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.

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

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.

©2011 Two Peds in a Pod®

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.

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

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®

Picture the Mission Impossible theme song in your head… da da da DUM DUM da da da DUM DUM dadada…dadada…dadada…DA DA! Keep this background music playing as you read.

Recently, Two Peds in a Pod went undercover as two unsuspecting moms surveying the scene on the shelves of a local chain pharmacy, seeking to uncover what medicines, ointments, and therapies avail themselves to the unsuspecting consumer. Today we break open the case.

All medication labels have an “active ingredient” list. This list contains the actual medicine that acts on your child’s body to hide symptoms or cure a condition.  Read this list carefully so that you know what you are actually giving your child. For example, Flu-Be-Gone claims it “cures the aches and cough of flu and helps your child sleep better.” In order to know just what is actually in Flu-Be-Gone, you need to read the active ingredients. Included might be acetaminophen (brand name Tylenol), a fever reducer and pain reliever, and diphenhydramine (brand name Benadryl), allergy medicine that has the common side effect of causing drowsiness and has some mild anti-cough properties. Notice neither active ingredient actually kills the flu germ. Additionally, you may already have these two medications in your medicine cabinet, or you might have already given your child diphenhydramine recently and giving Flu-Be-Gone would overdose your child. 

Also note, diphenhydramine is everywhere. If you see the word “sleep” or “PM” in the name of a product, you will usually find diphenhydramine in the active ingredient list. 

Now, let’s hone in on your choices for the anti-itch therapy, hydrocortisone. When your child’s health care provider advises treating an itchy bug bite, poison ivy, or allergic rash with hydrocortisone, make sure that the ACTIVE INGREDIENT in the product is “hydrocortisone 1%.” Hydrocortisone comes as a cream, ointment, spray, or stick (looks like a glue stick) and can have aloe, menthol, or other ingredients thrown in as well. Don’t bother with anything less than maximum strength. Regular strength is 0.5% and is generally ineffective.  Also, keep in mind that while ointment is absorbed a bit better, it is more greasy/messy than cream.

Don’t be fooled into thinking products with the same brand name contain similar active ingredients. Also, do not depend on your doctor to necessarily know the difference between the all the formulations.We noticed that the same brand name pain reliever, such as Midol, can have different active ingredients depending on which one you choose. Midol Teen contains acetaminophen, Midol liquid gels contains ibuprofen,  and Midol PM contains acetaminophen and diphenhydramine.

Let’s talk bellyache. Did you know that kids should not take adult pepto bismol because it has a form of aspirin in it? Aspirin may cause Reye’s syndrome, a fatal liver disorder. However, we did see a product called Children’s Pepto Bismol and guess what the active ingredient is? It is calcium carbonate, which is the SAME active ingredient as in Tums, and is safe to give kids. However, watch your wallet: the children’s pepto bismol that we found cost $6.00 for a box of 24 tablets. The TUMS that we found cost $4.50 for a bottle of 150 tablets of the same stuff, just in slightly higher dose. Check with your child’s doctor but in most cases, the kids can take the adult dose.

Also, be aware that cold and cough medicine have not been shown to treat colds successfully or even to actually relieve symptoms in most kids. In fact these medicines have potential for harmful side effects, accidental overdose, or accidental ingestion and are just not worth giving your children. However, we found tons of cold and cough medicines marketed for children. Here are the three most commonly used active ingredients:

• If you see “suppressant” you will likely find “dextromethoraphan” in the active ingredient list.
  
• If you see “expectorant” you will likely find “guaifenesin” in the active ingredient list.
  
• If you see “decongestant” you will likely find “phenylephrine” in the active ingredient list.

Many products combine two or all three of the above. We ask, even if these ingredients did work well in kids and were not potentially dangerous, what is the POINT of combining a cough suppressant with an expectorant? Can you really have it both ways?

( Remember, that Mission Impossible theme is still playing in the background.)

A few other tidbits. “Dramamine,” used for motion sickness, gets broken down in the body to diphenhydramine, that allergy medicine that we already talked about. So look at cost differences when choosing a motion sickness medicine. Both have the same side effect: sleepiness.

Many cough drops contain corn syrup and sugar. This is the same stuff lollipops are made of, so just call a candy a candy and keep your child’s throat wet with the cheaper choice, if you choose to do so.

Finally, we found one “natural children’s cough medicine” which claimed that it is superior because of its “all natural ingredients.” The first active ingredient listed? Belladonna. Sure it’s natural because it comes from a plant. So does marijuana. Just because it’s “natural” doesn’t mean it’s safe. Belladonna can cause delirium, hallucinations, and death and in fact has been used in high doses as a poison! Leave the cough medicine on the store shelf, and read our post about other ways to soothe a cough.

Bottom line:  remember always to check the “active ingredient” list when buying any over-the-counter medication for your children.

As we were wrapping up our mission, one of the pharmacy employees came over to us, raised an eyebrow at our clipboard, and asked, “Can I help you ladies with anything?” We were tempted to answer “YES, can you help us take notes?”  but we just smiled and said “No, we’re fine, thanks. Just checking out what’s available.”

