Ben’s runny nose, as depicted by Ben

Because we couldn’t have said it better ourselves, we have reprinted (with permission) our pediatrician colleague Dr. Roy Benaroch’s recent flu update from his blog The Pediatric Insider.

Some bad news about flu this year
We could be in for a rough influenza winter.

First, data just released from the CDC shows that a lot of the flu circulating in the USA isn’t a good match for the strains in this year’s flu vaccines. About 82% of flu since autumn is a type A H3N2, one that historically has been associated with more-severe illness. Of those, only about half are closely related to the A/Texas/50/2012 strain that was chosen in February to be included in the vaccine. Unfortunately, current methods of vaccine production take a long time, and manufacturers have to commit early—months ahead of time—to what will be included in the vaccines. In February, when the World Health Organization made their recommendations for the Northern Hemisphere 2014-2015 flu vaccine, they chose the H3N2 that was then in circulation. Since then, it’s “drifted”, or changed, to a related but non-identical type.

What this means is that the current vaccine is well-matched to only about 40% of circulating flu. The vaccine will probably offer some protection against the other 60%– illness will be milder and shorter—but a lot of people who got their flu vaccines are still going to get the flu, and spread the flu. Now, some protection is still better than none, so I’d still go and get that flu vaccine now if you haven’t gotten it already. An imperfect (or, honestly, far-less-than-perfect) flu vaccine is better than none. But it isn’t looking good this year.

And it gets worse. It’s becoming increasingly clear that Tamiflu, the anti-viral medication we rely on to help treat influenza, doesn’t work very well. As summarized by the Cochrane Collaboration earlier this year, studies show that Tamiflu is only modestly effective in reducing the length of influenza illness, and may be only slightly effective at reducing complications. If it does work for treatment of flu, it works best when started very early in the course of the illness. The FDA labeling calls for it to be started within 48 hours, but honestly it seems to barely work if started that late. Better to get it started within 24, or even better, 12 or 6 or 2 hours.

In practice, Tamiflu really doesn’t seem to do much of anything for most of the flu patients seen in hospitals and doctor’s offices, because we usually see patients too late. It does have a role in helping family members at risk for flu. They can start it immediately, at the first symptoms, and will probably get more benefit.

Tamiflu can also be used as a prophylactic, or preventive, agent in people exposed to flu with no symptoms, though again, the benefits are modest at best. Crunching the numbers, we probably have to treat about 33 people on average for just one person to benefit from prophylaxis. That’s not very good, especially considering that all 33 people will have to pay for it and risk the side effects.
And Tamiflu does have some significant side effects. Nausea and vomiting are quite common, but the scarier reactions are depression, hallucinations, and psychosis. Neuropsychiatric side effects are most common in people of Japanese ancestry.

So: the flu vaccine, this year, will probably offer only modest benefits. And Tamiflu really has very limited usefulness. It looks like we’d better prepare for a rough winter, and keep in mind some of the old-fashioned ways to keep from getting the flu:
• Stay away from sick people.
• If you’re sick, stay home.
• Keep your mucus to yourself—sneeze into your elbow, or better yet into a tissue. And then wash your hands.
• Don’t touch your own face. Flu virus on your hands doesn’t make you sick until you help it get into your body by touching your eyes, nose, or mouth.
• Wash or sanitize your hands frequently, and especially before touching your face or eating.

© 2014 Roy Benaroch, MD

In practice near Atlanta, Georgia, Dr. Roy Benaroch is an assistant clinical professor of pediatrics at Emory University, a father of three, and the author of  The Guide to Getting the Best Health Care for your Child and  Solving Health and Behavioral Problems from Birth through Preschool. Most recently he is the Narrator of the Great Courses Series: Medical School for Everyone. We are fans of his blog The Pediatric Insider

For all you medical photo geeks, Two Peds in a Pod is excited to announce that Dr. Lai is an associate editor of the newly published 3rd edition of Visual Diagnosis and Treatment in Pediatrics – for pediatric health care professionals or anyone who has enjoyed pinning our medical photos to Pinterest (we know you are out there).

Julie Kardos, MD and Naline Lai, MD

©2014 Two Peds in a Pod®

In spite of long TSA lines, rental car challenges and all the howling, the wolf family went to grandmother’s house every year for the holidays.

