Much to the chagrin of Bard’s mother, Bard the bat loved when his father held him right-side up…especially right before bedtime.

©2016 Two Peds in a Pod®

This very dusty binkie emerged from my daughter’s room just in time for her 16 th birthday. Yes, it’s a 16 year old binkie. Seeing the pacifier was like greeting an old friend. Any family who has a binkie addict knows how the binkie is a source of their child’s comfort and joy, and also how difficult it can be to wean. But take heart, someday your child’s binkie will lie forgotten and dusty. –Dr. Lai

Whether you love or hate the pacifier, at some point, to avoid the possibility of dental and speech articulation impairment, your child needs to wean. Besides, it’s nice to see your child’s entire face. You can start restricting your child’s use of the pacifier to crib/bed around two years old, and then entirely somewhere in the three year old year. Your child’s dependence on sucking for self-comfort decreases and he begins to want to dissociate himself from being a “baby.”*

Here are some ways you can encourage your child to do without his/her beloved pacifier:

• Throw the pacifier across the room and entice your child to say with you, “Yucky, binkies are for babies.”
• Restrict pacifiers to specific places such as your home, crib, or bed.
• Take a  “Binkie finding hunt” with your child and gather all the binkies into a basket. Have the binkie fairy come overnight, take the basket, and leave a present in the morning. Alternatively, one set of parents told me that they told their child that they were gathering binkies for babies who didn’t have any.
• If giving your child a pacifier is part of your bedtime routine, start to introduce something else such as a special blanket or stuffed animal.
• Sometimes as parents, we are the ones who have to be weaned. When your child is upset, do not automatically pop a binkie into your child’s mouth. Seek other ways to help your child calm himself. Hand him a book, or sit down and read with him. Refrain from handing your child your cell phone or ipad to watch a video- it can be harder to wean this habit!
• Vow to yourself not to buy new pacifiers at the grocery store. Gradually the pacifiers left in the house will disappear or the mold on them will prompt you to throw them away.
• Cut a small hole in the tip of the nipple- the binkie will not “be the same.” Tell your child that the binkie is broken and throw it away.
• Vacations disrupt schedules. Therefore, sometimes in an unfamiliar bed, children wean habits. Conveniently forget the binkie while going on vacation and do not introduce it on return home.
• By age three, most kids appreciate the value of a good bribe. Offer them a reward for going a whole week (or at least 3 days) without the binkie. One night doesn’t count because often the second night is more difficult for the child than the first when he is giving up the binkie. Once you have gone a week, the child will have no desire to go back. Just make sure you have disposed of every last binkie in your home so they will not have reminders of the “good old days.”

And now, a poem by Dr. Lai:

Ode to the Binkie

Bed time when toddlers start to shout,

It is you, dear binkie, who knocks them out.

Those thumb suckers look so snide,

But haven’t been without you on a long car ride.

None in the diaper bag, none in the crib?

Take one from our infant sib.

If you touch the ground, I’ll give you a quick blow,

Back into the mouth you’ll just go.

But now my child can run and jump with both feet off the ground,

Two to three word sentences she can sound.

If old enough to politely ask for you,

Then old enough to make permanent teeth go askew.

Oh dear binkie, you once had your place,

Now let’s take the cork from the face.

Once you were our beloved binkie,

But right now… you are just stinky.

*NOTE: we have different suggestions for thumb suckers. Clearly we can’t throw a thumb across the room and say “Thumbs are for babies!” To be very brief: aim for stopping thumb sucking by the time that permanent teeth grow in, by around age 6 or so. If you pluck it out right after your child falls asleep, often it stays out for most of the night.

Naline Lai, MD with Julie Kardos, MD

©2010, 2016 Two Peds in a Pod®

Photo credit: Lexi Logan

Back by popular demand: our picky eater post, with bonus recipes at the end.

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

Picky eaters come in two major varieties.

One kind is the child who eats the same foods every day and will not vary her diet. For example, breakfast is always the same cereal with milk and a banana, lunch is always peanut butter and jelly, and dinner is some form of chicken, rice, and peas. This diet is nutritionally complete (fruit, vegetable, protein, dairy, carbohydrate) but is boring to the parent.

