When one of Dr. Lai’s kids was around two years old, she deliberately let go of Dr. Lai’s hand when wading in waist high water. She exclaimed, “Look mommy, I can swim!” But she couldn’t, and as she started to sink, Dr. Lai scooped her up. What if she had taken swim lessons? Would that have been enough to prevent drowning? It may have helped, but that’s not enough. Kids need layers of protection to prevent tragedy in water.

Just in time for summer, we have new evidence about drowning prevention for both young kids and teens. Read on for updated swimming and water safety tips and an offer for free swim competency lessons for older kids.

Who is most at risk for drowning?

Children age 4 years and younger.

Most of these kids drown when parents do not realize kids have access to water. Think bathtubs, buckets, and toilets as well as ponds, puddles, and pools. Drowning is silent. Parents need to always watch their children around any body of water.

Adolescents aged 15-19.

Several factors contribute, including under-estimating risk (strong tides, swimming out too far), overestimation of skills, and substance use. Be sure to discuss rules of swimming with all of your children even if they are strong swimmers, and instruct them never to swim alone or without a lifeguard. Set an example yourself by wearing life jackets while boating and abstain from alcohol consumption. Alcohol contributes to half of all boating accidents in the United States.

Kids with autism.

Like children with other behavioral disabilities, they often wander away from adults without warning.

Children with seizure disorders.

Drowning is the leading cause of accidental death in children with epilepsy. Like ALL children, kids who have seizures should never be left alone for even a second in pools or baths.

Kids with a predisposition to cardiac arrhythmias.

If your family has a history of heart arrhythmias (eg. Long QT, Brugada syndrome, Ventricular tachycardia), unexplained sudden death at a young age, or an unexplained drowning, bring it to your pediatrician’s attention. In your child, let your pediatrician know about any fainting/near fainting episodes, “funny” heart beats, or chest pain.

When should I start swim lessons for my child?

There is no standard recommended age, but evidence suggests that swim lessons, even for kids as young as 1-4 years, can add a level of protection against drowning. Goals of swim lessons include the ability to enter the water, surface, turn around, swim for 25 yards, tread water or float, and to exit the water safely.

Swim lessons should also include real life “what to do in case of an accident” scenarios, such as swimming with clothes on, how to recognize a swimmer in trouble, and how to call for help. They should learn never to swim without adult supervision. Older children, and all adults for that matter, should learn CPR.

There is lack of evidence that swim lessons for babies under one year protects babies. Babies this young have relatively large heads compared to their body size and are incapable of picking up their heads out of the water to breathe if they are submerged. Think of swim “lessons” for babies as a fun, social activity instead of a potentially life-saving class.

Even if your children take swim lessons, THEY ARE NOT DROWN PROOF. Stay within arm’s length of all young children and non-swimmers.

How can I make kids in my backyard pool safer?

Install a fence that is at least 4 feet high around the pool.

The fence should be self-closing and self-latching, and isolates the pool completely from the rest of the yard and the house.

Pool covers and barrier alarms may add another level of protection, but there is no data that demonstrates definitively that they prevent drowning.

The Consumer Product Safety Commission has detailed instructions and information on the latest safety products recommended for home pools.

Always supervise your swimming children.

Adults should be very clear with each other about who is watching the swimmers. Stay at arm’s length of non-swimmers and young swimmers, and refrain from texting, drinking alcohol, reading, socializing, or any other activity that takes your eyes off of your child or could shift attention away from kids in the water. When kids drown, they drown silently, so you will likely not hear trouble.

Non-swimmers and small children should wear life jackets, even in your own pool, for maximum water safety. Inflatables are not substitutes. Look for US Coast Guard approved jackets.

It bears repeating: most drownings occur when parents had no idea that their child had access to water.

A few years ago, Dr. Lai’s toddler-aged neighbor waddled over to the ice bucket at a Fourth of July party. Toddlers have big pumpkin shaped heads and before Dr. Lai could blink an eye, her neighbor tumbled into the water head first. Luckily Dr. Lai’s husband was standing next to the bucket and pulled the toddler out.

As this case shows, you can’t let your guard down, even if no pool or large body of water is in sight.

Small, blow-up backyard pools are the same as bath tubs in terms of drowning risk, so never leave kids unattended around these pools. Stay at arm’s length of your babies and toddlers when they play in these pools.

Additionally, never leave kids unattended, even briefly, in the bathtub.

We’re going to the beach- can my baby go swimming in the ocean? How about a pool?

