close friend. Your baby knows your voice and maybe hearing you speak calmly to another adult will lull her into contentment.

– Call your child’s health care provider and review signs of illness.

– If you feel anger and resentment toward your crying baby, just put her down, walk outside and count to ten. It is impossible to think rationally when you are angry and you may hurt your child in order to stop your frustration. Seek counseling if these feelings continue.

Now for the light at the end of the newborn parenting tunnel: the peak age when babies cry is six weeks old. At that point, infants can cry for up to three hours per day. Babies with colic cry MORE than three hours per day. (Can you believe people actually studied this? I am amused that Dr. Lai won a prize in medical school for a paper on the history of colic). By three months of age crying time drops dramatically.

While most crying babies are healthy babies and just need to find the perfect upside-down-hot-dog position, an inability to soothe your baby can be a sign that she is sick. Never hesitate to call your baby’s health care provider if your baby is inconsolable, and don’t listen to the people who say, “Why do babies cry?…They just do.”

———

Thanks to our Facebook friends for other ideas for what the cartoon baby is saying:

“Stop looking at me like that and please loosen this blanket and don’t hold me up here like this and where is my hat my diaper is giving me a wedgie! JUST MAKE IT ALL STOP!”

“WHY CAN”T YOU LET ME GO BACK TO SLEEP, PEOPLE!”

———

Julie Kardos, MD with Naline Lai, MD

August 27, 2010 by twopedsinapod

Better Balance

I conduct sports-clearance physicals by the dozens these days, and I notice that although most kids have endurance, they lack balance. Balance will save your child from twisting an ankle on uneven turf. Balance helps your child stay straight when she stops suddenly. I have long wondered the easiest way for kids to practice their balance. When I suggest spending time in yoga’s “tree” or “half-moon” position, the kids all look at me quizzically.

Today a mom passed on to me a very simple balance exercise. Have your kids stand on one leg while they brush their teeth! Not as graceful looking as my yoga suggestions, but far more practical.

Naline Lai, MD with Julie Kardos, MD

August 25, 2010 by twopedsinapod

Back to School Transitions

Ah…you’ve tucked in your tired kids, now kick back and take out your Kleenex while you read Dr. Lai’s personal letter to her own child as she started school. The post is meant for all parents with a child who is approaching a major milestone. Then, come back to reality and read Dr. Kardos’s post on how to help kids get back to a healthy school year sleep pattern.

Best wishes for a smooth transition to school.

August 22, 2010 by twopedsinapod

Packing your child’s school lunch: Beware of junk food disguised as healthy food

Need ideas on what to pack in your child’s lunch bag? Beware of junk food masquerading as healthy food. Dr. Roxanne Sukol, an internist who writes the popular nutrition blog Your Health is on Your Plate , mom of three children, and friend of Dr. Kardos’s from medical school, shares her insights…

What should we pack in our children’s lunch bags? The key to retraining our children to eat real food is to restore historical patterns of food consumption. My great-grandparents didn’t eat potato chips, corn chips, sun chips, or moon chips. They ate a slice of whole-grain rye bread with a generous smear of butter or cream cheese. They didn’t eat fruit roll-ups. They ate apricots, peaches, plums, and grapes. Fresh or dried. Depending on where your family originated, you might have eaten a thick slice of Mexican white cheese (queso blanco), or a generous wedge of cheddar cheese, or brie. Sunflower seeds, dried apples, roasted almonds. Peanut butter or almond butter. Small containers of yogurt. Slices of cucumbers, pickles, or peppers. All of these make good snacks or meals. My mom is proud to have given me slices of Swiss cheese when I was a hungry toddler out for a stroll with my baby brother. Maybe that’s how I ended up where I am today.

When my own children were toddlers, I gave them tiny cubes of frozen tofu to grasp and eat. I packed school lunches with variations on the following theme: 1) a sandwich made with whole grain bread, 2) a container of fruit (usually apple slices, orange slices, kiwi slices, berries, or slices of pear), and 3) a small bag of homemade trail mix (usually peanuts + raisins). The sandwich was usually turkey, mayo and lettuce; or sliced Jarlsberg cheese, sliced tomato, and cream cheese; or tuna; or peanut butter, sometimes with thin slices of banana. On Fridays I often included a treat, like a few small chocolates.

Homemade trail mix is one terrific snack. It can be made with any combination of nuts, seeds, and/or dried fruit, plus bits of dark chocolate if desired. Remember that dark chocolate is good for you (in small amounts). Dried apple slices, apricots, kiwi or banana chips, raisins, and currants are nutritious and delicious, and so are pumpkin seeds and sunflower seeds, especially of course in homes with nut allergies. Trail mix can be simple or involved. Fill and secure baggies with ¼ cup servings, and refrigerate them in a closed container until it’s time to make more. I would include grains, like rolled oats, only for children who are active and slender.

If possible (and I do know it’s a big “if”), the best way to get kids interested in increasing the amount of real food they eat is to involve them in its preparation. That might mean smearing their own peanut butter on celery sticks before popping them into the bag. It might mean taking slices of the very veggies they helped carry at the weekly farmer’s market. Kids are more likely to eat the berries in their lunch bag if they picked them themselves. There’s a much greater chance they’ll eat kohlrabi if they helped you peel it, slice it, or squeeze a fresh lemon over it. That’s the key to healthy eating.

What do I consider junk food? Chips of all kinds, as well as those “100 calorie packs,” which are invariably filled with 100 calories of refined carbohydrate (white flour and sugar) in the form of crackers (®Ritz), cereal (®Chex), or cookies (®Chips Ahoy).

You can even find junk food snacks for babies and toddlers now: The main ingredients in popular ®Gerber Puffs are refined flour and sugar. Reviewers tout: “You just peel off the top and pour when you need some pieces of food, then replace the cap and wait for the next feeding opportunity.” [Are we at the zoo?] “He would eat them all day long if I let him.” [This is not a benefit. It means that the product is not nutritious enough to satisfy the child’s hunger.]

Beware not only of drinks that contain minimal amounts of juice, but also of juice itself. Even 100% fruit juice is simply a concentrated sugar-delivery system. A much better approach is to teach children to drink water when they are thirsty, (See my post entitled One Step at a Time) and to snack on fresh fruit when they are hungry. Milk works, too, especially if they are both hungry and thirsty!

TeachMed, LLC

http://yourhealthisonyourplate.com

Reprinted with permission in edited form for Two Peds in a Pod

Roxanne B. Sukol, MD is a 1995 graduate of Case Western Reserve School of Medicine. She is board-certified in Internal Medicine and practices in suburban Cleveland, Ohio. With special interests in the prevention and management of diabetes and obesity, Dr. Sukol writes the blog Your Health is on Your Plate . Because her patients (the grown-ups) are the ones packing the school lunches for our patients, we thank her for this post.

Julie Kardos, MD and Naline Lai, MD

August 18, 2010 by twopedsinapod

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Julie Kardos, MD with Naline Lai, MD

©2010 Two Peds in a Pod℠