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

My twins, when younger, ranged from the One Who Tried Anything to the One Who Refused Everything! My oldest child lived on cheerios and peanut butter and jelly for about two years, but now he eats crab legs and bulgur wheat and sushi. My point: I feel your frustration, and I will give you advice that works as well as optimism and a new way of thinking about feeding your children.

Fortunately, from a medical point of view, toddler/children nutrition needs to be complete as you look over several days, not just one meal. For example, if every three days your child has eaten some fruit, vegetables, protein, dairy, and complex carbs, then nutritional needs are met and your child will thrive. Of course, if your child’s pediatrician has determined that your child is not growing appropriately, you may need to look “beyond the picky” into medical causes and treatments of poor growth.

Ways to outwit, outplay, and outlast picky eaters

1. Never let them know you care about what they eat. If you struggle with your child at mealtimes, she will not eat and you will continue to feel bad about her not eating. Talk about the day, not about the food, at mealtime. You want your child to eat for the simple reason that she feels hungry, not to please you or anyone else, and not because she feels glad or mad or sad. Also, refrain from cooking a “special meal” for your toddler. Typically once a toddler catches on that you desperately want her to eat your cooking, she will refuse it.
2. Do let them help you cook. Even young children can wash vegetables and fruit, arrange food on platters, mix, pour, and sprinkle ingredients. Older kids can practice reading aloud from recipes and can help measure. Kids are more apt to taste what they help create.
3. Let them dip their food into salad dressing, apple sauce, ketchup, etc., which can make their food more appealing or interesting to eat.
4. Hide more nutritious food in the foods they already like. For example, carefully mix vegetables into meatballs or meatloaf or into macaroni and cheese. Bright green smoothies hiding kale and other greens are very popular. See the recipes at the end of this post for Zucchini chocolate chip muffins and Magic Soup.
5. Remember to offer foods that YOU do NOT like– your kids might like them! Here is an example: When my children were toddlers, we decorated Easter eggs at Dr. Lai’s house with her children. My kids asked if they could eat their decorated hard boiled eggs. Understand that hard boiled eggs is one food that I do NOT like. I don’t like their smell, their texture, and I really do not like the way they taste. Yet, all three of my kids, including my pickiest, loved those hard boiled eggs dipped in a little salt. Go figure. I had found an inexpensive, easy, healthy protein source to offer, even though I can’t stand the way my kitchen smells when I cook them.. but hey, if my kids actually EAT them…
6. In the same vein, offer foods that you assume they will not like. Dr. Lai was shocked to find that her pickiest eater enjoyed hot and spicy food.
7. Continue to offer foods even if your picky eater refuses them. Don’t force feed, just have them on the table. It could take 20 or 30 exposures before your kids might try them so do not despair. It took EIGHT YEARS of exposure to broccoli (one of my personal favorite vegetables) until two of my three kids decided they love it too. One still does not eat it. And that’s ok.
8. Hunger is the best sauce. Refrain from offering junk food as snacks or as reward for eating “real” food. Pretzels, crackers, cookies, candy, cake, and chips have NO nutritional value yet fill up small bellies quickly. Your insightful child will HOLD OUT for the junk and refuse good nutrition if they know they can fill up on snacks later. Along the same line, avoid bribing food for food. Chances are, if you bribe eating vegetables with cookies, the focus for the rest of the meal will be on the cookies and a tantrum will follow. You and your child will have belly aches from stress rather than full bellies. While it is tempting to let your child gaze all day, this will simply fill your child up so that she does not feel hunger at a meal or snack. Beware, even water can suppress the appetite.
9. If the goal is to have your children eat real food, then avoid “fake food.” Pouches with pureed fruit/veggie/cereal combos, fruit bars, fruit juice, protein shakes, and Puffs all may have nutrients but often have much sugar that grazes teeth and do not teach young taste buds the texture and flavors of healthier versions of actual fruits, vegetables, cereal, and protein sources such as meat.
10. It is okay to repeat similar meals day after day as long as they are nutritious. We might like variety as grownups but many toddlers and young kids prefer sameness and predictability.
11. Avoid becoming a “short order” chef. Picky eaters quickly take advantage of their power to make parents prepare multiple meals and likely end up not eating anyway. When your child says “I don’t want this! I want something else!” at breakfast, lunch, or dinner, you can answer calmly but firmly, “The meal is on the table.” It’s okay if they eat only one of the foods on the table. Next week she might try another. A different approach that some families use is to have one back-up meal that is the same every day for every meal and must be completely non-cook and nutritious. Examples are low sugar cereal and milk, peanut butter and jelly sandwich, yogurt with nuts or fruit mixed in, etc. that you agree to serve if your child does not want to eat what the rest of the family is eating.
12. You can give your child a pediatric multivitamin. This tactic is not giving up or cheating. It can give the Parent as Provider of Nutrients peace of mind. You can give the multivitamin every day or just on the days that you are convinced that your child has eaten nothing.
13. Read Green Eggs and Ham, by Dr. Seuss, to your young picky eater. It stars a picky eater who becomes convinced to “try them.” You may, however, need to learn to make green eggs!

