Not cute as a button: Babes and button batteries

In a couple of weeks my 16 month old nephew will visit my non-baby proofed house. Chances are, he will find things in my house to chew on besides turkey. The first items I am hiding are the devices which contain the tiny round batteries called button batteries. Below, Kristen Casavale of The Battery Controlled reminds us about the hidden hazards of button batteries.

Electronic devices are a part of daily life. And they’re getting smaller, slimmer and sleeker. But inside the battery compartment of mini remote controls, small calculators, watches, key fobs, flameless candles, singing greeting cards, and other electronics, is a very powerful coin-sized button battery. When swallowed, these batteries can get stuck in the throat and food pipe, causing severe burns in as few as two hours.

“Our trauma surgeon told us that they see 10 ingestions a month. Unfortunately, I didn’t really think twice about Emmett playing with the remote control,” said Karla Rausch, mom of son Emmett, age two.

Small children often have easy access to these devices; parents often don’t know about the risk, and little ones can’t always communicate with adults. Grown-ups may be unaware of an ingestion until the battery starts to erode through a child’s food pipe. The Battery Controlled is a partnership to raise awareness about the severity of the issue and share information with parents, caregivers and the medical community. Launched by Energizer and Safe Kids USA, this effort is committed to helping parents prevent children from swallowing coin-sized button batteries.

Teaching points for parents:

1. Keep out of reach. Devices with coin lithium “button” batteries have no place in unsupervised hands or toy boxes.
2. Get help fast. Life-threatening damage can happen in as few as 2 hours.
3. Tell others.

We, and my nephew, thank Kristen for her safety alert.

Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®

Those stinky kitchen sponges: how germy are they?

Dr. Lai and her husband had a running debate about when to replace kitchen sponges. Today we thank guest blogger Dr. Karina Martino, Food Safety Engineer, for exposing the germs in our kitchens. We certainly learned a lot, and Dr. Lai’s husband lost a bet.
Naline Lai, MD and Julie Kardos, MD

WHO’S THE WORST OFFENDER IN THE KITCHEN???

The winner is…….the kitchen sponge (and dishcloth)! The next worst offender is your kitchen sink. This is where vegetarians have a definite advantage since they don’t bring raw meat into their homes. There’s less chance of E. coli and Salmonella spreading, but vegetarians still have to be on the lookout for viruses and parasites.

What are the kitchen’s hot germ zones?

In descending order by highest bacterial count, these are:

1. Sponges and dishcloths

2. Sink drain area

3. Faucet handles

4. Cutting boards

5. Refrigerator handles

Here are simple steps that you can follow to create a healthier kitchen environment:

Dip sponges after every use in dilute sanitizer water (1 teaspoon bleach per quart of water); boil them for 3 minutes on a weekly basis.

• Change dish cloths daily, especially after wiping up raw meat juices.

• Wash sinks with hot soapy water prior to food preparation and before washing dishes.

• Wipe down refrigerator handles daily with dilute sanitizer water.

• Choose non-porous cutting boards that are easy to clean.

• Avoid rinsing raw meats. It contaminates the sink. If you cook meat at the correct temperature for enough time, bacteria on raw meat will be killed.

When we are handling food products everything in the kitchen must be clean, especially ourselves. It is vital to wash our hands with soap and hot water for at least 20 seconds before handling any food product. Each time you re-enter the kitchen from outdoors or any other place in the house where you might have contaminated your hands, you should wash your hands again.

Clean clothing, including aprons, is also an important part of personal hygiene. Dirty clothes and dish towels are a good place for bacteria to hide and grow. Sneezing and coughing spreads germs from our lungs, throats, and noses. When handling food, we must control the spread of germs from these natural occurrences by covering our mouths with disposable tissues and then rewashing our hands.

