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®

The first of many first days of school.

Parents, let’s admit it. Many of the tears shed on the first day of school are our own. The first day of school for parents is not easy. There is genuine sadness and ache that goes beyond the bittersweet as our kids approach momentous milestones such as kindergarten entry and college send off. As our pediatrician friend Dorothy Novick posted on Facebook, “Because here’s a thing no one ever says out loud on Facebook: as all the balloons and congrats explode on our feeds, many of us parents of graduates are experiencing some pretty serious grief. There’s true pride in the photos, yes, but there’s also honest to goodness grief.”

For your kid-remember the rules of drop off:

• For kids of all ages, convey to them that the transition is a positive experience. You give your child cues on how to act in any situation. Better to convey optimism than anxiety. Kids, no matter the age, mirror the emotions their parents convey.
• For daycare and preschool, take your child and place her into the arms of a loving adult- do not leave her alone in the middle of a room.
• Say good bye. Let your child know that you are leaving. Don’t try to sneak off. At any age, it’s unsettling for you to suddenly disappear.
• Do not linger. Prolonging any tears, only prolongs tears. The faster you leave, the faster happiness will start.
• For the younger ones- it’s ok to go back and spy on them to reassure yourself that they have stopped crying- just don’t let them see you. For the older ones-let them have their independence- this is what you’ve trained them for. In fact, encourage their independence. When your young adult asks you a question, ask it back. Chances are, they already know the answer. Just remind them that you are always available. Send the care packages and answer their midnight texts.

For yourself:

Congratulate yourself on reaching a family milestone. The first day of school for parents and children is momentous. Yes, the configuration of your family has changed and it will not be the first or last time. Acknowledge the ache of the passage of time, and reach out to others in similar situations.

Just as your child delights you with all of their unique interests and attributes, go show them all the amazing unique things you do. Take up ball room dancing, start a business painting colorful furniture or join an adult soccer league …these are all real life examples of things we know people embarked on when their kids went off to school.

Cry those “happy tears.” But be aware, sentimental “happy tears” can tip over into depression.

If negative thoughts or worries constantly impinge on your thoughts and weigh you down, then seek help. Talk to your doctor for advice. Also, the National Alliance on Mental Illness maintains a lists of resources.  Depression looks like sadness much of the time but it can also manifest as anger or anxiety.

Warning signs of depression include:

• Acting out of control
• Losing interest in activities which normally bring pleasure
• Changes in sleep patterns-difficulty falling asleep, numerous awakenings, or excess sleeping
• Having feelings of worthlessness about yourself or other
• Poor work performance
• Low energy or fatigue or conversely restless or “hyper” (excessive shopping binges)
• An increase in alcohol or drug use (attempts at “self-medicating”)
• Thoughts of being better off dead or a desire to hurt yourself or others

To end on an upbeat (and ok, bittersweet) note, we invite you to read the letter Dr. Lai wrote the day before her first child left for kindergarten.

A letter to my child

My Child,

As we sit, the night before kindergarten, your toes peeking out from under the comforter, I notice that your toes are not so little anymore.

Tomorrow those toes will step up onto to the bus and carry you away from me. Another step towards independence. Another step to a place where I can protect you less. But I do notice that those toes have feet and legs which are getting stronger. You’re not as wobbly as you used to be. Each time you take a step you seem to go farther and farther.

I trust that you will remember what I’ve taught you. Look both ways before you cross the street, chose friends who are nice to you, and whatever happens don’t eat yellow snow. I also trust that there are other eyes and hearts who will watch and guide you.

But that won’t stop me from worrying about each step you take.

Won’t stop me from holding my breath­.

Just like when you first started to walk, I’ll always worry when you falter.

I smile because I know you’ll hop up onto the bus tomorrow, proud as punch, laughing and disappearing in a sea of waving hands. I just hope that at some point, those independent feet will proudly walk back and stand beside me. Maybe it will be when you first gaze into your newborn’s eyes, or maybe it will be when your child climbs onto the bus for the first time.

Until then, I hold my breath each time you take a step.

Love,
Mommy

Naline Lai, MD and Julie Kardos, MD
©2018, 2023 Two Peds in a Pod®

A preschooler nibbles on her nails.

Stop nail biting! One of our readers wrote to us: “My 3.5-year-old daughter has started biting her nails to the quick. She does have a new little sister so perhaps it is stress/anxiety about that, but I don’t know what to do. Do I ignore it? Offer rewards for not biting? Please help – the habit drives me nuts and her poor little fingers are looking worse for the wear (and painful).”