Most pools, oceans, and lakes are much colder than bath water. Babies feel colder more quickly than adults. Remember your own parent telling you to come out of a pool because your lips were blue? Limit a baby’s exposure to cold water accordingly.

Chlorine will not hurt babies, but it can dry out skin. Apply moisturizer after swimming if your child’s skin gets dry.

Salt water is safe for babies and kids to swim in.

Young kids try to drink the water they swim in. Don’t let them. It’s not just your nephew who pees through his swim diaper that you need to worry about. Unfortunately, chlorine and salt fail to kill all viruses, bacteria, and parasites that might lurk in swimming water.

If your child swims outside, remember that sunburns occur more easily because sunlight reflects off the water. Apply sunscreen liberally before and after swimming, even if the sunscreen label says “waterproof.” Better yet, try to keep that baby hat on and have your child wear a sun protective shirt.

Can you suggest more ways my kids can play with water?

Water tables (which can double as sand tables in the spring, leaf tables in the fall and indoor snow tables in the winter) allow young toddlers to stand and play with toys in very shallow water.

Fill a bunch of different sized stacking cups with water for kids to pour, dump, or perhaps to mix with rocks, dirt, or leaves.

Simple squirt bottles are great fun. When Dr. Kardos’s twins were little they spent large amounts of time “watering” every plant, bush, flower, and blade of grass in the yard.

Transform chalk drawings into masterpieces by adding water.

Wet down your walkway and blow bubbles onto the cement – they will cling onto the walkway for a long period of time.

Local Parents: Do you live in Bucks County, PA? Has your child graduated from first grade? Do they know how to swim? The Y of Bucks County, in conjunction with the Children’s Hospital of Philadelphia, is offering free swim lessons for kids past first grade to achieve basic water skills competency. For more information on obtaining a voucher, email us at twopedsinapod@gmail.com.

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

Whenever we look at the child product recall lists from The Consumer Protection Safety Commission (CPSC), it never fails to amaze us that even big brand names crop up in product recalls for children. Ironically, most are not new-fangled products. Bouncer seats, high chairs, rattles, and bicycle helmets are often amongst the recalls. We figure after decades of baby product manufacturing, designers and production managers would understand what constitutes a potential hazard for kids.

We urge you to scrutinize the kid merchandise in your house and identify the potential hazards before your child ends up as the reason a product is on the CPSC list. In fact, you might have already missed a recall on your older products. According to kidsindanger.org, child product recalls occur a couple of times a week, but when a baby product is recalled, only 10-30 percent are ever retrieved. Because recalls occur AFTER injury or death occurs, it is better if parents assess the safety of child products before a recall.

Here are some common reasons for recalls:

Products fail to adhere to the American Academy of Pediatrics safe sleep guidelines. We know parents of crying young infants are often desperate to get some sleep themselves, but many sleep products are not studied. If it seems too good to be true, it probably isn’t. Infants are not ready developmentally to sleep through the night, so any product that promises to help your infant sleep through the night is, by definition, problematic. An example is the Rock ‘n Play sleeper which was recently recalled. The soft squishy inclined cradles clearly did not adhere to the safe sleep guidelines, but often we heard a parent say, ”But that’s the only place they will sleep.” Unfortunately, this recall does not undo the deaths of the 32 reported babies who died in the sleeper. In the wake of the recall, other companies who make similar sleepers are also recalling their products.

We cringe every time a family tells us they are using a new fangled piece of wrap-around-baby sleep gear or sleeping contraption, because
most involve soft surfaces (not advised), inclined surfaces (not advised) or things-in-the-crib-other-than-your-baby (also not advised).

Choking hazards: Babies and toddlers explore the world by mouthing objects. So drop on your hands and knees and see the world from their perspective. And don’t assume your kid has reached an age when “they should know better.” Ever wonder why many Monopoly game pieces go missing? Or why so many kids visit Emergency Departments after swallowing coins? In the past twenty years, the number of children visiting U.S. emergency rooms for swallowing objects doubled. Anything that can fit into a toilet paper tube (2.5 inches in diameter) is considered a choking hazard. Be aware that the toy may be too large to choke on, but a piece that breaks off may be small enough to choke on. Some great example of poorly thought-out products are teething necklaces made of beads strung together and decorative buttons on baby socks.