Zucchini muffins ( or just call them “green muffins”)

3 cups flour, 1Tbs baking powder, 1 tsp salt, 1/2 tsp baking soda 1 1/2 tsp cinnamon,  1/2 tsp nutmeg

2 eggs, 1/2 cup low-fat milk, 1/2 cup canola or vegetable oil, 1 cup sugar, 2 cups shredded zucchini – approximately 2 medium zucchini- leave skins ON. OPTIONAL (but yummy): 1/2 cup mini chocolate chips

Preheat oven to 375F.

Stir together flour, baking powder, salt, baking soda, cinnamon, and nutmeg.

In separate bowl, beat eggs with electric mixer x 1 minute. Beat in milk, oil, and sugar. Stir in zucchini until well blended.

Add flour mixture to batter a bit at a time and stir to mix.

Mix in chocolate chips, if desired.

Spoon into greased muffin tins or place paper muffin liners, sprinkle tops of batter with a bit of sugar or “cinnamon sugar”

Bake 20 minutes, or until tops are golden brown and spring back when you touch them.

Magic Soup recipe

Take a large soup pot. Add raw chicken parts (breasts, thighs- bones add to the flavor) and cover with water.

Add onion, carrots, celery, cauliflower.

Flavor with salt, small amount of pepper, and any spice you like- I use tarragon but you can also use cilantro, parsley, curry powder, ginger.

Bring to boil, then cover and simmer for approximately 2 hours. toward the end, add some nappa (Chinese cabbage) or regular cabbage, cook until cabbage is wilted.

Serve to picky eaters: pull out the soft chicken pieces to pick up, pull out cooked vegetables – good finger food as well. Serve the broth in a cup. Most vitamins are water soluble, which means that even if your child only drinks the soup or if you pour the soup over something your child already likes such as noodles or rice, they are still getting all of the nutrition from your soup (hence, “magic soup”).

Julie Kardos, MD with Naline Lai, MD

©2016, 2013,2009 Two Peds in a Pod®

The prom preparation aftermath

It’s not your imagination: baby and toddler nails are funky and warped. Now add the fact that babies and toddlers wiggle and squirm, and taking care of your young child’s nails will appear to be a daunting task.

Even soft newborn finger nails leave significant scratches on newborn faces. Newborns need their first “manicure” within days of birth. Although the nails are long enough to scratch, most of the nail is adherent to underlying skin. A nail clipper can not get underneath the edge of the nail easily. We recommend using an emery board or nail file for the first few weeks of nail trimming. File from the bottom up, not just across the nail, in order to shorten and dull the nail.

Babies gain weight rapidly in the first three months at a rate of about one ounce per day, and they grow in length at a rate of about an inch per month. Their finger nails grow rapidly as well and therefore need trims as often as two or three times a  week. Toe nails grow quickly as well but because they do not cause self-injury, infants seem to be okay with less frequent toe nail trimming.

