You wake up in the middle of the night to the sound of a seal barking inside your house. More specifically, from inside the crib or toddler bed. Unless you actually have a pet seal, that bark is the sound of your child with croup.
Although the United States is in the midst of an obesity epidemic, some children are underweight. Your child’s pediatrician charts your child’s height and weight in order to determine whether he is growing appropriately. Just as obesity has many causes, kids can be underweight for many reasons. Regardless of whether the cause of your child’s poor weight gain is medical or behavioral, the bottom line is that underweight kids use more calories than they take in.
Here are ways to increase calories. Remember, you cannot force children to eat if they are not hungry. For example, you can’t just demand that your child eat more noodles. Instead of trying to stuff more food into your child, increase the caloric umph behind a meal. Make every bite count:
Some causes of poor weight gain are medical. Have your child’s doctor exclude medical reasons of poor weight gain with a thorough history and physical exam before you assume poor weight gain is from low caloric intake. Sometimes, your child’s physician may need to check blood work or other studies to help figure out why he is not gaining weight appropriately.
Some common behavioral causes include drinking too much prior to eating, picky eating, or parents failing to offer enough calories. Sometimes tweens and teens develop a pathologic fear or anxiety about gaining weight and deliberately decrease their food consumption. These kids have eating disorders and need immediate medical attention.
A common scenario we often see is the underweight toddler whose parents describe as a “picky eater.” Meal times are stressful for the entire family. Mom has a stomach ache going into dinner knowing the battle that will ensue. Her child refuses everything on the table. Mom then offers bribes or other meal alternatives. Dad then gets into the fray by making a game out of eating, and when the child does not eat, in frustration he yells at the child. Grandma then appears with a big cookie because “well, he needs to eat SOMETHING.” All the adults end up arguing with each other about the best way to get their toddler to eat. If you recognize your family in this example, please see our post on how to help picky eaters for ways to break out of this cycle.
Just as obese children need to see their doctors to check for complications relating to their increased weight, underweight children require weight checks to make sure that they gain enough weight to prevent poor height growth and malnutrition.
Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®
As a call to service in honor of Martin Luther King Day, we bring you an eye opening child advocacy post from guest blogger Dr. Heidi Román, who works with underserved children and their families in California .
Early in my pediatric residency training I entered the exam room to see a one-year old patient. Her mom blurted out excitedly, “We finally have a place to live.” It turned out that they had been living in motels or with relatives for most of the child’s life. I paused for a moment as I realized that it had never really registered. She had been seen in our clinic for multiple visits, but no one had noticed the changing addresses. No one had asked the questions in a way that allowed her to tell us. They were homeless. This was my wake up call. Since then, I have met many families affected by homelessness. Many hard working families are pushed into poverty and homelessness by loss of a paycheck, foreclosure, or divorce. They are reluctant to talk about it. Children and families are the “hidden” homeless.
While the mainstream media consistently covers the recession, quoting jobs numbers and the like, there is a disturbing new set of data out that doesn’t seem to be getting much press. Last month the The National Center on Family Homelessness released their report on child homelessness entitled “America’s Youngest Outcasts 2010“, and the news is not good. During the time period of the recession (2007-2010) there was a 38% spike in the number of homeless children. Currently, there are 1.6 million homeless children in the United States. Children now make up almost 40% of the homeless population and families with children are the most rapidly growing segment of the homeless population.
That’s a lot of kids and families. And, as children are often not included in homeless statistics, the number is probably higher. Why don’t we hear about it more? Well, homeless families tend to be the invisible segment of the homeless population. They fly under the radar. They move from place to place. They “double up” with friends or relatives for a few months, and then stay in a shelter or motel for a while. They sleep in their car. Parents may not even report that they are homeless to teachers or health care providers for fear of losing their children. There are various reasons that families become homeless. Certainly worsening poverty, due to job loss or changes in welfare programs, is a major cause of housing loss for families. But, domestic violence or parental separation is also very often to blame.
