Do you recognize yourself in this scenario? It’s early morning and you hear your teen’s cell phone buzz but you do not hear your teen getting up for school. You go into his room several times to rouse him until he finally drags himself into the bathroom. Several times more you implore him to move quickly. You argue as you do every day that he needs breakfast. You pack his lunch, remind him to put it into his backpack and end up driving him to school because he missed the bus 15 minutes ago.

Here’s the thing: teens are developmentally capable of getting themselves up in the morning, washing, dressing, getting breakfast, packing a lunch, and arriving at the bus stop on time by themselves. If you are integral in your teen’s morning routine because he can’t wake up in time to get ready for school, then consider becoming much more involved in his bedtime routine.

The quick answer to, “Why is my teen so tired?” is that your teen likely is not getting enough sleep. How much sleep do teens need? According to the National Sleep Foundation, the average teen requires 8-10 hours of sleep per day in order to enjoy optimum health and to feel well-rested. But teens now get less sleep than they did twenty years ago.

Reasons for teen sleep deprivation are myriad. Children naturally become more nocturnal as they age. Their biologic circadian rhythms change to favor staying up late and sleeping late. Yet, just as their bodies crave a later start to the day, they enter high school, which usually starts earlier than their previous schools. Studies find in school districts that have experimented with later start times, teens do not stay up later, but do get more sleep per night. Overall, the teens function better in school, have fewer car accidents, and suffer less depression than their counterparts in other schools.

To gauge if your teen gets enough sleep, ask yourself, does he pop up in the morning, happy and awake seconds after the alarm sounds? If so, your teen reached her optimal amount of sleep. Keep in mind, this differs for everyone. Dr. Lai knew a teen who went to bed at 8 p.m. and slept until 2 a.m. At that point the teen woke up, did her homework and went happily to school.

Helping your teen sleep:

Cut down on screen time. Computer, phone, TV, tablets, and game consoles are known to delay sleep onset when used in the hour prior to going to bed. In fact, according to a study of teens in Norway, screen use for more than 4 hours per day, even when used early in the day, leads to an average of 2 hours less sleep a night.

Of course teens have lots of homework, but try watching her do homework with her cell phone buzzing for her attention every minute- it’s like having your toddler poke you for attention when you try to balance your checkbook. Suggest that your teen turn off her phone or leave it in another room for periods of time while she does homework. Getting homework done more efficiently will leave more time for sleeping.

After school activities are important, but some teens need to scale back in order to have time for homework and a bedtime that allows for at least 8 hours of sleep. Teens are often too illogical to say “no” to any of the obligations that come their way. You will have to be the bad guy.

What if your teen has an acceptable bedtime but can’t fall asleep? Caffeine may be the culprit. Even a cup of coffee in the morning can affect falling asleep at night- caffeine stays in the body for 24 hours. Often teens may not realize that the soda or ice tea they drank at dinner contains caffeine.
On that same note, cold medications can keep kids up at night and even prescription medications such as ones prescribed for Attention Deficit Hyperactivity Disorder interfere with falling asleep.

Make sure your teen’s sleep is restful and restorative. A clogged nose from allergies, or if he is itchy from bug bites, may be disturbing his sleep.
To shift a late bedtime up, have your teen move his bedtime up 15 minutes a night, but keep his wake-up time the same. Don’t let him nap in the day and gradually you will be able to shift him back. On weekends don’t allow him to sleep in. Sleeping in too long will result in late bedtimes and an overtired kid Monday morning. If you’ve tired everything, but if your kid has difficulty resetting her clock to an earlier bedtime, ask your doctor about using melatonin.
Now if your teen is getting the proper amount of sleep and good quality sleep and yet still feels tired, this is fatigue. Fatigue is how a woman feels when she is pregnant. A pregnant woman may have had plenty of sleep, but she still feels tired. Medical problems other than pregnancy can cause fatigue- “Mono” or Mononucleosis, anemia, and sleep apnea are just a few. Other causes of fatigue include mental illness and drug addiction. Weight loss and depression are other signs that should trigger you to bring your tired teen to his physician for further evaluation.

Although it’s hard to watch your kid learn the misery of sleep deprivation, do your best not to say “I told you so.” Keep in mind you are looking at the same child who, as a three-year-old protested leaving a party, insisting “I am not tired,” as he fell asleep midsentence during the car ride home. He just grew into the teen who says, “I am not tired,” as he falls asleep with ear buds in and with the lights still on. As Dr. Lai is fond of saying, “Choosing sleep is what distinguishes grown-ups from kids. You know you are a grown-up when instead of fighting sleep, you chose to sleep.”