Once the nails are easier to grab, you can advance to using nails scissors or clippers. Dr. Kardos used to hold her babies in a nearly sitting position on her lap facing outward. Once you have a good hold, gently press the skin down away from the nails and then clip or cut carefully.

Unfortunately, no matter how careful you are, many well-intentioned parents end up cutting their child’s skin at some point. Both Dr. Kardos and Dr. Lai have nicked their kids accidentaly. Dr. Kardos recalls snipping a bit of skin from one of her twins when he was a few months old. Picture a tiny benign paper-cut that seems to cause a disproportunate amount of bleeding. He wasn’t even all that upset, but the guilt! If you accidentally cut your child, wash the cut with soap and running water to prevent infection and apply pressure for a few minutes with a clean wash cloth to stop the bleeding. Avoid band-aids: they are a choking hazard in babies who spend most of their waking moments with their fingers in their mouths. Thankfully, rapidly growing  kids heal wounds rapidly.

While Dr. Lai gave most of her kids manicures while they were sleeping, Dr. Kardos trimmed her kids’ nails while awake to get them used to the feeling of a “home manicure.” She likes to think this practice avoided some later toddler meltdowns over nail trimming. However, as she found out in one of her three kids, some kids are just adverse to nail trimming, or have sensitive, ticklish feet and balk at trims. Yet, trim we must! Clip an uncooperative toddler’s nails about 10-20 minutes after she has fallen asleep- this, or wait until you have another adult at home with you. Have your helper hold onto your child’s hand or foot while distracting the toddler with singing, book reading, or watching a soothing video together. Then you can (quickly) trim nails.

However, even in infants, the sides of big toe nails grow into the skin. Luckily the nails are very soft, and with some soaking in warm water, you can pull the skin away from the nail and cut the nail to avoid having them dig in and result in infection, or paronychia.

While it’s tempting to complete your child’s mani-pedi with a coat of nail polish, keep in mind that a young children spend a lot of time with their hands, and their toes, in their mouths.  We’ve seen kids as old as ten years bite on their toe nails. Unfortunately, the nail polish on your bureau may contain toxic hydrocarbons such as toluene and formaldehyde. Even non-toxic nail polishes will still contain dyes, and just because a manufacturer uses the term non-toxic, it doesn’t necessarily mean a product is absolutely harmless. There are no specific standards for the use of the term non-toxic.  Bottom line, the only route that avoids any chemicals is not to apply any polish in the first place. (If you are wondering about any cosmetic, the California department of public health keeps a database of cosmetics with ” ingredients known or suspected to cause cancer, birth defects, or other reproductive harm.” )

Who ever thought parental obligations would include cutting someone else’s finger and toe nails? If you haven’t perfected the process yet, take heart.  You’ll have plenty of practice over the years, and if you are lucky, you’ll get a chance like Dr. Lai did last weekend to help prep nails for the prom.

Julie Kardos, MD and Naline Lai, MD

© 2010, rev 2016 Two Peds in a Pod®

Many of our patients have dogs in their homes, and many families choose to adopt a dog during summer. Unfortunately, dog bite rates are also highest in summer, and occur most often in five to nine year olds, according to the Centers for Disease Control. Today we re-post tips on how to introduce a dog into a home with children and how to best avoid dog bites. We thank our expert consultant, veterinarian Sharin Skolnik, DVM.

–Julie Kardos, MD and Naline Lai, MD

Two Peds: Are some breeds of dogs better for children?

Dr. Skolnik: Breed recommendations are tough, because there are such different personalities within every breed. Breeds bred to protect will tend to guard their family, but may not be friendly with other kids. I have had to euthanize golden retrievers and labs for severe aggression, and know some truly stellar pit bulls. I would like every family bringing a dog into their home to think about how much time and energy they can devote to the following: exercise/walks/play dates/ mental stimulation, grooming, feeding, veterinary care, and arranging travel concerns/contingency plans.  If I had to pick a good family breed, I would suggest a Cavalier King Charles spaniel, but only if you forced me to pick one! Choosing the right dog for your family is the first big step, but do many people think about what comes with getting a new member of the family? 