So now, we will don our stethoscopes and come out of hiding, go back into our offices and onto our website. Thanks for tuning in to this episode of Two Peds in a Pod…. Da da da, DUM DUM da da da, DUM DUM dadada…dadada…dadada…DA DA!!!

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

All acetaminophen (e.g., Tylenol) will soon be made at the same concentration, the Consumer Healthcare Products Association announced recently. In the past, manufacturers made most infant formulations more concentrated (thicker) than children’s formulations so parents would not need to give as much liquid to babies. However, this difference in concentration was the source of much confusion  and accidental overdoses. Now all acetaminophen will be made the same concentration (160mg per 5ml ).  Watch for these changes to hit the shelves as early as this summer.

You may also see other changes if the Federal Drug Administration implements the advice received from an advisory panel earlier in the week. Recommendations include adding weight based dosing guidelines for infants six months to  two years of age and for medicine to come with measuring devices clearly marked in milliliters in order to ensure more accurate dosing.

The American Academy of Pediatrics issued an updated policy on car child restraints earlier this week.

The highlights:

– babies/toddlers ride backwards in a rearfacing carseat until two years old

– kids ride in booster seats until the car’s seat belt fits correctly- usually at 4’9″  and between ages 8-12 years of age

– kids ride in the backseat until at least 13 years of age

Please see the complete policy and the reasons behind it on the AAP website.

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

Remember that funny Sesame Street sketch when Ernie has a banana in his ear and his buddy Bert keeps asking Ernie why he has a banana in his ear?  Ernie answers, “I can’t hear you Bert, I have a banana in my ear!” Ernie’s hearing loss was easily remedied by removing the banana. Temporary hearing loss produced by infection and fluid in the middle ear is remedied by removing the infection and fluid. Ear tubes (myringotomy or tympanostomy tubes) inserted into the eardrum will allow clearing.

Back when we were in training (sixteen years ago, but who’s counting?), Dr. Lai and I were taught any child with persistent fluid in her ears for three months, three ear infections in six months or four ear infections in one year was a candidate for ear tubes by an Otolaryngologist (Ear, Nose Throat Doctor). 

Now the recommendations for ear tubes have been modified. One large study  from 2007 showed toddlers who have ear tubes placed early because of persistent fluid in their middle ears fared the same developmentally as kids who delayed receiving ear tubes, eleven years later. So how do we decide who needs tubes and who doesn’t?

To understand the need for tubes, lets first look at anatomy. Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. This door is the ear drum. Next, open the door. You will find yourself in a room with a set of 3 bones.  Look down.  In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a cold, fluid can collect in the room and promote bacterial infection.  Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe, called the eustachian tube,  drains the fluid.  But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected. Otolaryngologists give the fluid a different way to escape by placing artificial drainage tubes in the ear drum (the door). The reason young kids get so many ear infections compared to older kids is because the positioning of the eustachian tube in young children does not allow adequate drainage.  Also, young children get many more colds —up to 10 per year.  Tubes buy time until a child’s anatomy changes with age and a child contracts fewer colds.

An operation to insert ear tubes is very brief, yet still has a baseline small risk of anesthesia. Then the ears must be kept dry because the tubes give the “outside” a direct link to the “inside” of the ear. Kids have to prevent pool water from entering their ears by wearing ear plugs. Many kids don’t like to wear the plugs and it’s difficult to get them to fit properly.  

In the past, one way doctors used to stall surgery in kids with reocuring infections was to start daily antibiotics. We gave this antibiotic for several months at a time to lower the ear infection rate. However, with the increased concern about antibiotic resistant “super germs,” this practice is falling out of favor. As for other medications, antihistamines and decongestants have not shown to  help treat or prevent ear infections.

So when is it appropriate to try to hold off on surgery, even in the child who has suffered several bouts of ear infections? If a child has normal hearing despite the history of ear infections, and has been developing language normally, then one option is to continue treating the ear infections with antibiotics as they come and make sure ear pain  is adequately controlled by using oral or topical medication. The same holds true for children with persistent middle ear fluid.

Current recommendations are for health care providers to check on kids with fluid every 3-4 months for signs of hearing loss or changes in ear anatomy until the fluid subsides. But no longer does the presence of persistent fluid without any hearing loss demand immediate surgical consultation.

Because all children are different, they may need different management even with the same ear infection and fluid history. Start asking your pediatrician about tubes not only if your child has suffered  from more than three ear infections within six months, but also if your child shows of hearing difficulty, delayed talking, or any developmental delay (which can be signs of hearing loss). Your child’s health care provider may need the additional input from an audiologist as well as an otolaryngologist.

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

The bad news is that influenza is now circulating in all 50 states. The good news is that according to the Centers for Disease Control, the vaccine covers all currently circulating strains. 

Reporter Melanie Cutler interviews Two Peds in a Pod for Five Tips to Keep Your Child Healthy This Winter  in the online news source  Newtown.Patch.com.