Once families become homeless, it is very difficult to escape. Even if the parents are lucky enough to find a job, it will likely pay only minimum wage. Adequate housing is still out of reach for these families. This is true regardless of the state, city, or town the family lives in; and the gap between income and housing costs is even greater in areas with a high cost of living.
Experiencing homelessness profoundly affects a child’s physical, psychological, and educational health. Homeless children have higher incidence of trauma-related injuries, poorly controlled asthma, developmental delays, growth problems, and anemia, among other health problems. Homeless children are far less likely to have a medical home or adequate health insurance. They are far more likely to utilize the ER for care at a later stage of illness. Homeless adolescents have much higher risk of being victims of violence or sexual abuse and have higher rates of substance use, HIV, and teen pregnancy.
Homeless children, regardless of cognitive ability, do far worse in school. They are more likely to change schools during the year or miss more school days, greatly affecting their ability to do well academically and flourish socially. Even simple things, like being asked by a teacher to draw their room or describe their house, become awkward and painful.
What’s being done about this? Sadly, not much. Per the State Report Card on Child Homelessness, only seven states have extensive plans relating to services for homeless families. In the current economic and political climate, the number of homeless children and families continues to increase and the services provided to them are shrinking.
What can we do?
Heidi Román, MD
Heidi Román MD, FAAP is a mother and pediatrician who practices in San Jose, California. She has special interest and experience working with under-served families from diverse racial and socio-economic backgrounds. Dr. Román is a passionate child health advocate who works towards improved health for all kids, both in and out of the clinic. She writes about everything from parenting to policy at mytwohats.wordpress.com.
©2012 Two Peds in a Pod®
When your baby turns one, you’ll realize he has a much stronger will. My oldest threw his first tantrum the day he turned one. At first, we puzzled: why was he suddenly lying face down on the kitchen floor? The indignant crying that followed clued us to his anger. “Oh, it’s a tantrum,” my husband and I laughed, relieved.
Parenting one-year-olds requires the recognition that your child innately desires to become independent of you. Eat, drink, sleep, pee, poop: eventually your child will learn to control these basics of life by himself. We want our children to feed themselves, go to sleep when they feel tired, and pee and poop on the potty. Of course, there’s more to life such as playing, forming relationships, succeeding in school, etc, but we all need the basics. The challenge comes in recognizing when to allow your child more independence and when to reinforce your authority.
Here’s the mantra: Parents provide unconditional love while they simultaneously make rules, enforce rules, and decide when rules need to be changed. Parents are the safety officers and provide food, clothing, and a safe place to sleep. Parents are teachers. Children are the sponges and the experimenters. Here are concrete examples of how to provide loving guidance:
Eating: The rules for parents are to provide healthy food choices, calm mealtimes, and to enforce sitting during meals. The child must sit to eat. Walking while eating poses a choking hazard. Children decide how much, if any, food they will eat. They choose if they eat only the chicken or only the peas and strawberries. They decide how much of their water or milk they drink. By age one, they should be feeding themselves part or ideally all of their meal. By 18 months they should be able to use a spoon or fork for part of their meal.
If, however, parents continue to completely spoon feed their children, cajole their children into eating “just one more bite,” insist that their child can’t have strawberries until they eat their chicken, or bribe their children by dangling a cookie as a reward for eating dinner, then the child gets the message that independence is undesirable. They will learn to ignore their internal sensations of hunger and fullness.
For perspective, remember that newborns eat frequently and enthusiastically because they gain an ounce per day on average, or one pound every 2-3 weeks. A typical one-year-old gains about 5 pounds during his entire second year, or one pound every 2-3 months. Normal, healthy toddlers do not always eat every meal of every day, nor do they finish all meals. Just provide the healthy food, sit back, and enjoy meal time with your toddler and the rest of the family.
A one-year-old child will throw food off of his high chair tray to see how you react. Do you laugh? Do you shout? Do you do a funny dance to try to get him to eat his food? Then he will continue to refuse to eat and throw the food instead. If you say blandly,” I see you are full. Here, let’s get you down so you can play,” then he will do one of two things:
1) He will go play. He was not hungry in the first place.