Ingestion hazards:

• Magnets might be a fun toy, yet they can stick together after a kid swallows them and erode through any piece of gut trapped between them. In fact, even when a parent is fairly certain that their child ate only one single magnet, we pediatricians know that because magnets can be so dangerous, we will check an X-ray, just in case there are more. After all, even an older kid is sometimes too embarrassed to fess up on the number swallowed.
• Batteries can corrode through the lining of the intestines, constituting an emergency. Check to make sure all battery backings are secure. Particularly problematic are button batteries. They are tiny and easily swallowed.
• Brightly painted wooden toys are beautiful, but they may contain lead paint. So can kid jewelry. Lead poisoning occurs usually through eating or drinking contaminated objects such as lead containing paint or paint chips. Be aware of old toys (think antique doll houses) made prior to 1978 (when lead was taken out of paint in the US), toys manufactured in China or other Pacific Rim countries, or imported candies from Mexico. If you are wondering about possible lead exposure, ask your child’s doctor to test your child for lead exposure with a simple blood test. Avoid purchasing home lead kits because they can be inaccurate.

Head entrapment hazards: Infant heads and toddler heads can get wedged. Be aware that slates on a crib need to be no more than 2 ⅜ inches apart, or no bigger than the diameter of a soda can. Beware of baby carriers or high chairs that could allow babies to slip through.

Fall hazard: Check to see all buckles are secure and unlikely to catapult your child out of the restraint. Baby carriers and strollers, especially the jogging ones, seem to crop up often in recalls.

For general guidelines for baby proofing click here.

Sign up for child product recall alerts through the CPSC, the American Academy of Pediatrics,  or kidsindanger.org. Help other families by reporting product concerns to CPSC.

Dr. Lai tells this tale: Years ago, my first child’s crib came with plastic clips which held up her mattress. As my husband and I assembled the crib, a few of the clips snapped and broke. By my second child, even more clips broke apart. By my third child, the crib clips were recalled.

Perhaps we should have been suspicious the first time.

Naline Lai, MD and Julie Kardos, MD
©2019 Two Peds in a Pod®

Do you ever wonder if some of the health advice your mom gave you growing up was actually correct?

On this Mother’s Day, we credit those moms who really do know a thing or two about child health.

1- Give your child chicken soup when she is sick.
There is merit to chicken soup. Children need to drink extra fluids when they are sick. Fevers, coughs, diarrhea, vomiting, and infections all can contribute to dehydration. Chicken soup is a great tasting fluid, has electrolytes (salt), and the vegetables that you cook in it leak all of their vitamins into the soup. Basically this is homemade “smart water” heated up. An added bonus: the chicken gives kids protein they need to fight infection.

If your child does not like chicken soup, you can hydrate them with water, apple juice, or milk (yes, kids can drink milk even if they have a cough or a fever).

2-Wear your gloves.
Moms do know how to dress kids for cold weather. Gloves are important because fingertips are at risk for frostbite. So are noses, but you can’t put gloves on that appendage.

3- Give honey for a cough.
We have written about this before- honey beats out placebo and even cough medicine in a few studies of parents’ perception of children’s sleep when sick with a cough. You can put it into tea, warm or cold milk, or give it straight off a spoon. Just be sure to brush their teeth afterward. And we remind you to NOT give honey to babies younger than one year of age because of concern for infant botulism.

4- Get some Vitamin D.
While we advise sunscreen for when your kids play outside, she is right that vitamin D , which comes from sun exposure and certain foods, is important. It not only contributes to bone health, but also modulates the immune system. Just focus on providing vitamin D-containing foods rather than tanning sessions.

5- Turn that music down. High frequency hearing loss is related to exposure to loud noises over time.

6- Take that out of your mouth!
“That” might refer to toys or a kids’ own fingers. Babies and toddlers, of course, developmentally need to mouth objects as part of exploration, and some soothe their gums while teething as they chomp on their fingers or on large, non-chokable toys. Your job is constant supervision to prevent them from placing small chokable or toxic objects (button batteries) into their mouths. Unfortunately, older kids have been known to put necklace beads, coins, game pieces, and their own fingers in their mouths. Some bite their nails or suck their thumbs. Your mom was right when she told you to “take that out of your mouth” in effort to avoid germ spread and to avoid choking.

7- Your nose is runny because it’s cold outside. While kids can’t catch a cold virus from cold temperatures, cold temperatures can cause a nose to run. This phenomenon, dubbed vasomotor rhinitis, occurs when the vessels in the nose dilate and cause congestion.