You don’t appreciate how much your baby has grown until you attempt a diaper change on a plane. For families with young children, Thanksgiving or any holiday can become stressful when travel is involved. Often families travel great distances to be together and attend parties that run later than children’s usual bedtime. Fancy food and fancy dress are common. Well-meaning relatives who see your children once a year can be too quick to hug and kiss, sending even not-so-shy kids running. Here are some tips for safer and smoother holiday travel:
If you are flying:

• Do not offer Benadryl (diphenhydramine) as a way of “insuring” sleep during a flight. Kids can have paradoxical reactions and become hyper instead of sleepy, and even if they do become sleepy, the added stimulation of flying can combine to produce an ornery, sleepy, tantrum-prone kid. Usually the drone of the plane is enough to sooth kids into a slumber.
• Not all kids develop ear pain on planes as they descend- some sleep right through landing. However, if needed you can offer pacifiers, bottles, drinks, or healthy snacks during take-off and landing because swallowing may help prevent pressure buildup and thus discomfort in the ears. And yes, it is okay to fly with an ear infection.

General tips for visiting:

• Traveling 400 miles away from home to spend a few days with close family and/or friends is not the time to solve your child’s chronic problems. Let’s say you have a child who is a poor sleeper and tries to climb into your bed every night at home. Knowing that even the best of sleepers often have difficulty sleeping in a new environment, just take your “bad sleeper” into your bed at bedtime and avoid your usual home routine of waking up every hour to walk her back into her room. Similarly, if you have a picky eater, pack her favorite portable meal as a backup for fancy dinners. But when you return home, please refer to our podcast and blog posts on helping your child to establish good sleep habits and on feeding picky eaters! One exception is when you are trying to say bye-bye to the binkie or pacifier.
• Supervise your child’s eating and do not allow your child to overeat while you catch up with a distant relative or friend. Ginger-bread house vomit is DISGUSTING, as Dr. Kardos found out first-hand when one of her children ate too much of the beautiful and very generously-sized ginger bread house for dessert.
• Speaking of food, a good idea is to give your children a wholesome, healthy meal at home, or at your “home base,” before going to a holiday party that will be filled with food that will be foreign to your children. Hunger fuels tantrums so make sure his appetite needs are met. Then, you also won’t feel guilty letting him eat sweets at a party because he already ate healthy foods earlier in the day.
• If you have a young baby, be careful not to put yourself in a situation where you lose control of your ability to protect the baby from germs. Well-meaning family members love passing infants from person to person, smothering them with kisses along the way. Unfortunately, nose-to-nose kisses may spread cold and flu viruses along with holiday cheer.
• On the flip side, there are some family events, such as having your 95-year-old great-grandfather meet your baby for the first time, that are once-in-a-lifetime. So while you should be cautious on behalf of your child, ultimately, heed your heart. At six weeks old, Dr. Lai’s baby traveled several hours to see her grandfather in a hospital after he had a heart attack. She likes to think it made her father in law’s recovery go more smoothly.
• If you have a shy child, try to arrive early to the family gathering. This avoids the situation of walking into house full of unfamiliar relatives or friends who can overwhelm him with their enthusiasm. Together, you and your shy child can explore the house, locate the toys, find the bathrooms, and become familiar with the party hosts. Then your child can become a greeter, or can simply play alone first before you introduce him to guests as they arrive. If possible, spend time in the days before the gathering sharing family photos and stories to familiarize your child with relatives or friends he may not see often.
• Sometimes you have to remember that once you have children, their needs come before yours. Although you eagerly anticipated a holiday reunion, your child may be too young to appreciate it for more than a couple of hours . An ill, overtired child makes everyone miserable. If your child has an illness, is tired, won’t use the unfamiliar bathroom, has eaten too many cookies and has a belly ache, or is in general crying, clingy, and miserable, despite your best efforts, just leave the party. You can console yourself that when your child is older his actions at that gathering will be the impetus for family legends, or at least will make for a funny story.
• Enjoy your CHILD’s perspective of Thanksgiving and other winter holidays: enjoy his pride in learning new customs, his enthusiasm for opening gifts, his joy in playing with cousins he seldom sees, his excitement in reading holiday books, and his happiness as he spends extra time with you, his parents.

We wish you all the best this Thanksgiving!

Julie Kardos, MD and Naline Lai, MD

©2014 Two Peds in a Pod®
Updated from our 2009 articles on these topics

It’s gift-giving season! Now that your families are another year older, it’s time to update our sometimes-you-just-want-to-buy-something holiday gift idea list arranged by ages and developmental stages.

0-3 months: Babies this age have perfect hearing and enjoy looking at faces and objects with contrasting colors. Music, mobiles, and bright posters are some age appropriate gift ideas. Infants self-soothe themselves through sucking- if you can figure out what your nephew’s favorite type of binkie is, wrap up a bunch-they are expensive and often mysteriously disappear.