As many of you have likely already discovered, telling your kid, or pleading with them, or bribing, ignoring, or yelling at them, will not help your kids stop nail biting.

Nail biting is a common childhood habit. Really common. In fact, according to this review article from 2015, it is THE most common habit seen in school-aged and college-aged kids. As many as 60% of kids, at some point, bite their nails. Nail biting usually starts between the ages of three to six years, so our reader’s child is right on target for this habit.

I am amused that many of the parents who ask me how to help their kids stop biting their nails are, themselves, nail biters. I will point out that even if we can’t stop nail biting, the concerned parent is a living example of a nail biter who still grows into a successful adult.

Assuming that your child is otherwise acting well, eating and sleeping normally, and mostly cheerful, it is not always important to identify the trigger of nail biting. More importantly, make sure your child washes their hands after playing outside and before eating (and nail biting) to limit germ spread. Check their fingers for signs of infections that can result from nail biting.

What to do

A quick internet search reveals dozens of products that you can dab onto your child’s fingers to discourage nail biting. Products with nasty tasting ingredients such as “bitter apple” tote promises such as “stop nail biting instantly.” Unfortunately, most nail biters are not deterred by paint-on products.

Usually kids have a hard time breaking a habit unless they REALLY want to break it themselves. Here are some suggestions to help:

• Offer painting nails or small rewards for not biting nails.
• Don’t be a nag.
• Establish a code word for stop biting your nails that only your child knows. The word can be a nonsense word (e.g. oogleschmertz) or a word entirely out of context (e.g. elephant). For younger kids especially, this creates an environment of humor, rather than annoyance when you are reminding them to stop biting.
• Substitute a less annoying habit for nail biting. Hand them something to keep their hands busy. Give them a squishy toy to squish or a hair scrunchy to wear on their wrist to flick.
• Offer older kids sugarless chewing gum to keep their teeth busy.

If all else fails, take heart in one study that came out in favor of nail biting (and thumb sucking). Perhaps it’s not imperative to stop nail biting after all. The study showed that nail biters and thumb suckers had a lower rate of atopic sensitization (medical term for allergic eczema) than their non-nail biting or thumb sucking peers. The researchers conclude “Although we do not suggest that children should be encouraged to take up these oral habits, the findings suggest that thumb sucking and nail biting reduce the risk for developing sensitization to common aeroallergens.” In other words, the nail biters show fewer allergy symptoms in their skin than the non-nail biters.

Let’s face it: We all are creatures of habit. The key is to make sure the habit is not self-detrimental. Every childhood habit does not need to be broken immediately, even if it drives us parents crazy.

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

Nine-year-olds love collecting little treasures.

It’s a funny thing about nine-year-olds. You may look at your own nine-year-old and think: where did my baby go? Gone is the nine-MONTH-old who worried about approaching strangers and howled when you walked away. Now you have a nine-YEAR-old who may shoo you away when you drop her off at a friend’s house.

Yes, some nine-year-olds may seem embarrassed by their parents, yet they absolutely want you around on the sidelines. They want you to attend their sporting events or school concerts and to organize their birthday parties. Just try not to take it personally when they want to spend more time with friends.

Nine-year-olds can get a little stinky, even if puberty is years away for many of them. Be sure to let them know that their bodies will change gradually over time. Get them deodorant and remind them to use it. Talk to girls about periods because some start around 10 years of age.

Because of increased attention span and intellectual growth, nine-year-olds will reliably carry out chores and perform many self care tasks. Encourage them to be more self sufficient. You will be happy for the help and you will build your nine-year-old’s self-esteem. On the academic side, they read chapter books and often enjoy non-fiction books. At this age, they enjoy a variety of clubs, team activities, and hobbies.

Remember the basics:

-Eat: Teach basic nutrition

-Sleep: Most nine-year-olds need around 11 hours of sleep per night.

-Pee/poop: While nine-year-olds use the bathroom independently, occasionally ask your child if they are constipated, and ask if they try to “hold it” all day in school. If the answer to either one of these questions is yes, see our post on these topics.

-Love/guidance: Just like you did when they were toddlers, remember to praise your nine-year-old for positive behaviors such as saying “please” and “thank you” or for helping you clear the dinner table. Once they know that you approve, they will repeat those behaviors. Nine-year-olds are known for whining for long periods of time. Dr. Lai remembers her son whining about losing screen time. He would suddenly appear out of nowhere and whine two inches from her face wailing,”Why? Why? Why?” Watch out, if you give into a whining kid, even sometimes, you’ll end up encouraging their whining. Think slot machines— even though gamblers usually lose at slot machines, they continue to play them because SOMETIMES gamblers do win.