2) He will think twice about throwing food in the future because whenever he throws food, you put him down to play. He will learn to eat the food when he feels hungry instead of throwing it.
Sleep: The rule is that parents decide on reasonable bedtimes and naptimes. The toddler decides when he actually falls asleep. Singing to oneself or playing in the crib is fine. Even cries of protest are fine. Check to make sure he hasn’t pooped or knocked his binky out of the crib. After you change the poopy diaper/hand back the binky, LEAVE THE ROOM! Many parents tell me that “he just seems like he wants to play at 2:00am or he seems hungry.” Well, this assessment may be correct, but remember who is boss. Unless your family tradition is to play a game and have a snack every morning at 2:00am, then just say “No, time for sleep now,” and ignore his protests.
Pee/poop: The rule is that parents keep bowel movements soft by offering a healthy diet. The toddler who feels pain when he poops will do his best not to have a bowel movement. Going into potty training a year or two from now with a constipated child can lead to many battles.
Even if your child does not show interest in potty training for another year or two, talk up the advantages of putting pee and poop in the potty as early as age one. Remember, repetition is how kids learn.
Your one-year-old will test your resolve. He is now able to think to himself, “Is this STILL the rule?” or “What will happen if I do this?” That’s why he goes repeatedly to forbidden territory such as the TV or a standing lamp or plug outlet, stops when you say “No no!”, smiles, and proceeds to reach for the forbidden object.
When you feel exasperated by the number of times you need to redirect your toddler, remember that if toddlers learned everything the first time around, they wouldn’t need parenting. Permit your growing child to develop her emerging independence whenever safely possible. Encourage her to feed herself even if that is messier and slower. Allow her to fall asleep in her crib and resist rocking her to sleep. Everyone deserves to learn how to fall asleep independently. You don’t want to train a future insomniac adult.
And if you are baffled by your child’s running away from you one minute and clinging to you the next, just think how confused your child must feel: she’s driven towards independence on the one hand and on the other hand she knows she’s wholly dependent upon you for basic needs. Above all else, remember the goal of parenthood is to help your child grow into a confident, independent adult… who remembers to call his parents every day to say good night… ok, at least once a week to check in…. ok, keep in touch with those who got him there!
Julie Kardos, MD with Naline Lai, MD
©2012 Two Peds in a Pod®
There is a saying we heard in medical school, “Half of what you learn now will change in ten years… you just don’t know which half.” In pediatrics, where we specialize in change, the saying certainly holds true. We ring in the New Year by picking the top 2011 changes in pediatrics all parents should be aware of:
Car seats– keep children rear facing in car seats until two years old (or until they physically cannot fit rear-facing any more) and keep your child in a booster seat until a seat belt fits properly– across his chest and not his neck, and low on the waist across the hip bones, not across his belly. Sitting in the back seat is the safest spot for those 12 years and under. For more information check out our post Buckle up: the latest in car seat safety.
Meningitis Vaccine– A booster dose for older teens is now recommended for the vaccine against the germ Neisserria meningitidis in addition to the dose routinely given to tweens.
Flu vaccine– Having an egg allergy is no longer an absolute contraindication to getting the flu vaccine. Turns out there is so little egg in the vaccine, most kids with egg allergies can safely receive the injectable form, though they still should not receive the spray-up-the-nose form. Ask your child’s pediatrician or allergist if your egg-allergic child is a candidate.
Bye-bye food pyramid– The difficult to understand food pyramid finally bit the dust and is replaced by My Plate .
SIDS prevention and safe sleep– keep soft bedding away from baby’s face- no crib bumpers! And continue to place your baby on his back to sleep. AAP Expands Guidelines for Infant Sleep Safety and SIDS Risk Reduction and Sleep Safety: How to decrease your baby’s risk of Sudden Infant Death Syndrome (SIDS)
An old recommendation gets reinforced: in 2011, Dr Wakefield’s paper suggesting a link between the Measles, Mumps and Rubella (MMR) vaccine and autism is reaffirmed as fraudulent. MMR vaccine schedule does not change.