3-6 months: Babies start to reach and grab at objects. They enjoy things big enough to hold onto and safe enough to put in their mouths- try bright colored teething rings and large plastic “keys.” New cloth and vinyl books will likewise be appreciated; gnawed books don’t make great hand-me-downs.

6-12 months: Around six months, babies begin to sit alone or sit propped. Intellectually, they begin to understand “cause and effect.” Good choices of gifts include toys with large buttons that make things happen with light pressure. Toys which make sounds, play music, or cause Elmo to pop up will be a hit. For a nine-month-old old just starting to pull herself up to a standing position, a water or sand table will provide hours of entertainment in the upcoming year. Right now you can bring winter inside if you fill the water table with a mound of snow. Buy some inexpensive measuring cups and later in the summer your toddler will enjoy standing outside splashing in the water.

12-18 months: This is the age kids learn to stand and walk. They enjoy things they can push while walking such as shopping carts or plastic lawn mowers. Include gifts which promote joint attention. Joint attention is the kind of attention a child shares with you during moments of mutual discovery. Joint attention starts at two months of age when you smile at your baby and your baby smiles back. Later, around 18 months, if you point at a dog in a book, she will look at the dog then look back at you and smile. Your child not only shows interest in the same object, but she acknowledges that you are both interested. Joint attention is thought to be important for social and emotional growth.

At 12 months your baby no longer needs to suck from a bottle or the breast for hydration. Although we don’t believe mastery of a  sippy cups is a necessary developmental milestone , Dr. Lai does admire the WOW cup because  your child can drink from it like she does from a regular cup. Alternatively, you can give fun, colored actual traditional plastic cups, which difficult to break and encourage drinking from a real cup!

18-24 months: Although kids this age cannot pedal yet, they enjoy riding on toys such as “big wheels” “Fred Flintstone” style. Dexterous enough to drink out of a cup and use a spoon and fork, toddlers can always use another place setting. Toddlers are also able to manipulate shape sorters and toys where they put a plastic ball into the top and the ball goes down a short maze/slide. They also love containers to collect things, dump out, then collect again.

Yes, older toddlers are also dexterous enough to swipe an ipad, but be aware, electronics can be a double edged sword— the same device which plays karaoke music for your daddy-toddler sing-along can be transformed into a substitute parent. The other day, a toddler was frighted of my stethoscope in the office. Instead of smiling and demonstrating to her toddler how a stethoscope does not hurt, the mother repeatedly tried to give her toddler her phone and told the child to watch a video. Fast forward a few years, and the mother will wonder why her kid fixates on her phone and does not look up at the family at the dinner table. Don’t train an addiction.

2-3 years: To encourage motor skills, offer tricycles, balls, bubbles, and boxes to crawl into and out of. Choose crayons over markers because crayons require a child to exert pressure and therefore develop hand strength. Dolls, cars, and sand boxes all foster imagination. Don’t forget those indestructible board books so kids can “read” to themselves. By now, the plastic squirting fish bath toys you bought your nephew when he was one are probably squirting out black specks of mold instead of water- get him a new set. Looking ahead, in the spring a three- year-old may start participating in team sports (although they often go the wrong way down the field) or in other classes such as dance or swimming lessons. Give your relatives the gift of a shin guards and soccer ball with a shirt. Offer to pay for swim lessons and package a gift certificate with a pair of goggles.  

3-4 years: Now kids engage in elaborate imaginary play. They enjoy “dress up” clothes to create characters- super heroes, dancers, wizards, princesses, kings, queens, animals. Kids also enjoy props for their pretend play, such as plastic kitchen gadgets, magic wands, and building blocks. They become adept at pedaling tricycles or even riding small training-wheeled bikes. Other gift ideas include crayons, paint, markers, Play-doh®, or side-walk chalk. Children this age understand rules and turn-taking and can be taught simple card games such as “go fish,” “war,” and “matching.” Three-year-olds recognize colors but can’t read- so they can finally play the classic board game Candyland®, and they can rote count in order to play the sequential numbers game Chutes and Ladders®.  Preschool kids now understand and execute the process of washing their hands independently… one problem… they can’t reach the faucets on the sink. A personalized, sturdy step stool will be appreciated for years. 

5-year-olds: Since 5-year-olds can hop on one foot, games like Twister® will be fun. Kids this age start to understand time. In our world of digital clocks, get your nephew an analog clock with numbers and a minute hand… they are hard to come by. Five-year-olds also begin to understand charts— a calendar will also cause delight. They can also work jigsaw puzzles with somewhat large pieces.