If you have not done so already, teach your nine-year-old to use a phone and teach them whom to call in an emergency. Some kids this age come home to an empty house for a little while until parents return from work. Review what you expect them to do while they are alone.

Reminder about car safety: Many should still be in booster seats because they are not yet 4 ft 9 inches tall. They should NOT sit in the front seat of a car; the back seat is still safer for them.

Nine-year-old kids are still part of the golden age of parenting— too old to take a nap, but too young to drive. Enjoy spending time with your nine-year-old doing things that interest both of you. Enjoy their enthusiasm and increased ability to understand higher concepts. Time spent with parents or other caregivers who enjoy them contributes to building their resilience.

Speaking of nine-year-olds, please celebrate with us NINE YEARS of Two Peds in a Pod®! We are enjoying the journey and hope that our advice can help build resilience and self-confidence in the parents we write for! Our best present from you is your continued presence.

Happy Ninth Birthday to your nine-year-old and to Two Peds in a Pod®!

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

How can you tell if your child’s scrape is infected if his skin is already bright red?

I heaved a sigh of relief. My children greeted my husband and me at the door. The children had just baby-sat themselves. I thought everyone was unscathed until I saw one of my children covered in bandages. Cuts and scrapes? Apparently, although I had admonished them not to ride anything with wheels and not to climb on anything above the ground, the child with the bandages had tripped over her own feet during a benign game of four square.

“Did you wash the scrapes?” I asked.

“Yes,” the kids said, proudly nodding. They knew the first line of defense against a wound infection is to wash out cuts and scrapes. But as it turns out, they had only dabbed the cuts with wet paper towels. Aghast, I propelled the injured child off to the bathroom and hosed down the cuts. Too many times I have seen a minor scrape turn into a major skin infection.

When a wound is not thoroughly cleansed, the bacteria which normally live on intact skin (Staphylococcus or Streptococcus) find an opportunity to enter the body through the wound and cause infections. Even a mosquito bite can turn into a raging, puss-filled mess if scratched often and not cleansed enough. These days, some children carry on their skin a type of Staphylococcus called MRSA (Methicillin Resistant Staphylococcus Aureus). Since this germ can be tough to treat when it causes an infection, a thorough cleansing is more important than ever.

While infection is rarely introduced from the actual object that cuts the child, exceptions include cuts caused by animal or human bites (the human mouth is particularly filthy) and cuts caused by old, dirty or rusty metal. Tetanus lives in non-oxygenated places such as soil. So for deep or very dirty wounds, make sure your child’s tetanus vaccine is up to date.

Despite what many believe, wiping the surface of a cut with a wipe is not adequate to cleanse a wound. “Irrigate, irrigate, irrigate,” a wise Emergency Department physician explained to me when I was a resident in training. “I have never had someone return with a wound infection,” she said proudly. In the emergency room, saline is usually used. At home, soap and running water are effective. Stay away from hydrogen peroxide and rubbing alcohol because they can irritate rather than help the skin.

After washing your child’s cuts and scrapes, you can use bandages to help prevent further exposure to germs and to avoid irritation from clothes or from your child’s scratching, probing fingers. Infections, if they occur, can set in 2-3 days after your child gets her wound. Remove the bandage daily and check the wound for signs of infection such as pus, increased redness, warmth and pain. Wash the wound again, and then replace the bandage. You could also apply topical antibiotic such as Bacitracin to further help prevent wound infection.

So, even if your child just took a shower, wash him again if he scrapes himself. The sooner you irrigate even the tiniest of wounds, the better.

An ounce of prevention is worth a pound of antibiotics.

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

hurray! launching a new look (photo credit: pixabay)

It’s no longer a secret. Many of you have noticed our new Two Peds in a Pod® logo. And indeed, we’re launching a whole new look. It’s a new vibe with the same dependable and relevant pediatric advice in a mobile friendly format!

The average blog’s lifespan is counted in months, not years, and as we complete our ninth year, we’re proud to have exceeded that expectation many times over. But it’s now harder to hang in.

Please don’t let us disappear off the internet!

As more and more advertisers jockey for spots at the top of search engines and more content crowds the web, it has grown tougher to reach parents. In fact, if you are reading this on Facebook, it’s because we’ve just paid Facebook to have this post reach all of our followers. We’re proud to avoid distracting pop-out ads on our blog, and we’re depending on your grassroot efforts to inform other parents and caregivers about our site. Invite your friends to follow us!

It’s been nine years, and like a cat with nine lives, we are determined to land on our feet. We believe, more than ever, that the internet is the best medium to reach you at all hours of the day. Help grow our worldwide presence.