Genital Wart and cancer from HPV prevention in males– HPV vaccine is now not only approved for boys, but recommended for boys, as well as girls, by the ACIP (vaccine branch of the CDC). With over 35 million people having received this vaccine, evidence supporting its safety has become well established.
All liquid acetaminophen products (Tylenol) are now the same strength. Watch out if you have the old formulation in your medicine cabinet, double check the dosing.
Changes in when and how to start solids foods: For about the last fifteen years, pediatricians advised delaying the start of solid foods and the start of commonly allergenic foods such as eggs or wheat to prevent food allergies. Unfortunately, food allergies have risen during this time. Current advice is back to the old advice. According to the National Institute of Allergy and Infectious Diseases sponsored guidelines (November 2011 Pediatrics), solid foods should be introduced by 4-6 months of age and any potentially allergenic foods may be introduced at this time as well.
We look forward to more advances in pediatrics for 2012. Please keep reading and tell parents about us.
Best wishes for a healthy New Year.
Your Two Peds,
Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®
As a new year rolls around and our pockets start to feel empty after the holidays, we look back at an older post for ways to penny-pinch without short-changing your kids: Save money: How to penny pinch without hurting your children. And whether your children receive gift cards, gelt, or cash gifts this season, we direct you to the popular post Teaching kids money smarts for ideas on how to help them manage their new stash.
Best wishes from your Two Peds,
Drs. Kardos and Lai
©2011 Two Peds in a Pod®
Your toddler wakes from his afternoon nap a tad grumpy and with flushed cheeks. You grab your thermometer and see that his temperature is… 104F! But, because you have read our prior posts about fever Part 1 and Part 2, you do not panic. He has no cough, no runny nose, no vomiting, no diarrhea, no rash. He is fully immunized. In fact, considering how well he was acting before his nap, you are very surprised to find fever. You give him Tylenol and and hour later he becomes a happy toddler. This pattern continues for three days. He has fever, but no new symptoms, and he continues to run about energetically. On the fourth day, the fever breaks. A rash pops up, and your pediatrician diagnoses your child with roseola.
A viral illness seen in kids typically between six months and two years of age, roseola usually runs a course similar to your toddler’s illness and requires no specific treatment. Many kids remain relatively cheerful despite the fever, and those who become fretful regain their good moods after a fever reducer medication such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) is administered. The associated light-pink rash may cover a child from head to toe as seen in our photo. The rash does not itch or hurt. Once the rash appears, the child is no longer contagious. If you press on the rash and lift up, the redness will momentarily turn white (blanches). It lasts for hours to a few days, and then fades. Up to 50% of affected kids never even get the rash.
My twins had roseola at age 18 months. I remember one had fever for three days, the other had fever for two days, and both acted quite well despite their high temperatures. I kept waiting for more symptoms, dreading what I thought would turn out to be twin colds or worse, twin stomach viruses (double diarrhea really stinks), but no other symptoms emerged. When one broke out in a rash, I remember thinking “Oh finally, I know what you both have… roseola.” My other twin never did get the rash. Thus, I suppose my family shows that 50% of affected kids really don’t get the rash.
What else causes fever for a few days and no other symptoms in a young child? In girls and uncircumcised boys, we mainly worry fever alone can be the sole sign of a urinary tract infection.
In general, if your child seems especially ill, refuses to drink, becomes difficult to console, has any new rash WITH FEVER, or has fever alone for MORE than a few days, then you should call your child’s doctor. For more information on when to call your child’s physician, please see our “How sick is sick” post.
Now that you’ve learned about the symptoms, if you recognize Roseola, you’ll be “spot on”.
Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®
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This post was inspired by a newborn whose mom asked me about his eyes. “Here’s looking at you, kid!”
What is this goop in my baby’s eye?
Blocked tear ducts: About 25 percent of infants, by the second or third week of life, develop some slightly yellow or clear eye discharge from one or both eyes. The discharge looks worse when the infants first awaken. At this age, they start to produce some tears (although they do not “cry tears” until closer to three months old). But because newborn tear ducts, the drainage system for tears, are not completely open, tears either spill over, causing a watery discharge, or accumulate in the eyes during sleep and become slightly thicker “goop” that wipes away easily.