8-year-olds: Kids at this point should be able to perform self help skills such as teeth brushing. Help them out with stocking stuffers such as toothbrushes with timers. They also start to understand the value of money (here is one way to teach kids about money). The kids will appreciate gifts such as a wallet or piggy bank. Eight-year-olds engage in rough and tumble play and can play outdoor games with rules. Think balls, balls, balls- soccer balls, kickballs, baseballs, tennis balls, footballs. Basic sports equipment of any sort will be a hit. Label makers will also appeal to this age group since they start to have a greater sense of ownership.

10-year-olds: Fine motor skills are quite developed and intricate arts and crafts such as weaving kits can be manipulated. Give a “cake making set” (no, not the plastic oven with a light bulb) with tubes of frosting and cake mix to bake over the winter break. Buy two plastic recorders, one for you and one for your child, to play duets. The instrument is simple enough for ten-year-olds or forty-year-olds to learn on their own. Ten-year-olds value organization in their world and want to be more independent. Therefore, a watch makes a good gift at this age. And don’t forget about books: reading skills are more advanced at this age. They can read chapter books or books about subjects of interest to them. In particular, kids at this age love a good joke or riddle book.

Tweens: Your child now has a longer attention span (30-40 minutes) so building projects such as K’nex® models will be of interest to her. She can now also understand directions for performing magic tricks or making animal balloons. This is a time when group identity becomes more important. Sleepovers and scouting trips are common at this age so sleeping bags and camping tents make great gifts. Tweens value their privacy – consider a present of a journal with a lock or a doorbell for her room.

Teens: If you look at factors which build a teen into a resilient adult, you will see that adult involvement in a child’s life is important. http://www.search-institute.org/research/developmental-assets

We know parents who jokingly say they renamed their teens “Door 1” and “Door 2,” since they spend more time talking to their kids’ bedroom doors than their kids. Create opportunities for one-on-one interaction by giving gifts such as a day of shopping with her aunt, tickets to a show with her uncle, or two hours at the rock climbing gym with dad.

Encourage physical activity. Sports equipment is always pricey for a teen to purchase- give the fancy sports bag he’s been eying or give a gym membership. A running watch is always appreciated or treat them to moisture wicking work-out clothes or a gift card to a sports equipment store.

Sleep! Who doesn’t need it, and teens often short change themselves on sleep and fall into poor sleep habits.  Help a teen enjoy a comfortable night of rest and buy  luxurious high thread count pillow cases, foam memory pillows, or even a new mattress. After all,  it been nearly 20 years since you bought your teen a  mattress and he probably wasn’t old enough at the time to tell you if he was comfortable. Since a teen often goes to bed later than you do, a remote light control will be appreciated by all.

Enjoy your holiday shopping!

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

Modified from our original November 2012 post

No doubt, there has been an uptick in respiratory illness in our area, but the news media is causing panic specifically over one of them: enterovirus D-68.
The name “enterovirus” does not imply “deadly.” Many of you are well familiar with hand-foot-mouth disease, aka “Coxsackie virus.” Guess what? This extremely common, benign but annoying virus is also an enterovirus!

Let’s put into perspective how this “new” respiratory virus compares with an “old” well-known respiratory virus, influenza (The Flu). Remember that both flu and enterovirus D-68 are tracked by REPORTED cases. Most of the time doctors do not test children with mild disease so most reported cases are hospitalized patients.

Enterovirus D-68, the numbers: From mid-August through the first week in October (peak enterovirus season)- 664 people are known to have been infected in the USA, most of whom are children. You can track these numbers on this Centers for Disease Control website.
Influenza, the numbers: Each year in the US, approximately 200,000 people (children and adults) are hospitalized from complications of the flu. This year’s flu season in the northern hemisphere is just starting. Generally peak flu season is in the winter months. Large numbers of people contract the flu but they are not sick enough to be hospitalized- they suffer a week of fever, cough, sore throat and body aches at home but recover uneventfully. Up to 20% of the population are infected with flu each season.

Death from enterovirus D-68: 1 child. Four other children died who tested positive for this virus but it is unknown if the virus caused their deaths.
Death from influenza during the 2013-2014 flu season: 108 children

Symptoms of enterovirus D-68: range from mild cold symptoms to high fever and severe respiratory symptoms
Symptoms of flu: usually abrupt at the onset: fever, body aches, cough, and runny nose. Please see our prior post for more information.

Prevent enterovirus D-68: same as for all “cold” viruses- wash hands, sneeze/cough into elbow, not hands.
Prevent flu: Same as for enterovirus D-68, AND we have an Influenza vaccine for all children aged 6 months and above, with a few exceptions-see our article for more information. Last year the flu vaccine was about 60% effective: it’s not perfect, but it is certainly better than not vaccinating.