Wishing you all Peds on earth!

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

Read our very first blog post from 2009 here.

ick, a tick

I was grumpy all morning after realizing that my dog was out of tick repellent. Really grumpy. I did not like the thought of having to remove a tick from my dog.

After all, on the East Coast of the United States, we are seeing ticks galore. All month long, parents who have had to remove a tick have been bringing us presents such as the one pictured here. Yes, that is a tick you see nicely trapped in tape. Sometimes when parents bring us a tick, it’s still clinging to the child and they ask us to remove it. To save you a trip to the doctor’s office, here is a quick refresher on how to pluck the bugs off:

How to remove a tick:

1. Take a deep breath and pretend that it’s just a speck of lint—not an ugly critter with a bloated stomach and writhing legs.
2. Use tweezers and firmly clasp the head. If the tick is tiny, you will end up grabbing the entire body.
3. Pull the tick straight up and off. Hint: Press down on the skin on either side of the tick so that the skin doesn’t pull up when you pull the tick off. This lessens any pinching sensation your child may feel.

How NOT to remove a tick:

Please do not try to burn a tick off—you’ll just burn your child’s skin.
Avoid suffocation techniques such as covering a tick with petroleum jelly (Vaseline) or nail polish. These techniques are not very effective, they allow the tick to stay on for a longer period of time, and also they may cause the tick to become slippery and difficult to grasp.

What to do after you have removed the tick:

After removal, if the tick’s head is left behind, don’t go digging for it. Just like a tiny splinter, your skin will naturally try to expel it. Soaking the area in warm water will help the process along. Don’t worry about disease transmission: there is not any disease stuck in a tick’s head.

Wash the skin where the tick was using soap and water as you would any cut to prevent a skin infection. A small, minimally tender, pimple-like bump is a common reaction which may linger for a few days. This bump is an irritation response of the skin. If the tick was a deer tick (typically the size of a poppy or sesame seed), watch for the rash of Lyme disease that appears as a flat, pink, round patch about a week later. The patch may clear in the center and grows to at least 2 1/2 inches across.

My daughter told me that once, a girl at her lunch table had a tick on her. None of the kids could pick it off and the girl sat screaming until the lunch lady came over to help her. Maybe you’ll be the lucky adult called over to help next time.

Just remember…pretend it’s a speck of lint.

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

Teach your child to recognize poison ivy: “leaves of three, let’em be!”

Recently we’ve had a parade of itchy children troop through our office.  The culprit: poison ivy.

Myth buster: Fortunately, the rash of poison ivy is NOT contagious. You can “catch” a poison ivy rash ONLY from the plant, not from another person.

Another myth buster: You can not spread the rash of poison ivy on yourself through scratching.  However, where  the poison (oil) has touched  your skin, your skin can show a delayed reaction- sometimes up to two weeks later.  Different  areas of skin can react at different times, thus giving the illusion of a spreading rash.

Some home remedies for the itch:

Hopping into the shower and rinsing off within fifteen minutes of exposure can curtail the reaction.  Warning, a bath immediately after exposure may cause the oils to simply swirl around the bathtub and touch new places on your child.

Hydrocortisone 1%-  This is a mild topical steroid which decreases inflammation.  We suggest the ointment- more staying power and unlike the cream will not sting on open areas, use up to four times a day

Calamine lotion – a.k.a. the pink stuff- This is an active ingredient in many of the combination creams.  Apply as many times as you like.

Diphenhydramine (brand name Benadryl)- take orally up to every six hours. If this makes your child too sleepy, once a day Cetirizine (brand name Zyrtec) also has very good anti-itch properties. Some doctors recommend giving it twice a day- ask your pediatrician.

Oatmeal baths – Crush oatmeal, place in old hosiery, tie it off and float in the bathtub- this will prevent oat meal from clogging up your bath tub. Alternatively buy the commercial ones (e.g. Aveeno)

Do not use alcohol or bleach– these items will irritate the rash more than help

The biggest worry with poison ivy rashes is the chance of infection.  Just like with an itchy insect bite, with each scratch, your child is possibly introducing  infection into an open wound.  At night, turn up the air conditioning and put your child into pajamas that cover up the poison ivy. Kids who don’t scratch in the day often scratch subconsciously at night. Unfortunately, it is sometimes difficult to tell the difference between an allergic reaction to poison ivy and an infection.  Both are red, both can be warm, both can be swollen.

However, infections cause pain – if there is pain associated with a poison ivy rash, think infection.  Allergic reactions cause itchiness- if there is itchiness associated with a rash, think allergic reaction.  Because it usually takes time for an infection to “settle in,” an infection will not occur immediately after an exposure to poison ivy.  Infection usually occurs on the 2nd or 3rd day of scratching.  If you have any concerns take your child to her doctor.