While the Centers for Disease Control (CDC) provides information about illness from food in homes, it does not yet offer statistics about how many people become ill from their kitchen sponges. However, here are some facts for you to keep in mind:

• The kitchen environment can be more heavily contaminated with fecal bacteria (those bacterial species associated with feces) than the bathroom, suggesting that the risk of spreading infection in the home may be highest in the kitchen-the area in the home where food is prepared.

• Microbiological surveys of domestic kitchens have found significant contamination from a variety of bacterial contaminants, including E. coli, Campylobacter, and Salmonella.

• Pathogenic organisms (germs that cause disease) have been shown to be introduced in the home by people, food, water, pets and insects.

• The domestic kitchen is not used only for food preparation, but may serve as a laundry, a workroom, and a living area for family pets. Each of these functions can serve to introduce bacterial contamination into the kitchen environment.

Moreover, research focusing specifically on the kitchen environment has found:

• 67% of kitchen sponges may be contaminated with fecal bacteria

• Contaminated cloth towels serve to transfer bacteria to dishes during drying

• 82% of sink faucet handles are contaminated during food preparation

• 60% of people do not wash the cutting board after cutting raw meat or poultry and before cutting fresh vegetables for salads

• 9% do not wash the work surface at all after cutting raw chicken

So, please don’t duplicate these mistakes! The next time that you get ready to do your dishes with your six-month-old sponge… think again!… either toss it or get your Clorox immediately!

Karina G. Martino, PhD

Dr. Martino received her Masters degree and her PhD in Food Safety Engineering from Michigan State University. A former professor at University of Georgia, she now has her own consulting business (www.kgminnovations.com) and is the mom of two children.

Who would have thought? Walking in a prewinter wonderland

If you live on the East Coast of the United States, you were bombarded today by a surprise pre-Halloween snowstorm. Now that we have our power back, we thought we’d share with you a few posts we were reminded of today:

As Dr. Lai struggled with chimney flues, she was reminded about hidden sources of carbon monoxide.

Scrambling around for a halloween costume reminded Dr. Kardos of ways to keep the candy intake down to a reasonable amount.

Squeezing children’s toes into snow boots from last year reminded us of how to dress your child appropriately for cold weather.

Looking for matching mittens reminded us of home remedies to prevent dried chapped hands.

Surely the cold, harsh weather is the fault of the retail industry- the big box stores lined their shelves with winter-holiday knick-knacks halfway through October. Mother Nature, like other mothers, was not pleased.

Naline Lai, MD and Julie Kardos, MD

Should I vaccinate my child?

Yes, yes, yes.

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

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

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

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

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

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

Should you vaccinate your child?

YES!

Julie Kardos, MD and Naline Lai, MD
©2011 Two Peds in a Pod®

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

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

Hear ye, hear ye: how can I tell if my child hears?

I just watched “The Miracle Worker” with my oldest son. This classic 1962 movie depicts Helen Keller, who was deaf and blind, struggling to understand language, with the help and supreme patience of her determined teacher Annie Sullivan.

As I watched the movie, I was reminded about how children depend on their senses to learn about the world. Starting today, Two Peds in a Pod will bring you periodic posts about the early development of senses. We start with hearing.

Unlike eyesight, which is limited at birth, babies are usually born with normal hearing. Before leaving the hospital after birth, or by two weeks of age, your newborn should receive a hearing test. Then, at every well child check, your child’s health care provider will ask you questions to confirm your child’s hearing remains the same.

Even though they are unable to localize where sound is coming from, newborns will startle to new or sudden sounds and their eyes will open wider in response to the sound of your voice. All babies babble, even deaf ones, but language progression will stop in children who cannot hear. By six months, kids usually babble one syllable at a time. By nine months, children will produce syllables that sound like whichever language they hear the most. At this point they should also respond to their name. Babies who fail to meet these milestones may do so because they cannot hear.

For older kids, hearing screening may be conducted in schools or the pediatrician’s office. The American Academy of Pediatrics recommends formal hearing screens starting at four years old. These screening tests can detect subtle hearing loss that parents did not notice. Kids who fail the screen should have a more comprehensive hearing evaluation by an audiologist. Many kinds of hearing loss are either reversible or manageable. The earlier the diagnosis the better.