Babies with blocked tear ducts have normal appearing sclera (the whites of the eyes) and normal vision. Blocked tear ducts are not painful. Fortunately, the tear ducts open up spontaneously in most babies without intervention. This process, which is usually complete by three month of age, can take up to one year of age. An infection in the eye causes a baby’s eye to become painful, red on the inside, and sensitive to light. The discharge becomes pus-like and increases in amount. If you are not sure if your baby’s eye discharge is from an infection or a blocked duct, consult your pediatrician.
Why do my baby’s eyes cross?
Young infants’ eyes may cross as they gaze at an object. This crossing is a result of an immature nervous system. By three to four months of age, a baby’s eyes should always move in concert when she gazes or follows an object with her eyes. If your baby’s eyes cross after this age, alert your child’s pediatrician, who will likely refer your baby for an exam by an ophthalmologist who is comfortable examining babies. It is important to make sure the eyes are both seeing equally and adequately, as well as to make sure the eye muscles work properly. See our previous post on crossed-eyes.
What is normal vision for a newborn?
Babies are born nearsighted. They see clearly the distance to a face when being held. Some newborns will stick out their tongues in response to seeing their parents do the same. So, be sure to look at your infant when you are feeding or rocking her. Far vision develops gradually over months to years. A child’s vision is not 20/20 until about five-years old.
When will my baby’s eyes change color?
The color of a baby’s eyes generally becomes established during the first year. Some stay the same color from birth. My own children were all born with either blue or grey eyes but now all are brown, much to the delight of their blue-eyed grandmother. My oldest was nine months before his eyes turned brown. Some of my patients did not develop their permanent eye color until two years.
Here a few more eye facts: The part of the eye with color is called the iris. The hole in the center of the iris is called the pupil. Pupils should always look black. In a photograph they can look red from a flash. However, if you ever see white, yellow, or grey reflected in the pupils, alert your baby’s doctor.
Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®
Pertussis is “whooping cough,” also known as the “100 day cough.” In children and adults, the disease starts out looking like a garden-variety cold, complete with runny nose, runny eyes, and mild cough. Sometimes fever is present, sometimes not. However, after a few days, coughing spasms emerge – severe, persistent coughing spasms that go on and on and on. In between coughing fits, children may appear okay.
There is no treatment except to “ride it out” and the cough can last up to three months. Doctors prescribe antibiotics to a child with pertussis because antibiotics can decrease how much a person with whooping cough will spread it to others. Close contacts of kids with pertussis may also receive antibiotics to reduce their chance of getting pertussis.
Whooping cough gets its name from the “whoop” noise kids make after a coughing fit. The fits leave them so breathless that it’s difficult to take a breath in again after the coughing spell. To hear the “whoop” with coughing fit, visit www.whoopingcough.net.
Teens and adults with whooping cough don’t tend to make the whoop sound because their airways are bigger, but the coughing spasms can leave them feeling like they might throw up or pass out. Some in fact do end a coughing fit with vomiting or fainting.
Babies don’t make the whoop either. Instead, babies with pertussis simply cannot catch their breath and stop breathing. That is why babies are the ones who tend to die from this illness. Dr. Lai and I both have watched over hospitalized infants blue from pertussis.
Thankfully, we have a vaccine that is effective at preventing pertussis. The “P” in pertussis is the “P” in the DtaP vaccine that children receive as babies, usually at two, four, and six months of age. The DtaP vaccine is then next given after the first birthday, another between ages four and six years old, and another at age eleven years. Teens who have not received the pertussis vaccine since they were in preschool, and adults who care for infants also should also get the vaccine. For more specific up-to-date recommendations: www.vaccineinformation.org/pertuss/.
As we enter the season for catching snowflakes and coughs, we hope none of your children catch whooping cough.
Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®
revised Nov 16, 2011 to reflect the indications for antibiotic prophylaxis