Two Peds: Any suggestions for screening a dog before bringing it into the family?

Dr. Skolnik: Many rescue groups use experienced foster homes to get an idea of where a dog is at before placement, which is wonderful. Look for a puppy or dog that is not too hyper or timid, unless you have the time and energy to devote to modifying these behaviors. Inquisitive but not pushy is ideal. Having said that, dogs are incredibly trainable in the right hands. Use care when bathing, feeding, or taking things away from a newly adopted dog. Trust is a two-way deal, and positive and gentle first interactions will set the stage for the relationship.

Two Peds: Why are young kids prone to dog bites by the family dog?

Dr. Skolnik: Many factors: kids are usually very bad at reading dog body language. For that matter, many adults I meet think that a wagging tail indicates a friendly dog, when in fact it means the dog is willing to interact, positively or negatively. Kids are usually loud and move unpredictably and quickly. Never leave kids and dogs unsupervised, because the kids may not understand how to be gentle and respectful of the dog. It is important to set clear and consistent expectations for both kids and dogs on what counts as acceptable behavior.

Two Peds: What should parents teach their children about approaching a dog?

Dr. Skolnik: Teach them to always ask an owner’s permission with unknown dogs. Look for “soft” features like relaxed ears, floppy wagging tail, wiggling body. Tense body, rigid tail (wagging or not), backing up, dilated pupils– leave that dog alone. Supervision by responsible adults is key.

Two Peds: How can a dog be taught to “respect” a child?

Dr. Skolnik: The same way dogs learn to leave people’s houses and other pets alone. “Claim” items as yours, and not the dog’s, while meeting their needs. When I adopt a new dog: Guinea pigs/cats/shoes/etc. are mine. Every time the dog shows an interest in one of these things, he is told firmly “No.” The dog is given plenty of walks through the woods, praise for desired behaviors, some one-on-one time, and a few weeks later and we usually are on the same page. Consistency in training is key. The dog can’t be allowed to chase the cat when you are not home, so keep them separated! Set the dog up for praise, gently but firmly correct missteps, don’t overcorrect or correct after the fact. The latter only increase anxiety and the likelihood of future behavior problems

A common mistake in dog discipline is relying too much on punishment/ negative corrections and ignoring “good” behavior. For example; yelling at the dog for grabbing at the kids’ clothes, hands, whatever and ignoring the dog when it is chewing one of its own toys. Dogs are pack creatures; they rarely will play by themselves. Single-dog homes especially need to budget enough time each day to meet the dog’s mental and physical needs.

Two Peds: Should a dog that bites a kid be given a second chance? Can dogs be rehabilitated?

Dr. Skolnik: Depends on the scenario. A very forward dog with a history of unprovoked aggression towards kids is going to require a huge commitment to prevent injury and likely needs to go where there are no children, or humanely put to sleep. Most vets are pretty intolerant of dog aggression towards children. Now if an adult dog unfamiliar with kids snaps when a kid grabs an ear, or tries to take something away, or if the dog gave some warning that the kid should back off– I would blame the adults that put those two in the situation. Dogs (and people) can be rehabilitated, but there will always be the possibility of relapse. There are no guarantees with behavior modification.

Sharin Skolnik, DVM, holds a Bachelor’s degree from Cornell University School of Agriculture and Life Science and a veterinary degree from University of Pennsylvania School of Veterinary Medicine. She has been practicing veterinary medicine for over 20 years and is a member of the AVMA and the NJVMA. She currently works at Chesterfield Veterinary Clinic in Bordentown, New Jersey.

Her “children” include horses, dogs, cats, guinea pigs, hamsters, sheep, chickens, and rabbits. She is also a long time friend of Dr. Kardos’s. Their children play well together under close supervision.

© 2011, 2016 Two Peds in a Pod®

We see this a couple times a year… an earring which looks fine when viewed from the front…

…is actually embedded when viewed from the back. When you flip up this child’s ear lobe, you will notice how the skin has nearly completely engulfed the earring back. Young children heal well and the skin in the back of an ear can grow over the back of an earring fairly easily. So, change earrings often and “watch their backs.” It’s not enough just to spin the earrings around from the front.