Overall, remember that enterovirus D-68 is one of many cold viruses that circulate the country. We are all familiar with back-to-school viruses. My teen-aged son told me, amid his sniffles and nose-blowing last week, that “more than half my school has a cold now.”
Certainly some of those colds could be enterovirus-D-68. But please don’t panic. All respiratory illnesses, including colds, have the potential to travel into your child’s lungs. It is more important to practice good illness prevention techniques and to recognize the signs of difficulty breathing. As we have said before, if we parents could worry all illnesses away, no one would ever be sick.

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

Continuing our series on the essentials of life…

If you have a newborn, stop reading and go back to feeding. It’s too early for your baby to sleep through the night. All babies lose a little weight in the first couple days of life, but then they are expected to gain. In fact, you may find that you need to awaken your baby to eat every couple of hours to eat in order to stabilize her weight loss. (see our prior post on breast feeding your newborn and our formula feeding post). While you feed your newborn, listen here to understand newborn sleep patterns:

Click here for our podcast – Sleep During the First Six Months

So, when to expect your baby to sleep longer at night? Usually after three months, your baby naturally takes more milk at each feeding and thus lasts longer between feedings. And once your baby is at least six months old, your baby may be able to sleep through the night. Set reasonable expectations. For some babies, sleeping through the night means six hours, for others ten.

At six months, object permanence fully emerges. Your baby will understand that you are somewhere even when you are not within sight. This is why he laughs hysterically when you play peek-a-boo with him. If he is dependent on you rocking him or feeding him to fall asleep, then he will look for you every time he awakens for help falling back to sleep. Also, don’t be fooled into thinking that because your baby nurses or drinks from a bottle at every night time wakening, he must be hungry. Usually he’s just looking for a way to fall back to sleep.

Training starts with making sure your baby knows how to fall asleep on his own. Make sure he can fall asleep on his own at the beginning of the night. Then train for the middle of the night. Above all, make sure you and your partner are on board with the same training strategy.  Keep bedtime roughly the same time every night, and start the bedtime routine before your baby is crying from exhaustion so he can enjoy this time with you. A typical bedtime routine for an older infant is bath (if it is a bath night), formula/breastfeed, wipe gums/brush teeth, read book, lullaby, kiss, and then bed. The exact order and events do not matter much, just finish the routine BEFORE your baby falls asleep. Lay him down on his back awake so that he has an opportunity to fall asleep on his own.

Don’t be frustrated if you try to sleep train for a few days and give up. There is no such thing as “missing” a golden window of opportunity to sleep train. If it’s not working out this week, try again next week.

Ultimately, use these principles behind a soothing, consistent bedtime and bedtime routine all the way through high school!

Sweet dreams.

Click here for our podcast- Sleep from 6mo to toddler

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

As we said to Robin Young on NPR’s Here and Now, “a lot of life’s issues all boil down to the essentials of life…eat, sleep, drink, pee, poop and love.” Continuing our ideas and updates on all of those baby essentials, here’s the scoop on poop :

Okay, admit it.

Before you became a parent, you never really gave much thought to poop.

Now you are captivated and can even discuss it over meal time: your child’s poop with its changing colors and consistency. Your vocabulary for poop has likely also changed as you are now parents. Before your baby’s birth, you probably used some grown-up word like “bowel movement” or “stool” or perhaps some “R” rated term not appropriate to this pediatric site. But now, all that has changed.

As pediatricians, we have many conversations with new parents, and some not-so-new parents, about poop. Mostly this topic is of real interest to parents with newborns, but poop issues come out at other milestones in a child’s life, namely starting solid foods and potty training. So we present to you the scoop on poop.

Poop comes in three basic colors that are all equal signs of normal health: brown, yellow, and green. Newborn poop, while typically yellow and mustard like, can occasionally come out in the two other colors, even if what goes in, namely breast milk or formula, stays the same. The color change is more a reflection of how long the milk takes to pass through the intestines and how much bile acid gets mixed in with the developing poop.

Bad colors of poop are: red (blood), white (complete absence of color), and tarry black. Only the first poop that babies pass on the first day of life, called meconium, is always tarry black and is normal. At any other time of life, black tarry stools are abnormal and are a sign of potential internal bleeding and should always be discussed with your child’s health care provider, as should blood in poop (also not normal) and white poop (which could indicate a liver problem).

Normal pooping behavior for a newborn can be grunting, turning red, crying, and generally appearing as if an explosion is about to occur. As long as what comes out after all this effort is a soft poop (and normal poop should always be soft), then this behavior is normal. Other babies poop effortlessly and this, too, is normal.