Your teen may look grown up, but he still needs you to enforce good habits, including establishing a bedtime that allows him to function optimally during the day. Remember to check in with your teen before bed, just like you talked to him at bedtime when he was young. Your involvement at bedtime can result in less stressful mornings for both of you.

For more, if you live in the Bucks County PA area, go to the  Community Conversations Workshop March 25 , 2015 at 7pm at Council Rock South High School, Holland, PA. We will be part of a group of experts talking about Communication Do’s and Don’t, Optimizing Teen Sleep and Dealing with Stressed Out Students. Presented by the Council Rock Education Foundation and the Council Rock Coalition for Healthy Youth. Made possible by The Children’s Hospital of Philadelphia. 

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

Time for a Two Peds photo quiz.

What is up with this baby’s belly-button?

It’s called an umbilical hernia, which is an out-pouching at the belly button, caused by loose belly muscles.

In the womb, babies’ belly muscles migrate across the abdomen and meet in the middle. Sometimes they don’t meet up before birth, causing a small bit of the gut to out-pouch. Usually more noticeable during crying, umbilical hernias do not hurt, nor do they get “stuck” out like a groin hernia (located at the scrotum or labia) and thus they are not a medical emergency. In fact, they do not even need treatment.

Fortunately, umbilical hernias tend to close up on their own by age five years, often much sooner. Don’t do what my grandmother suggested, which was to place a quarter on top of my son’s umbilical hernia and then tie it into place with a belt-like contraption. This does NOT hasten the hernia’s resolution.

Sometimes if an umbilical hernia is particularly large, it fails to regress after a few years, and at that point, for cosmetic reasons, a surgeon can repair it.

We see many babies with umbilical hernias in our office, and we are happy to reassure parents about them. If you were wondering, my son who had the umbilical hernia as a baby, now has a belly button that looks exactly the same as his twin who did not an umbilical hernia. Both are “in-ies.”

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

Let’s face it, it’s hard to move when it’s cold , and it’s freezing at my home.  I believe today’s high is 20 degrees Fahrenheit.  Now while this may not deter younger children from bundling up and going sledding, teen couch potatoes are busy whining that it’s “too cold.”  So there they sit.

What’s the secret to keeping them active in the winter months?  Have them schedule an activity, and be an example yourself.

Ideas for teens (and you) to do when it’s cold outside:

• Have a 15-minute dance party
• Have a Wii contest
• Try swimming (indoors please!)
• Dust off the treadmill or stationary bike in the basement and GET ON IT
• Play ping-pong
• Do a few chores
• Jump rope
• Jog during T.V. commercials
• Pull out some “little kid games” such as hopscotch, hula-hoop or Twister
• Let each child in your house choose an activity for everyone to try

Teens, like everyone else, need exercise to stay healthy.  Staff from the Mayo Clinic recommend kids ages 6-17 years should have one hour of moderate exercise each day.  Exercise can help improve mood (through the release of endorphins), improve sleep and therefore attention (critical with finals coming up), and improve cardiovascular endurance. Those spring sports really ARE just around the corner.

Here are some numbers to get the kids moving:  All activities are based on 20 minutes and a teen who weighs 110 pounds.  The number of calories burned depends on weight.  If your teen weighs more, he will burn a few more calories, if he weighs less, he’ll burn a few less.  Below the table are links to some free and quick calorie calculators on the web so your teen can check it out for him self.  For those attached to their phones, there are web apps too.

What’s the worst that can happen?  You’ll have a more fit, better rested, and happier teen!  Or at least you’ll have a cleaner home!

Try these activity calculators:

http://primusweb.com/fitnesspartner/calculat.htm

www.caloriesperhour.com/index_burn.php

http://www.caloriecontrol.org/healthy-weight-tool-kit/lighten-up-and-get-moving

Deborah Stack, PT, DPT, PCS

With nearly 20 years of experience as a physical therapist, guest blogger Dr. Stack heads The Pediatric Therapy Center of Bucks County in Pennsylvania www.buckscountypeds.com. She holds both masters and doctoral degrees in physical therapy from Thomas Jefferson University.