Sometimes speech, behavior, or attention problems are secondary to hearing difficulties. School aged children may mispronounce words because they cannot hear sounds clearly. These children commonly do not distinguish well between the “s,” “ch,” and “sh” sounds (please click here to review language development). Symptoms attributed to Attention Deficit Hyperactivity Disorder such as difficulty focusing or inattentiveness may actually result from hearing loss. Some kids who “just don’t listen” to adults simply can’t hear well enough to follow directions.

As your child’s hearing loss progresses, you may notice your child’s language regresses, or that your child turns the volume up on the TV. Your child may accuse you of mumbling or ask you to often repeat questions. Although a common myth, a child who talks loudly is not necessarily deaf. After all, a child does not need to raise his own voice in order to understand himself.

Finally, I should mention signs of “selective hearing loss.” Many parents describe this form of “hearing loss” to me in the office. In these cases, a child does not hear her mom say “Clean your room,” yet hears her mom whisper “Let’s go out for ice cream.”

We address the topic of listening, as opposed to hearing, in our next post.

Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®

It’s a gas! your young infant’s burps and farts

Gas is another topic most people don’t think much about until they have a newborn. Then suddenly gas becomes a huge source of parental distress, even though parents are not the ones with the gas. It’s the poor newborn baby who suffers, and as all parents know, our children’s suffering becomes OUR suffering.

So what to do?

First, I reassure you that ALL young babies are gassy. Yes, all. But some newborns are not merely fussy because of their gas. Some become fussy, ball up, grunt, turn red, wake up from a sound sleep, and scream because of their gas. In other words, some babies really CARE about their gas.

Remember, newborns spend nine months as a fetus developing in fluid, and have no experience with air until they take their first breath. Then they cry and swallow some air. Then they feed and swallow some air. Then they cry and swallow some more air. Eventually, some of the air comes up as a burp. To summarize: Living in Air=Gas Production.

Gas expelled from below comes from a different source. As babies drink formula or breast milk, some liquid in the intestines remains undigested, and the normal gut bacteria “eat” the food. The bacteria produce gas as a byproduct of their eating. Thus: a fart is produced.

The gas wants to escape, but young babies are not very good at getting out the gas. Newborns produce thunderous burps and expulsions out the other end. I still remember my bleary-eyed husband and I sitting on the couch with our firstborn. On hearing a loud eruption, we looked at each other and asked simultaneously, “Was that YOU?” Then looked at our son and asked “Was that HIM?”

Gas is a part of life. If your infant is feeding well, gaining weight adequately, passing soft mushy stools that are green, yellow, or brown but NOT bloody, white, or black (for more about poop, see our post The Scoop on Poop), then the grunting, straining, turning red, and crying with gas is harmless and does not imply that your baby has a belly problem or a formula intolerance. However, it’s hard to see your infant uncomfortable.

Here’s what to do if your young baby is bothered by gas:

Start feedings before your infant cries a long time from hunger. When infants cry from hunger, they swallow air. When a frantically hungry baby starts to feed, they will gulp quickly and swallow more air than usual. If your infant is wide awake crying and it’s been at least one or two hours from the last feeding, try to quickly start another feeding.
Burp frequently. If you are breastfeeding, watch the clock, breastfeed for five minutes, change to the other breast. As you change positions, hold her upright in attempt to elicit a burp, then feed for five more minutes on the second breast. Then hold your baby upright and try for a slightly longer burping session, and go return her to the first breast for at least five minutes, then back to the second breast if she still appears hungry. Now if she falls asleep nursing, she has had more milk from both breasts and some opportunities to burp before falling asleep.
If you are bottle feeding, experiment with different nipples and bottle shapes (different ones work better for different babies) to see which one allows your infant to feed without gulping too quickly and without sputtering. Try to feed your baby as upright as possible.
Hold your infant upright for a few minutes after feedings to allow for extra burps. If a burp seems stuck, lay her back down on her back for a minute and then bring her upright and try again.
To help expel gas from below, lay her on her back and pedal her legs with your hands. Give her tummy time when awake. Unlike you, a baby can not change position easily and may need a little help moving the gas out of their system.
If your infant is AWAKE after a feeding, place her prone (on her belly) after a feeding. Babies can burp AND pass gas easier in this position. PUT HER ONTO HER BACK if she starts to fall asleep or if you are walking away from her because she might fall asleep before you return to her. Remember, all infants should SLEEP ON THEIR BACKS unless your infant has a specific medical condition that causes your pediatrician to advise a different sleep position.
Parents often ask if changing the breast feeding mother’s diet or trying formula changes will help decrease the baby’s discomfort from gas. There is not absolute correlation between a certain food in the maternal diet and the production of gas in a baby. However, a nursing mom may find a particular food “gas inducing.” Remember that a nursing mom needs nutrients from a variety of foods to make healthy breast milk so be careful how much you restrict. Try any formula change for a week at a time and if there is no effect on gas, just go back to the original formula.
Do gas drops help? For flatulence, if you find that the standard, FDA approved simethecone drops (e.g. Mylicon Drops) help, then you can use them as the label specifies. If they do not help, then stop using them.

The good news? The discomfort from gas will pass. Gas discomfort typically peaks at six weeks and improves immensely by three months. At that point, even the fussiest babies tend to mellow. The next time your child’s gas will cause you distress won’t be until he becomes a preschooler and tells “fart jokes” at the dinner table in front of Grandma. Now THAT is a gas.

Julie Kardos, MD with Naline Lai, MD

That bites: recognizing spider bites

Wondering what crawled into your child’s room and bit her in the middle of the night? If you see two little pinpricks side by side, it’s probably a spider. Spider fangs make two little bite marks. Unfortunately, by the time you examine it in the morning, the bite may be so puffy and red that the two marks are no longer visible. With the exception of the Black widow spider and the Brown recluse spider, most spider bites are harmless and cause only a little bit of irritation. Over-the-counter hydrocortisone 1% ointment, ice, and an analgesic such as acetaminophen or ibuprofen can take the edge off of the itch and/or pain.

Nipping conflicts between dogs and kids

Many of our patients have dogs in their homes, and many choose to add a dog to their family during summer. Unfortunately, dog bite rates are also highest in summer, and occur most often in five to nine year olds, according to the Centers for Disease Control. Our guest expert today, veterinarian Dr. Sharin Skolnik, provides tips on how to introduce a dog into a home with children and how to best avoid dog bites. Interestingly, we noticed similar behavioral management strategies work for dogs and kids.

–Julie Kardos, MD and Naline Lai, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

Sharin Skolnik, DVM, holds a Bachelor’s degree from Cornell University School of Agriculture and Life Science and a veterinary degree from University of Pennsylvania School of Veterinary Medicine. She has been practicing veterinary medicine for 17 years and is a member of the AVMA and the NJVMA. She currently works at Chesterfield Veterinary Clinic in Bordentown, New Jersey.

Her “children” include five horses, eight dogs, eight cats, nine guinea pigs, nine hamsters, six sheep, 40 chickens, and 50 rabbits. She is also a long time friend of Dr. Kardos’s. Their children play well together under close supervision.

Hand-foot-mouth disease

WE HAVE UPDATED THIS POST and added photos- please read it here.

We’re seeing a lot of this stuff around the office. It’s hand-foot-mouth disease, a common, self-limited illness caused by the Coxsackie virus most often in the spring and summer. Named for rashes which can affect the hands, feet or mouth, this illness can cause fever for the first few days as well as some loose stools.