Besides its color, another topic of intense fascination to many parents is the frequency and consistency of poop. This aspect is often tied in with questions about diarrhea and constipation. Here is the scoop:

It is normal for newborns to poop during or after every feeding, although not all babies poop this often. This means that if your baby feeds 8-12 times a day, then she can have 8-12 poops a day. One reason that newborns are seen every few weeks in the pediatric office is to check that they are gaining weight normally: that calories taken in are enough for growth and are not just being pooped out. While normal poop can be very soft and mushy, diarrhea is watery and prevents normal weight gain.

After the first few weeks of life, a change in pooping frequency can occur. Some formula fed babies will continue their frequent pooping while others decrease to once a day or even once every 2-3 days. Some breastfed babies actually decrease their poop frequency to once a week! It turns out that breast milk can be very efficiently digested with little waste product. Again, as long as these babies are feeding well, not vomiting, acting well, have soft bellies rather than hard, distended bellies, and are growing normally, then you as parents can enjoy the less frequent diaper changes. Urine frequency should remain the same (at least 6 wet diapers every 24 hours, on average) and is a sign that your baby is adequately hydrated. Again, as long as what comes out in the end is soft, then your baby is not “constipated” but rather has “decreased poop frequency.”

True constipation is poop that is hard and comes out as either small hard pellets or a large hard poop mass. These poops are often painful to pass and can even cause small tears in the anus. You should discuss true constipation with your child’s health care provider. A typical remedy, assuming that everything else about your baby is normal, is adding a bit of prune or apple juice, generally ½ to 1 ounce, to the formula bottle once or twice daily. True constipation in general is more common in formula fed babies than breastfed babies.

Adding solid foods generally causes poop to become more firm or formed, but not always. It DOES always cause more odor and can also add color to poop. Dr. Kardos still remembers her surprise over her eldest’s first “sweet potato poop” as she and her husband asked each other, “Will you look at that? Isn’t this exactly how it looked when it went IN?” If constipation, again meaning hard poop that is painful to pass, occurs during solid food introductions, you can usually help by giving more prunes and oatmeal and less rice and bananas to help poop become softer and easier to pass.

Potty training can trigger constipation resulting from poop withholding. This poop withholding can result in backup of poop in the intestines which leads to pain and poor eating. Children withhold poop for one of three main reasons.

They are afraid of the toilet or potty seat.

They had one painful poop and they resolve never to repeat the experience by trying to never poop again.

They are locked into a control issue with their parents. Recall the truism “You can lead a horse to water but you can’t make him drink.” This applies to potty training as well.

Treatment for stool withholding is to QUIT potty training for at least a few weeks and to ADD as much stool softening foods and drinks as possible. Good-for-poop drinks and foods include prune juice, apple juice, pear juice, water, fiber-rich breads and cereals, beans, fresh fruits and vegetables. Sometimes, under the guidance of your child’s health care provider, medical stool softeners are needed until your child overcomes his fear of pooping and resolves his control issue. For more information about potty training we refer you to our post with podcast on this subject.

Our goal with this blog post was to highlight some frequently-asked-about poop topics and to reassure that most things come out okay in the end. And that’s the real scoop.

Julie Kardos, MD and Naline Lai, MD

©2014 Two Peds in a Pod®

modified from original 2009 post

We gave our kids their back-to-school haircuts, donated their pants that fit like floods, and bought them new folders and notebooks. As shown on our back-to-school supply list photo, back-to-school also means the start of hand sanitizer and tissue season. Yes, it’s time for your child’s yearly flu vaccine. Even if you gave your child a flu vaccine last year, she’ll need another one this season. Not only does the flu or influenza virus (not to be confused with “the stomach bug/stomach flu”) usually come back every season in a slightly different form, but your child’s immunity has waned over the past year. With every flu season, the Centers for Disease Control comes out with new recommendations. Here is a snap shot:

Who needs the flu vaccine?
All children aged 6 months or older, with a few exceptions discussed below, should receive a flu vaccine every year.

How many doses of flu vaccine does my child need this year?

If your child is nine years or older, your child only needs one dose this season.

If your child is younger than nine, your child only needs one dose this season UNLESS:

• This year will be the first time your child receives the flu vaccine. Then, she will need a second (booster) dose at least 4 weeks later.
• Your child skipped last year’s flu vaccine. Then, she may need a booster dose this year. Check with your child’s doctor.

Which type of flu vaccine is better, a shot or the mist (squirt in the nose)?

This year, the Centers for Disease Control suggests,  if available, to give children aged 2-8 years the squirt in the nose. However, if the mist is unavailable, do not delay the vaccine. Give your child a flu shot instead. For older kids, the data is not as clear cut as to which vaccine works better to prevent the flu. Give your child either form of the vaccine.