© 2011, 2013, updated 2015 Two Peds in a Pod®

A typical measles rash, courtesy of the public health library, Centers for Disease Control and Prevention

Who knew when we first published this post in June 2014 that another measles outbreak would occur in the US. In light of the numerous measles cases that emerged out of the California Disneyland exposure, we re-publish signs of measles in children. Parents who have children who are not completely immunized against measles should be especially vigilant.

Measles typically starts out looking like almost every other respiratory virus— kids develop cough, runny nose, runny bloodshot eyes, fever, fatigue, and muscle aches.

Around the fourth day of illness, the fever spikes to 104 F or more and a red rash starts at the hairline and face and works its way down the body and out to arms and legs, as shown here at the Immunization Coalition site. Many kids also develop Koplik spots on the inside of the mouth: small, slightly raised, bluish-white spots on a red base 1-2 days before rash. Call your child’s doctor if you suspect that your child has measles. Parents should be most suspicious if their children have not received MMR vaccine or if their immunized child was exposed to a definite case of measles or visited an area with known measles.

In the US, one in 10 kids with measles will develop an ear infection and one in 20 will develop pneumonia. Roughly one in 1000 kids develop permanent brain damage, and up to two in 1000 who get measles die from measles complications. Kids under age 5 years are the most vulnerable to complications. These statistics are found here. For global stats on measles, please see this World Health Organization page.

There is no cure for measles and there no way to predict if your child will have a mild or severe case. Fortunately, one dose of the MMR (Measles, Mumps, Rubella) vaccine is 92-95% effective at preventing measles, and two doses are 97-99% effective at preventing measles. That’s the best we can do, and this protection rate works great when everyone is vaccinated. The American Academy of Pediatrics recommends giving the first dose of MMR vaccine at 12-15 months and the second dose at school entry, between 4-6 years of age.

If parents refuse the MMR vaccination for their children, then more people are left susceptible to measles. This leads to more people who can spread  the disease when it hits a community. Measles is one of the most contagious diseases known: 9 out of 10 unvaccinated people exposed to measles will become sick, and infected people are contagious even before symptoms appear. One of the reasons behind the increase in measles cases is the increase in unvaccinated children. One patient of Dr. Kardos’s was a four-year-old boy who was behind on his vaccines and hospitalized for measles pneumonia. Before he was diagnosed he exposed an entire Emergency Department to measles.

In our global world, another reason for the spike in measles cases is the increase in travel between countries. In fact,  young children traveling internationally should now get the MMR vaccine outside of the routine schedule. If you plan on traveling,  check here to see if you need to give your child the MMR vaccine on an early schedule.

With increased vigilance and vaccination, hopefully measles will once again become a disease few doctors have ever encountered. After all, vaccines did eradicate small pox. The last case of smallpox in the United States was in 1949, and the last case in the world was in 1977. In the meantime, you’ll know how to “spot” a case of measles too.

Julie Kardos, MD and Naline Lai, MD
©2014 Two Peds in a Pod®, updated February 2015

Raw hands- recognize your kid?

I wash my hands about sixty times a day, maybe more. This frequent washing, in combination with cold Pennsylvania air, leads to chapped hands. Here are the hands of a patient. Do your children’s hands look like these?

To prevent dry hands:

• Don’t stop washing your hands, but do use a moisturizer afterwards.

• Whenever possible, use water and soap rather than hand sanitizers. Hand sanitizers are at minimum 60% alcohol- very drying. Be sure to fully dry hands after washing.

• Wear gloves or mittens as much as possible outside even if the temperature is above freezing. Remember chemistry class- cold air holds less moisture than warm air and therefore is unkind to skin. Gloves will prevent some moisture loss.

• Before exposure to any possible irritants such as the chlorine in a swimming pool, protect the hands by layering heavy lotion (Eucerin cream) or petroleum based product (i.e. Vaseline or Aquaphor) over the skin.

To rescue dry hands:

• Prior to bedtime, smother hands in 1% hydrocortisone ointment. Avoid the cream formulation. Creams tend to sting if there are any open cracks. Take old socks, cut out thumb holes and have your child sleep at night with the sock on his hands. Repeat nightly for up to a week. Alternatively, for mildly chapped hands, use a petroleum oil based product such as Vaseline or Aquaphor in place of the hydrocortisone.

• If your child has underlying eczema, prevent your child from scratching his hands. An antihistamine such as diphenhydramine (Benadryl) or cetirizine (Zyrtec) will take the edge off the itch. Keep his nails trimmed to avoid further damage from scratching.