Generally, any poison ivy rash which is in the area of the eye or genitals (difficult to apply topical remedies), appears infected, or is just plain making your child miserable needs medical attention.

When all else fails, comfort yourself with this statistic: up to 85% of people are allergic to poison ivy.  If misery loves company, your child certainly has company.

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

In the wake of chef Anthony Bourdain and designer Kate Spade’s deaths from suicide, you may be wondering how to address the topic of suicide with your child.  We bring back psychotherapist Dina Ricciardo’s post  for guidance:

“Hi, it’s me, Hannah.  Hannah Baker.” So begins the first episode of 13 Reasons Why, a thirteen installment Netflix series that focuses on the aftermath of the suicide of a 17-year-old high school student.  Based on the novel by Jay Asher, the series has sparked quite a bit of debate and concern among parents and mental health professionals.  At its best, the series has served as a conversation starter; at its worst, it has glamorized suicide and the fantasy of revenge.  At the end of the day, however, an important question remains:  How do we talk with our kids about suicide?  While many difficult topics have become increasingly safer to discuss, suicide is one that is still shrouded in secrecy and shame. In fact, it is so difficult to talk about that I had a hard time writing this post.  Finding the right words about something that often remains unspoken is not an easy task.  So if circumstances require it, how are we to explain suicide to our children?

According to the American Foundation for Suicide Prevention, research has shown that over 90% of people who died by suicide had a diagnosable, though not always identified, brain illness at the time of their death.  Most often this illness was depression, bipolar disorder, or schizophrenia, and was complicated by substance use and abuse.  Just as people die from physical illnesses, they can die as the result of emotional ones.  If we can change the narrative about suicide from talking about it as a weakness or character flaw to the unfortunate outcome of a serious, diagnosable, and treatable illness, then it will become easier for us to speak with honesty and compassion.

Telling the truth about any death is important. While it is natural for us adults to want to protect our children from pain, shielding them from the truth or outright lying will undermine their trust and can create a culture of secrecy and shame that can transcend generations.  We can protect our children best by offering comfort, reassurance, and simple, honest answers to their questions. It is important to recognize that we adults typically offer more information than our children require.  We should start by offering basic information, then let them take the lead on how much they actually want to know.

For young children, your statements may look something like this: “You have seen me crying, that is because I am sad because Uncle Joe has died.”  They may not even ask how the death occurred, but if they do, you can say “He died by suicide. That means he killed himself.”  The rest of the conversation will depend on the child’s response.  With older children, the narrative can follow a similar theme yet use more sophisticated language.  The older the child, the more likely they are to ask direct questions.  Some examples of honest answers are “Do you know how people have illness in their bodies, like when Grandma had a heart attack and our neighbor had cancer?  People can get illness in their brains too, and when that happens, they feel confused, hopeless, and make bad decisions. Uncle Joe didn’t know how to get himself help to stop the pain.”  If they ask how the suicide occurred, you can say “With a gun” or “She cut herself.”  Sometimes you will have to say “I don’t know. I wish I knew the answer.”  Whatever the age of your child, do your best to use simple, truthful language.

Regardless of age, children converse about and process death differently than adults.  If you tell your child about a suicide, it is likely that he/she will want to talk about multiple times over the course of days, weeks, or even years.  Keep the dialogue open, and check in with them periodically if they have questions.  If you find that you or your family is in need of the support of a professional, you might want to consider a bereavement group or a trained professional who specializes in grief.  These resources are available through online directories, local hospitals, and the Psychology Today therapist finder.  Overall, be aware that providing truthful information, encouraging questions, and offering loving reassurance to your children can allow your family to find the strength to cope with terrible loss.

(Excerpts taken from The American Foundation for Suicide Prevention’s “Talking to Children about Suicide”, www.afsp.org.)

Links:

Sesame Sreet Workshop’s When Families Grieve
The Dougy Center for Grieving Children and Families
The American Foundation for Suicide Prevention
Hands Holding Hearts (Bucks County, PA)
The Jed Foundation

Dina Ricciardi, LSW, ACSW

©2017 Two Peds in a Pod®

Guest blogger Dina Ricciardi is a psychotherapist in private practice treating children, adolescents, and adults in Doylestown, PA. She specializes in disordered eating and pediatric and adult anxiety, and is also trained in Sandtray Therapy. Ricciardi is a Licensed Social Worker and a member of the Academy of Certified Social Workers. She can be reached at dina@nourishcounseling.com.