Who cannot receive the mist?
Kids younger than 2 years; kids with certain medical conditions such as ongoing asthma (wheezing in the past year, or 2 through 4 years of age with asthma) and diabetes; kids undergoing  aspirin therapy; kids who have had influenza antiviral therapy in the last 48 hours; kids with immune deficiencies; and kids around immunosupressed people who require a protective environment (e.g. around people hospitalized in a bone marrow transplant unit), should not receive the mist. These kids should receive the injectable form of flu vaccine. Your child’s doctor can provide the complete list of contraindications.

Who should NOT receive any flu vaccine?
Babies younger than 6 months old and children with severe egg allergy (anaphylaxis) should not receive the flu vaccine.

Our office is slotted to receive our annual supply of flu vaccine in the next few weeks. Our own families have learned to expect the annual flu vaccine with the start of each school year. Now we just need to convince them that they needed the haircuts.

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

In the next month, we’ll be updating our posts on baby basics. As we said to Robin Young on NPR’s Here and Now,  “a lot of life’s issues all boil down to the essentials of life…eat, sleep, drink, pee, poop and love.”  Over the next month we’ll be giving you ideas and updates on all of those essentials. We start off with “eat” and how to transition your baby to solid foods:

While starting your child on solid food isn’t always “love at first bite” it also does not have to be complicated or stressful.

Here are some overriding principles to keep in mind when feeding your baby:

1) It’s not just about the food. It’s about teaching your child to eat when hungry and to stop when not hungry.

2) Eating a meal with family is social as well as nutritious. Keep eating pleasant and relaxed. No need to force-feed or trick your child into eating. Feed your baby along with other family members so your baby can learn to eat by watching others eat.

3) Babies start out eating pureed foods on a spoon between 4-6 months and progress to finger foods when physically capable, usually between 7-9 months. Teeth are not required; hand to mouth coordination is required.

Before four to six months of age, a baby slumps when propped in a sitting position and tends to choke on solids. After four months, babies are less likely to reflexively “tongue thrust” food right back out of their mouths.  Putting cereal into a bottle doesn’t count as “eating” and is not necessary.

Timing matters when offering solid food for the first time. Babies learn to expect a breast or a bottle when hungry. So make sure your baby is happy and awake but NOT hungry the first time you feed her solid food because at this point she is learning a skill, not eating for nutrition. You should wait about an hour after a milk feeding when she is playful and ready to try something new. Keep a camera nearby because babies make great faces when eating food for the first time. Many parents like to start new foods in the morning so that they have the entire day to make sure it agrees with their baby. Watch for rash or stomach upset.

What should you feed your baby first? There is no one right answer to this question. The easiest food to offer is one that is already on the breakfast, lunch, or dinner table that is easy to mush up.  In some cultures, a baby’s first food is a smash of lentils and rice. In other cultures it’s small bits of hard-boiled egg or a rice porridge. Just avoid honey before one year of age because honey can cause botulism in infants. The bottom line: it doesn’t matter much what you start with, as long as it’s nutritious. Dr. Kardos is proud to say that she fed her nephew his first solid food this summer: watermelon! (He loved it). Even if you start with a mashed up  banana or a yam, plan to add iron-containing foods sooner rather than later. Pediatricians recommend a diet with iron-containing solid foods because a baby’s iron needs will eventually outstrip what what she stored from her mother before birth as well as what she can get from breast milk or formula. Iron-containing food include iron-fortified baby cereal (such as oatmeal or rice) and  pureed meats (such as chicken, beef or fish). Note, with baby cereals, make them up with formula or breast milk, not water or juice, for more nutritional “oomph.”

Some babies will learn in just one feeding to swallow without gagging and to open their mouths when they see the spoon coming. Other babies need more time. They may tongue-thrust the food back out, cough when trying to swallow, cry, or appear clueless when the spoon comes back to them. To avoid the tongue-thrust reflex or the gag reflex, place the spoon gently to one side of your baby’s tongue during a feed. If you see your baby is distressed, just end the meal. Some babies take several weeks to catch on to the idea of eating solids. Try one new food at a time. Then, if your baby has a reaction to the food, you’ll know what to blame.

Some babies just never seem to like mushed up foods and prefer to suck on foods at first (like Dr. Kardos’s nephew did with his watermelon). One practice called baby-led weaning describes another way of introducing solids.

Stage one and stage two baby foods are similar. No need to test all stage one foods before going onto stage two. The consistency of the food is the same. The stages differ in the size of the containers and stage one foods do not contain meat. Some stage two foods will combine ingredients. Combinations are fine as long as you know your baby already tolerates each individual ingredient (i.e. “peas and carrots” are fine if she’s already had each one alone). Avoid the dessert foods. Your baby does not need fillers such as cornstarch and concentrated sweets.