Naline Lai, MD and Julie Kardos, MD

© 2016 Two Peds in a Pod®

This Mother’s Day, we honor Dr. Kardos’s mom, who passed earlier this year.

Dr. Kardos and I had been planning a post on nasal congestion in kids, but because we couldn’t have said it any better, we share a poem that Dr. Kardos’s mom wrote on this topic.

–Drs. Lai and Kardos

Runny Noses

My grandsons seem always to have runny noses;

They drip from their noses and land on their toeses;

One kid especially, his name is Aaron,

Will hug you so tight that what’s runnin’ you’re sharin’.

Alex will wipe with the back of his hand;

His runs in the house, on the beach, on the sand.

Jacob is older and he’ll use a tissue,

So his runny nose is not much of an issue.

In case they have colds, I hand each one a sweater,

But wearing a sweater does not make things better.

Allergic to dust? That’s the answer I’m seeking;

But while I keep dusting, their noses keep leaking.

They eat well and sleep well and play hard all day

In spite of their dripping that won’t go away.

So I’ve come to conclude, and I’m happy to say

That the noses of kids prob’ly just come that way.

by Felice Kardos (1943-2016)

An inadvertent sunburn tattoo

I was greatly relieved recently when my teen arrived back from a music department trip to Disney without a sunburn. I had pictured a bright red cherry tomato coming off the plane. For those of us stuck in the middle of an East Coast perpetual rain cloud, it’s hard to believe that anyone outside of the South needs to worry about sunscreen. But soon enough, you will be scratching your head in a pharmacy aisle asking yourselves these questions:

What is SPF?

• SPF stands for Sun Protection Factor. SPF gives you an idea of how long it may take you to burn. SPF of 15 means you will take 15 times longer to burn without sunscreen. If you would burn after one minute in the sun, that’s only 15 minutes of protection!
• The American Academy of Pediatrics recommends applying a minimum of SPF 15 to children, while the American Academy of Dermatology recommends a minimum of SPF 30. We both apply sunscreen with SPF 30 to our own kids (mom hint: the high SPF sunscreens tend to be watery).
• Apply all sunscreen liberally and often– at least every two hours. More important than the SPF is how often you reapply the sunscreen. All sunscreen will slide off of a sweaty, wet kid. Even if the label says “waterproof,” reapply after swimming.
• Watch out for sunlight reflecting off water as well as sunburning on cool days. One pediatrician mom I know was aghast at seeing signs posted at her kid’s school reminding parents to apply sun screen “because it will be in the 80’s.” Kids burn on 60 degree days too. Lower temperatures do not necessarily mean less UV light.

Why does the bottle of sunscreen say to “ask the doctor” about applying sunscreen to babies under 6 months of age?

• Sunscreens were not safety-tested in babies younger than 6 months of age, so the old advice was not to use sunscreen under this age. The latest American Academy of Pediatrics recommendation is that it is more prudent to avoid sunburn in this young age group than to worry about possible problems from sunscreen. While shade and clothing are the best defenses against sun damage, you can also use sunscreen on exposed body areas.
• Clothing helps to block out sunlight. In general, tighter weaves protect better than loose weaves. Expensive “sun-protective clothing” is not always better— a study from 2014 suggests regular clothing may be as protective.
  
• Hats help prevent burns as well.
• Remember that babies burn more easily than older kids.

Which brand of sunscreen is best for babies and kids?

• Although clothing and shade block harmful rays the best, no one brand of sunscreen is better for children than another. We both tell our patients to apply a “test patch” the size of a quarter to an arm or leg of your baby and wait a few hours. If no rash appears, then use the sunscreen on whatever body parts you can’t keep covered by clothing. Look for UVA and UVB protection. More expensive does not always mean “better” and SPF above 50, according to the American Academy of Dermatology, has not been proven to be more effective than 50.