8-Take a nap.
Just like a little exercise goes a long way to improving health, a little nap can go a long way to restoring your energy level. Young kids tend to give up naps anywhere from 2 to 5 years old. If they are sleeping well overnight and are not sleepy during the day, they don’t need naps anymore. However, sometimes even after they give up nap time, kids fall behind on sleep: from illness, from a later bedtime due to a social event, or homework. A short nap can help them catch up on sleep and thus improve their mood and help their brains retain new knowledge. Just be aware that if you let your child nap for too long or too close to bedtime, they might have difficulty falling asleep that night which can put them in a vicious sleepy cycle.

Happy Mother’s Day – may you moms get a nice little nap today!

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

Do you wonder if any communication actually occurs when you talk to your teen? We invite you to read this post for some coaching on how to talk to your teen in ways that they will find palatable.

Julie Kardos, MD and Naline Lai, MD

©2019 Two Peds in a Pod®

Keeping an eye on allergies

We see people posting photos of beautiful spring blossoms across social media, which also means it’s pollen season. Click here if your kids are rubbing their itchy allergy eyes!

Julie Kardos, MD and Naline Lai, MD

©2019 Two Peds in a Pod®

Your child lies. What do you do?

Read our post to learn the truth of why your child might lie.

Julie Kardos, MD and Naline Lai, MD

©2019 Two Peds in a Pod®

A spoonful of sugar or a spoonful of stevia?

What’s better to give my child, Tylenol or Advil? Acetaminophen or Ibuprofen?

We really shouldn’t be using brand names, but this question comes up often, and just like Kleenex or Band-aid or Post-it, we more often hear parents refer to the brand names than the  generic names.

Tylenol is a brand name for acetaminophen. Sometimes on medicine labels it is listed as APAP.

Motrin and Advil are brand names for ibuprofen.

Acetaminophen and ibuprofen are the SAME in these two effects:

Both treat pain.
Both lower fever.

Here is how acetaminophen and ibuprofen are DIFFERENT:

1. Acetaminophen is digested by the liver, and ibuprofen is digested by the kidneys.
2. The dosing is different. Acetaminophen is dosed at 15mg/kg of your child’s weight, with a maximum dose of 650mg (2 adult “regular strength” tablets). Ibuprofen is dosed at 10mg/kg of your child’s weight with a maximum dose of 400mg (2 adult tablets), unless your child’s doctor directs you otherwise. Some kids can have higher doses.
3. Acetaminophen effects last about 4-6 hours, while ibuprofen effects last 6-8 hours. So you can give a dose of acetaminophen every 4 hours and ibuprofen every 6 hours.
4. Acetaminophen can be given to babies down to 2 months of age. We generally wait until 6 months to give ibuprofen. This is because studies of safety and usefulness of ibuprofen in younger babies have not been conducted. So if your child needs pain or fever medicine and is younger than 6 months old, give acetaminophen.
5. Acetaminophen comes in several forms: as a liquid, pill, and suppository. Ibuprofen comes in liquid and pill form but has no suppository option. Suppositories are useful in kids who cannot or will not take the oral formulation.

Ibuprofen is an “anti-inflammatory” medicine. That means it decreases inflammation. So if your child has an inflamed throat or ear infection,  very sore muscles or a sprained, swollen ankle, ibuprofen is the better choice because you get the pain relief plus the “anti-inflammation” properties of the medicine.

Should I alternate acetaminophen with ibuprofen?

For treating fever, planned alternation of the two may lead to dosing confusion. To avoid the risk of accidentally overdosing your child, we suggest that parents just pick one medicine and stick with it. Many parents have “fever phobia” and for this we strongly encourage you to check out our post about fever. The goal is not to lower fever but to help your child feel better. In fact, while one study suggests that alternating the two MAY lead to better fever control, there is not enough evidence for the American Academy of Pediatrics to recommend either way.

For treating pain, planned alternation may be helpful. One of Dr. Kardos’s patients recently sprained his ankle. To get him through the night, she had the parent give tylenol, then 3 hours later give ibuprofen, then 3 hours later give tylenol, then 3 hours later give ibuprofen. When you break this down, the patient got acetaminophen every 6 hours and ibuprofen every 6 hours, and because they were staggered, the parent could give the next medicine dose before the prior one wore off. In situations of pain, this alternating of medicine plan helped avoid the need for prescription pain medicine.

How is the liquid medicine formulated? How do I measure out the dose?

In the United States, Infant Tylenol and Children’s Tylenol come as a liquid form in the concentration, or “thickness,” of 160mg per 5ml. That means that you get 160mg of acetaminophen in every 5 ml that you measure out. Yes, both infant and children’s Tylenol liquid are 160mg per 5ml. Consumer alert: The “infant” formulation comes in a smaller bottle and the children’s form comes in a larger bottle, yet typically the infant form is more expensive. Go figure.