If you look carefully at the photos above, you will see faint red bumps on this child’s feet. The rash may also look like tiny blisters and will always blanch (if you press on it and lift up your finger, the redness will briefly disappear- just as if you pressed on a sunburn). The same rash may appear on the hands and is not itchy. The child’s throat above is red in the back and has several ulcers, or canker sores. The hands, feet and mouth are not always simultaneously affected, and although we don’t call the illness Hand-foot-mouth-tush disease, sometimes kids also get a red bumpy rash on their buttocks.

The throat ulcers can be quite painful and the rash on the feet may be slightly tender. Usually the rash on the hands is not felt by the child. You can alleviate your child’s throat pain with acetaminophen (brand name Tylenol) or ibuprofen (brand names Advil or Motrin). For toddlers and older, Magic mouthwash, a mix of 1/4 tsp diphenhydramine (plain liquid Benadryl) and 1/4 tsp Maalox (the regular adult stuff) squirted over mouth ulcers prior to eating a meal (three times a day) is an age old way to sooth sores.

Because this virus is contagious through saliva, prevent kids from sharing cups, eating utensils, and tooth brushes and clean up toddler drool. This vigilance can prevent the virus from spreading to family members and friends. Children with this virus can still attend daycare as long as they are not feeling ill. Typically after the first few days of illness, fever and pain subside. Most commonly the rash and mouth ulcers last about a week or two.

Unfortunately there is no treatment for hand-foot-mouth disease, but fortunately your child’s body is fully capable of fighting off the virus. Your role is to help soothe pain. Otherwise, kids may refuse to drink and end up dehydrated. When my son had this illness at age two, he liked sucking on a washcloth soaked in very cold water. I also gave him lots of sherbet, ice cream, milk shakes, and noodles. These foods were easier for him to swallow while his throat was sore.

Kids can get this virus more than once, and many strains of this virus circulate. Even parents are not always immune. So now add Coxsackie virus, or hand-foot-mouth disease, to your Dr. Mom and Dr. Dad list of manageable diseases. Knowledge is power. However, if your child’s fever lasts more than three days, he does not drink enough to urinate his baseline amount, he is unconsolable or seems disoriented or if your parent gut-instinct tells you something more might be wrong, do get your child to medical attention.

Thrush: out of the mouth of babes

Cottage cheese like curds coat the inside of your baby’s tongue and inner cheeks. What is this white stuff that won’t wipe off? Not breast milk, not formula, it’s thrush.

Thrush, fancy medical name Oral Candidiasis, is caused by an overgrowth of yeast, called Candida. Although not painful, it may cause discomfort akin to having a film of cotton coating the inside of the mouth.

We all have Candida on our bodies. Usually we have enough bacteria on our bodies to suppress the growth of Candida, but in cases when there is less than usual bacteria such as in young babies or for kids who are on antibiotics, Candida can emerge. For older kids on inhaled steroids for asthma, failure to rinse out the mouth after medication use also promotes an environment conducive to thrush.

To treat thrush, we usually prescribe Nystatin, an anti-fungal/anti-yeast medication, which works topically. Parents apply the medicine to the inside of the baby’s mouth after feedings four times per day. Use Nystatin until thrush is no longer visible for 48 hours. A course takes one to two weeks to complete. An oral medication called fluconazole (brand name Diflucan) may also be prescribed.

Watch out. Thrush may be thriving on mom’s breasts or on pacifiers or bottle nipples. Mothers can apply the same medicine to their breasts after breast feeding. Scrub pacifiers, bottle nipples, and any other object that goes in to a baby’s mouth extra well with hot water and soap or use the dishwasher.

Thrush that persists despite proper treatment can signal an immune system problem. So if your child’s thrush is not resolving in the expected time, let your child’s health care provider know.

A newborn’s tongue may always look slightly white. This “coated tongue” in young babies could be residual breast milk or formula and does not need treatment. If you are not sure, bring him in to see his health care provider for proper diagnosis.

Julie Kardos, MD with Naline Lai, MD
©2011 Two Peds in a Pod®