• For extremely raw hands, your child’s doctor may prescribe a stronger cream and if there are signs of a bacterial skin infection, your child’s doctor may prescribe an antibiotic.

Happy moisturizing. Remember how much fun it was to smear glue on your hands and then peel off the dried glue? It’s not so fun when your skin really is peeling.

Naline Lai, MD and Julie Kardos, MD
© 2009, 2015 Two Peds in a Pod®

“Let’s skip this ride.”

Should I vaccinate my child? Yes, yes, yes!

The recent measles outbreak originating in Disneyland among mostly-unvaccinated children and adults highlights how important it is to continue to immunize children against preventable infectious diseases, even if we think they are rare.

There are many deadly diseases we can’t prevent, but we do have the power to prevent a few. We now have the ability to prevent your children from getting some types of bacterial meningitis, pneumonia, and overwhelming blood infections. With vaccines we can prevent cases of mental retardation, paralysis, blindness, deafness, and brain infections. Immunizations are a safe way of boosting children’s natural immune systems. Yet some of our parents continue to doubt the benefits of vaccines and to fear harm from them.

Let’s look at another kind of prevention.  You would never drive your car without putting a seatbelt on your child. Even if you don’t know anyone who was in a fatal car accident, you still buckle you and your child up. You may know a kid who emerged from a car accident with only a scrape, yet you still buckle you and your child up.

You may never know a child who is paralyzed by polio or who died of whooping cough, but it does happen and can be prevented. Just like with car accidents, it’s better to prevent the injury than to play catch-up later. Dr. Kardos’s grandfather routinely rode in the front seat of his car without his seatbelt because he “had a feeling” the seatbelt might trap him in the car during an accident. Never mind that epidemiologists and emergency room doctors have shown people are much more likely to die in a car accident if they are not wearing a seat belts, he just “had a feeling.”

We know no one likes a needle jab, but for most vaccines, no one has invented any better way of administration.

When it comes to your children, parental instinct is a powerful force. We routinely invite our patients’ parents to call us about their children if their instincts tell them something might be wrong, and we always welcome and at times rely on parents’ impressions of their children’s illnesses to help us make a diagnosis and formulate a treatment plan.

However, in the face of overwhelming evidence of safety and benefits of vaccines,  we pediatricians despair when we see parents playing Russian roulette with their babies by not vaccinating or by delaying vaccinations. We hope fervently that these unprotected children do not contract a preventable debilitating or fatal disease that we all could have prevented through immunizations.

There is no conspiracy here. We both vaccinate our own children. We would never recommend any intervention where the potential for harm outweighs the potential for good. We have valid scientific data that every year vaccines save thousands of lives. One of them could be your child’s life.

Should you vaccinate your child?

YES!

Julie Kardos, MD and Naline Lai, MD

©2015 Two Peds in a Pod®

Updated from our earlier 2011 post

Visit these posts for more infomation about vaccines: How Vaccines Work, Evaluating Vaccine Sites on the Internet, Do Vaccines cause autism? and Closure: there is no link between the MMR vaccine and autism

Also, please visit  the recent Institute of Medicine’s analysis of vaccine side effects.

How often should your child take a bath? What’s wrong with bubble bath? And how about the teens? Come find out as Kelley interviews us in Happy Healthy Kids.

“You just can’t understand worry until you have a child of your own.”

Welcome to cold and flu season. Now that flu and many other illnesses are circulating, we want to help you answer these questions: How will I know if my child is too sick? When do I need to worry? When should I call the pediatrician?”

Here is how to approach your own ill child.

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

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

Breathing:

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

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

Thinking:

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

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

Drinking/peeing:

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

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

A note about fever:

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

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

To summarize, any deviation from normal breathing, thinking, or drinking/urinating (peeing) is a problem that needs medical attention, even if no fever is present. In addition, any illness that gets worse instead of getting better is a problem that needs medical attention. Also, remember to let your child’s doctor know if your child is missing any vaccines.

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

Julie Kardos, MD and Naline Lai, MD
© 2015 Two Peds in a Pod®
updated from original posting on 11/12/2009, revised 2018

“Now what kind of soup did the doctor recommend? Was that tomato soup? Mushroom barley?”