Children’s liquid Ibuprofen comes in two different concentrations or “thicknesses.” One is for babies and comes with a medicine dropper, and one is for older kids and comes with a cup for dosing. Read the label carefully and use the measuring device (dropper or cup) that comes with the medicine.

Are there side effects?

Just like all medicine, acetaminophen and ibuprofen can cause side effects, and in rare instances, allergic reactions. So you should have a valid reason for using them that is more important than the possible side effects. Again, both treat pain and treat discomfort from fever. If your child has a fever but is otherwise comfortable, you do not have to treat the fever just for the sake of lowering it. If your child has a liver or kidney disease, your child’s doctor might want you to avoid one or the other medicine, so ask before you dose your child.

Both medicines, even though they are over-the-counter, are toxic if overdosed. Be sure your child can’t get into either one by mistake, and if they do, call poison control immediately: 1800-222-1222.

Which one do we recommend over the other?

Tylenol or Advil? The answer: it depends what you are treating, how long you want the symptoms controlled, and which medicine your child tolerates better.

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

Having trouble figuring out what to feed your toddler? Read our post for easy, healthy, and economical toddler meal ideas, featuring finger food suggestions. Spoiler alert: you can stay out of the “baby and toddler food aisle” of your local food market!

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

Does your child have an earache?

In the aftermath of flu and croup season, we are diagnosing a fair share of ear infections. But not all earaches are due to ear infections.

Read our post about ear pain and what to do about it.

Julie Kardos, MD and Naline Lai, MD
©2019 Two Peds in a Pod®

“Should I give my kid the Gardasil® vaccine?” Friends and relatives, as well as our patients’ parents, continue to ask us this question.

Our answer is always: “Yes.”

Gardasil® vaccine is the current HPV vaccine on the United States market. The vaccine prevents cancer-causing strains of human papillomavirus from infecting a person’s body. HPV cancers include cervical cancer in women, penile cancers in men, and cancers of the mouth and throat in everyone. The vaccine also protects against genital warts.

According to the  Centers for Disease Control report, nearly 90 million HPV vaccines were distributed from June 2006 through March 2016. That’s a lot of vaccinations. In the US, the large majority of HPV vaccine given was the Gardasil® vaccine.

You can read a detailed report of the way the safety of the vaccine was studied here. 

Here are the updates:

1. The vaccine prevents cancer-causing strains of HPV from infecting teens and young adults. You can read the latest study about this here. 
2. The vaccine is still safe. The HPV vaccine has still NOT caused any deaths, has NOT caused cases of premature ovarian failure, and has NOT caused any new chronic pain syndromes or neurologic diseases. If you read on the internet or on Facebook any gory tales about Gardasil, you can check those stories on “Snopes.” This website determines whether a popular internet story is a myth or a fact. 
3. Your child may need only two doses of HPV vaccine instead of three. We now know that younger teens achieve immunity with fewer doses than older teens. So, if your child gets the FIRST dose of this vaccine prior to his 15th birthday, then he needs only one more dose of vaccine 6 months later. Those starting the Gardasil® vaccine on or after their 15th birthday still need 3 doses of vaccine for maximum protection against the disease.
4. If your child has a weak immune system, they also might need three doses. Children with weakened immune systems (check with your child’s pediatrician) should get 3 doses of Gardasil®.
5. Teens and tweens are more likely to feel dizzy or to faint after all vaccinations, not only after the HPV vaccine. There are reports that HPV vaccine causes kids to faint, but fainting may occur with any teen vaccine. It is well known that surges of anxiety can cause fainting.  Although they are older, teens are often very apprehensive about getting vaccines. Babies and toddlers rarely faint. Although a toddler may be mad about a vaccine injection, they are not anxious. To prevent any light headedness, your teen’s doctor may have them sit for a few minutes after a vaccine. 

There’s a reason why we give the vaccine “so young.” Once people are infected, the vaccine does not work as well. Even though it may be difficult to imagine your child needing protection from a sexually transmitted disease, prevention of cancer-causing strains of human papillomavirus is most effective when HPV immunization is given well before your kids have had any exposure to the virus.

Yes, the HPV vaccine is safe, and yes, we gave it to our own kids.

Julie Kardos, MD and Naline Lai, MD
Ⓒ2019 Two Peds in a PodⓇ