What do we know about the ingredients in sunscreen such as oxybenzone? In the United States sunscreen ingredients are considered medications and are regulated by the FDA. Oxybenzone is one of the oldest broad-spectrum (UVA and UVB) sunscreens, and was approved by the FDA in 1978. Oxybenzone’s main side effect is that it can cause allergic reactions of the skin. Recently, some people question whether oxybenzone can be a hormone disrupter and have questioned the use of oxybenzone. At this point, no hormonal disturbances have been clearly found in humans and the American Academy of Dermatology continues to support the use of oxybenzone.

Sunscreens made with zinc oxide and titanium dioxide (the white stuff on a lifeguard’s nose) have not garnered any questions nor sparked any debate about safety. Interestingly, zinc oxide is not only an effective sunscreen but also you will recognize it as the main ingredient in many newborn diaper rash creams.

Any info about the popular sprays? For spray formulations of any type of sunscreen, many doctors are concerned that any aerosolized oily substance will irritate the lungs and are looking into long term effects now. Avoid spraying sun screen near a child’s head to avoid inhalation. Also with the spray, some dermatologists worry that people might not be as thorough when they apply a spray as when they apply a cream.

Can I use last year’s sunscreen? Most sunscreens have expiration dates, as long as your bottle hasn’t expired, then it should be effective. In general, sunscreens are designed to last about three years before they expire.

Remember when we used to call sunscreen lotion “suntan lotion,” and when tolerating red, blistering shoulders was considered a small price to pay for a tan? Live and learn.

Naline Lai, MD and Julie Kardos
Two Peds in a Pod® rev ©2016 , 2015

The classic bullseye rash of Lyme

Our infectious disease colleagues warn us that this year, winter in the Northeast United States was not cold enough for long enough to kill off as many ticks as usual. Thus, we folks in Pennsylvania are in for a more burdensome Lyme disease season. We’ve already had children come to our office this spring with concerns of tick bites, so here’s an update on Lyme disease:

Lyme disease is spread to people by blacklegged ticks. Take heart- even in areas where a high percentage of blacklegged ticks carry the bacteria that causes Lyme disease, the risk of getting Lyme from any one infected tick is low. Niney-nine percent of the little critters DON’T carry Lyme disease… but there are an awful lot of ticks out there. Blacklegged ticks are tiny and easy to miss on ourselves and our kids. In the spring, the ticks are in a baby stage (nymph) and can be as small as a poppy seed or sesame seed. In order to spread disease, the tick has to be attached and feeding on human blood for more than 36 hours, and engorged.

In areas in the United States where Lyme disease is prevalent (New England and Mid-Atlantic states, upper Midwest states such as Minnesota and Wisconsin, and California), parents should be vigilant about searching their children’s bodies daily for ticks and for the rash of early Lyme disease. Tick bites, and therefore the rash as well, especially like to show up on the head, in belt lines, groins, and armpits, but can occur anywhere. When my kids were young, I showered them daily in summer time not just to wash off pool water, sunscreen, and dirt, but also for the opportunity to check them for ticks and rashes. Now that they are older I call through the bathroom door periodically when they shower: “Remember to check for ticks!” Read our post on how to remove ticks from your kids.

“I thought that Lyme is spread by deer ticks and deer are all over my yard.” Nope, it’s not just Bambi that the ticks love. Actually, there are two main types of blacklegged ticks, Ioxdes Scapularis and Ioxdes Pacificus, which both carry Lyme and feed not only on deer, but on small animals such as mice. (Fun fact: Ioxdes Scapularis is known as a deer tick or a bear tick.)

Most kids get the classic rash of Lyme disease at the site of a tick bite. The rash most commonly occurs by 1-2 weeks after the tick bite and is round, flat, and red or pink. It can have some central clearing. The rash typically does not itch or hurt. The key is that the rash expands to more than 5 cm, and can become quite large as seen in the above photo. This finding is helpful because if you think you are seeing a rash of Lyme disease on your child, you can safely wait a few days before bringing your child to the pediatrician because the rash will continue to grow. The Lyme disease rash does not come and then fade in the same day, and the small (a few millimeters) red bump that forms at the tick site within a day of removing a tick is not the Lyme disease rash. Knowing that a rash has been enlarging over a few days helps us diagnose the disease. Some kids have fever, headache, or muscle aches at the same time that the rash appears.