Not all kids like all foods. Don’t worry if your baby hates carrots or bananas. Many other choices are available. At the same time, don’t forget to offer a previously rejected food multiple times because taste buds change.

Be forewarned: poop changes with solid foods. Usually it gets more firm or has more odor. Food is not always fully digested at this age and thus shows up in the poop. Wait until you see a sweet potato poop!

By six months, babies replace at least one milk feeding with a solid food meal. Some babies are up to three meals a day by 6 months, some are eating one meal per day. Starting at six months, for cup training purposes, you can offer a cup with water at meals. Juice is not recommended. Juice contains a lot of sugar and very little nutrition.

Offer finger foods when your baby can sit alone and manipulate a toy without falling over. When you see your baby delicately picking up a piece of lint off the floor and putting it into his mouth, he’s probably ready.  Usually this occurs between 7-9 months of age. Even with no teeth your baby can gum-smash a variety of finger foods. Examples include “Toasted Oats” (Cheerios), which are low in sugar and dissolve in your mouth eventually without any chewing, ½ cheerio-sized cooked vegetable, soft fruit, ground meat or pieces of baked chicken, beans, tofu, egg yolk, soft cheese, small pieces of pasta. Start by putting a finger food on the tray while you are spoon feeding and see what your child does. They often do better feeding themselves finger foods rather than having someone else “dump the lump” into their mouths.

Children should always eat sitting down and not while crawling or walking in order to AVOID CHOKING. Also, you don’t want to create a constantly munching toddler who will grow into a constantly munching ten year old.

Finger food sample meals: Breakfast: cereal, pieces of fruit. Lunch: pasta or rice, lentils or beans, cooked vegetables in pieces, pieces of cheese. Dinner: soft meat such as chicken or ground beef, cooked veggies and/or fruit, bits of potato, or cereal. need other ideas? Check out this post on finger foods. By nine months, kids can eat most of the adult meal at the table, just avoid choking hazards such as raw vegetables, chewy meats, nuts, and hot dogs. You can use breast feedings or formula bottles as snacks between meals or with some meals. By this age, it is normal for babies to average 16-24 oz of formula daily or 3-4 breast feedings daily.

Avoid fried foods and highly processed foods. Do not buy “toddler meals” which are high in salt and “fillers.” Avoid baby junk food- if the first three ingredients are “flour, water, sugar/corn syrup”, don’t buy it. We are amazed at the baby-junk food industry that insinuate that “fruit chews,” “yogurt bites” and “cookies” have any place in anyone’s diet. Instead, feed your child eat REAL fruit, ACTUAL yogurt, and healthy carbs such as pasta, cous-cous, or rice.

Organic and conventional foods have the same nutritional content. They differ in price, and they differ in pesticide exposure, but no study to date has shown any health differences in children who consume organic vs conventional foods. For more information, see this American Academy article and this study as well as our own prior post about organic vs conventional foods.

A word about food allergies: Even the allergists lack a definitive answer of what makes a child allergic to a food, and the American Academy of Allergy, Asthma, and Immunology now recommends offering foods, including the more “allergic” foods, early to avoid later food allergy. This is a change from recommendations issued about 15 years ago. For safety concerns, if a household member has a life threatening allergy to a food, continue to avoid bringing that food into the house to ensure the safety of the allergic person. However, if no one at home has a peanut allergy, then a thin spread of peanut butter on a bit of toast or cracker is safe for your finger-feeding baby. Focus more on avoiding choking hazards than on avoiding theoretically allergenic foods.

And a word about fish:  For years, experts fretted about pregnant women and children exposing themselves to high mercury levels by eating contaminated fish. However, the  realization that fish is packed with nutrition, and the data that show only a few types of fish actually contain significant mercury levels, now leads the FDA to encourage fish intake in young children and pregnant women. Please check this FDA advice for specific information about which fish to offer your child and the nutritional benefits of different kinds of fish.

Bon appetite,

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

Updated from our original 2009 post

Yet another reminder about the signs and symptoms of measles from a health agency landed in our email inbox the other day. The reason? According to the Centers for Disease Control, as of this point, the United States has seen more measles cases this year (almost 600 reported) than in the past decade (typically 60 cases per year). Organizations are reminding physicians about the symptoms of measles because thanks to  vaccinations, many pediatricians have not seen a case of the measles in decades. In this post, we pass the information on to you. After all, you will be the first to recognize that your child is ill.

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.

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% effective at preventing measles, and two doses are 97% effective at preventing measles. That’s the best we can do, but this 97% 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 often need to 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®