Now that we are in the middle of the 2015 flu season, we have parents asking us every day how they can tell if their child has the flu or just a common cold. Here’s how:

Colds, even really yucky ones, start out gradually. Think back to your last cold: first your throat felt scratchy or sore, then the next day your nose got stuffy or then started running profusely, then you developed a cough. Sometimes during a cold you get a fever for a few days. Sometimes you get hoarse and lose your voice. Kids are the same way. In addition, they often feel tired because of interrupted sleep from coughing or nasal congestion. This tiredness leads to some extra crankiness.

Usually kids still feel well enough to play and attend school with colds, as long as their temperatures stay below 101°F and they are well hydrated and breathing without any difficulty. The average length of a cold is 7-10 days although sometimes it takes two weeks or more for all coughing and nasal congestion to resolve.

Important news flash about mucus: the mucus from a cold can be thick, thin, clear, yellow, green, or white, and can change from one to the other, all in the same cold. The color of mucus does NOT tell you if your child needs an antibiotic and will not help you differentiate between a cold and the flu.

The flu, caused by influenza virus, comes on suddenly and makes you feel as if you’ve been hit by a truck. Flu always causes fever of 101So, if your child has a runny nose and cough, but is drinking well, playing well, sleeping well and does not have a fever and the symptoms have been around for a few days, the illness is unlikely to “turn into the flu.”

Remember: colds = gradual and annoying. Flu = sudden and miserable.

Fortunately, a vaccine against the flu can prevent the misery of the flu. In addition, vaccines against influenza save lives by preventing flu-related complications that can be fatal such as pneumonia, encephalitis (brain infection), and severe dehydration.  Even in a year, like this one, when the flu vaccine is not well matched to the currently circulating strains, its still worth getting the vaccine. 

Be sure to read our guest article on ways to prevent colds and flu and our thoughts on over the counter cold medicines.  Now excuse us while we go out to buy yummy-smelling hand soap to entice our kids to wash germs off their hands. After that you’ll find us cooking up a pot of good old-fashioned chicken soup, just in case…

Julie Kardos, MD and Naline Lai, MD
revised from our Sept 2009 post

©2015 Two Peds in a Pod®

For kids over one year of age, the Honey Bear offers grrr-eat relief

So many children (and their parents) have colds now. Are you staring at the medicine display in the pharmacy, wondering which of the many cold medicines on the shelf will best help your ill child? How we wish we had a terrific medication recommendation for  treatment of a kid’s cold. Unfortunately, we do not.

The safety and effectiveness of cough and cold medicine has never been fully demonstrated in children.  In fact, in 2007 an advisory panel including American Academy of Pediatrics physicians, Poison Control representatives, and Baltimore Department of Public Health representatives recommended to the U.S. Food and Drug Administration (FDA) to stop use of cold and cough medications under six years of age.

Thousands of  children under twelve years of age go to emergency rooms each year after over dosing on cough and cold medicines according to a 2008 study in Pediatrics . Having these medicines around the house increases the chances of accidental overdosing. Cold medications do not kill germs and will not help your child get better faster. Between 1985 and 2007, six studies showed cold medications didn’t have significant effect over placebo.  

The self billed “snot sucker” Nose Frida

So why are children’s cough and cold medicines still around? A year after the advisory panel published their recommendations, FDA advised  against using these medications in children younger than two years but data about these medications in older children is still rolling in.   FDA continues to advise caution with these medications. The producers of cold medicines said at that point they would launch new studies on the safety of medication for those two to twelve years of age. In the meantime pharmaceutical companies stopped manufacturing cold medicine products for those under two years of age and changed the labels to read “for four years old and above.”

Yes, watching your child suffer from a cold is tough. But why give something that doesn’t help her get better and has potential side effects? Don’t despair, even if you can’t kill a cold virus, there are plenty of things you can do to make your child feel better. If she has a sore throat, sore nose, headache, or body aches, consider giving acetaminophen or ibuprofen to treat the discomfort. Give honey for her cough  if she is over one year of age. Run a cool mist humidifier in her bedroom, use saline nose spray or washes, have her take a soothing, steamy shower, and teach her how to blow her nose. Break up that mucus by hydrating her well — give her a bit more than she normally drinks. For infants, help them blow their noses by using a bulb suction. However, be careful, over-zealous suctioning can lead to a torn-up nose and an overlying bacterial infection. Use a bulb suction only a few times a day.

Best of all, when your kids have a cold, unlike you, they can take as many naps as they want.

Naline Lai, MD and Julie Kardos, MD

©2015 Two Peds in a Pod®

updated from our  2011 post