If your child has primary Lyme disease (enlarging red round rash), the diagnosis is made by a doctor examining your child. Your child does not need blood work because it takes several weeks for a person’s body to make antibodies to the disease, and blood work tests for antibodies against Lyme disease, not actual disease germs. In other words, the test can be negative (normal) when a child does in fact have early Lyme disease.

The second phase of Lyme disease occurs if it is not treated in the primary phase. It occurs about one month from the time of tick bite. Children develop a rash that looks like the primary rash but appears in multiple body sites all at once, not just at the site of the tick bite. Each circular lesion of rash looks like the primary rash but typically is smaller. Additional symptoms include fever, body aches, headaches, and fatigue without other viral symptoms such as sore throat, runny nose, and cough. Some kids get the fever but no rash. Some kids get one-sided facial weakness. This stage is called Early Disseminated disease and is treated similarly to the way that Early Lyme disease is treated- with a few weeks of antibiotics.

The treatment of early Lyme disease is straightforward. The child takes 2-3 weeks of an antibiotic that is known to treat Lyme disease effectively such as amoxicillin or doxycycline. Your pediatrician needs to see the rash to make the diagnosis. This treatment prevents later complications of the disease. While the disease can progress if no treatment is undertaken, fortunately children do not get “chronic Lyme disease.” Once treatment is started, the rash fades over several days. Sometimes at the beginning of treatment the child experiences chills, aches, or fever for a day or two. This reaction is normal but you should contact your child’s doctor if it persists for longer.

Later stages of Lyme disease may be treated with the same oral antibiotic as for early Lyme but for 3-4 weeks instead of 2-3 weeks. The most common symptom of late stage Lyme disease is arthritis (red, swollen, mildly painful joint) of a large joint such as a knee, hip, or shoulder. Some kids just develop joint swelling without pain and the arthritis can come and go.

For some manifestations, IV antibiotics are used. The longest course of treatment is 4 weeks for any stage. Children do not develop “chronic Lyme” disease. If symptoms persist despite adequate treatment, sometimes one more course of antibiotics is prescribed, but if symptoms continue, the diagnosis should be questioned. No advantage is shown by longer treatments. Some adults have lingering symptoms of fatigue and aches years after treatment for Lyme disease. While the cause of the symptoms is not understood, we do know that prolonged courses of antibiotics do not affect symptoms.

For kids eight years old or older, if a blacklegged tick has been attached for well over 36 hours and is clearly engorged, and if you live in an area of high rates of Lyme disease-carrying ticks, your pediatrician may in some instances choose to prescribe a one time dose of the antibiotic doxycycline to prevent Lyme disease. The study that this strategy was based on and a few other criteria that are considered in this situation are described here.* Your pediatrician can discuss the pros and cons of this treatment.

Bug checks and insect repellent. Protect kids with DEET containing insect repellents. The Centers for Disease Control recommends 10 to 30 percent DEET- higher percent stays on longer. Spray on clothing and exposed areas and do not apply to babies under two months of age. Grab your kids and preform daily bug checks- in particular look in crevices where ticks like to hide such as the groin, armpits, between the toes and check the hair. Be suspicious of random scabs. Dr. Lai once had a elementary school patient who had a blacklegged tick in the middle of his forehead. The mother noticed it at breakfast, tried to brush it off, thought it was a scab and sent the boy to school. Later that day the teacher called saying, “I think your son has a bug on his face.”

Misinformation about this disease abounds, and self proclaimed “Lyme disease experts” play into people’s fears. While pediatricians who practice in Lyme disease endemic areas are usually well versed in Lyme disease, if you feel that you need another opinion about your child’s Lyme disease, the “expert” that you could consult would be a pediatric infectious disease specialist.

For a more detailed discussion of Lyme disease, look to the Center for Disease Control website: www.cdc.gov.

Julie Kardos, MD and Naline Lai, MD

©2016 Two Peds in a Pod®, updated from our original post in 2009

*link corrected 4/18/2016

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