Parents often ask how they can tell if their child has The Flu or just a common cold. Here’s how:

A cold, usually caused by one of many viruses such as rhinovirus, starts out gradually. Think back to your last cold: first your throat is scratchy, then the next day your nose gets stuffy or then starts running profusely, then you develop a cough. Sometimes during a cold you get a fever for a day or two. Sometimes you get hoarse, losing your voice. Usually kids still feel well enough to play and attend school with colds, as long as their fevers stay below 101 and they are well hydrated and breathing without difficulty. The average length of a cold is 7-10 days although sometimes you feel lingering effects of a cold for 2 weeks or more.

The flu, caused by influenza virus, comes on suddenly and basically makes you feel as if you’ve been hit by a truck. Flu always causes fever of 101 or higher and some respiratory symptom such as runny nose, cough, or sore throat (many times, all three at once actually). Children, more often than adults, sometimes have vomiting and/or diarrhea with the flu along with their respiratory symptoms. Usually the flu causes total body aches, headaches, and the sensation of your eyes burning. The fever usually lasts 5-7 days. All symptoms come on at once; there is nothing gradual about coming down with the flu.

Fortunately, vaccines against the flu can prevent the misery of coming down with the flu. In addition, vaccines against influenza save lives by preventing flu related complications that can be fatal such as flu pneumonia, flu encephalitis (brain infection), and severe dehydration. Hand washing also helps prevents spread of flu as well as almost every other disease of childhood. Please see our blog post on flu posted on September 6, 2009 for more information on prevention and care of children with flu.

The much touted “Tamiflu” is a prescription medication that can ameliorate the effects of the flu. In an otherwise healthy person, this medicine can shorten duration of symptoms by ½ to 1 day. Are you underwhelmed by this fact? So is the medical profession, which is why we reserve this medicine for people ill enough to need hospitalization or who we know have underlying medical conditions, because this medicine has been shown to decrease hospital stays and complication of flu in people who have asthma, diabetes, immune system defects, and heart disease.

Because of all the hype over the novel H1N1 flu (again, please see our blog post on this subject) I am already getting many anxious phone calls and office visits from parents who are worried that their child might have “the flu” when their children are having runny noses and some cough but no fever. Hopefully this blog post will help you sort out your child’s symptoms.

Julie Kardos, MD

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 full.

2)      Eating a meal with family is social as well as nutritious. Keep eating pleasant and relaxed and never force feed or trick your child into eating.

Start with food on a spoon at 4-6 months. Before this age, babies don’t really digest solids. Also it’s hard to feed a baby who still slumps when propped in a sitting position. In addition, the normal “tongue thrust” reflex is less pronounced after 4 months of age. Putting cereal into a bottle doesn’t count as “eating” and is not necessary.

Timing is important 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 first, 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.  Start a new food in the morning so that you have the entire day to make sure it agrees with your baby. Watch for rash or stomach upset. Once you know the food agrees with your baby, that food can be fed at night if you prefer.

Traditional first food in the USA is single grain rice cereal because it is easy to digest and most kids are not allergic to it. This is the one food I suggest keeping store bought rather than home made because this cereal is fortified with iron which is important for your baby’s growth. Mix the cereal with breast milk or formula so it smells familiar to your baby and because it adds calories (vs. mixing with water).  Don’t worry about measuring. This is not an exact science. Just mix up a small amount to the consistency that you would likely eat oatmeal. Then put a small amount in a spoon and Go For It.

Some babies take one feeding to “figure it out.” They learn quickly to swallow without gagging and 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 seem clueless when the spoon comes back to them. Don’t worry and go back to the above ground rules. Quit and try again another day. Some babies take several weeks to catch on to the idea of eating solids.

It is ok to try another single-ingredient food such as fruit or vegetable or another kind of cereal such as oatmeal if you think your baby does not like rice cereal. The overriding principal is to try one new food at a time so that if your baby has a reaction to the food, you know what to blame.

Stage 1 vs. Stage 2 baby food: The only difference is the size of jars. The consistency of the food is the same. Some stage 2 foods 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 they’ve already had each one). Avoid the “dessert” jar foods. Your baby does not need fillers such as cornstarch or concentrated sweets. You could also make your own baby food by making a puree with cooked vegetables or soft fruits. Again, avoid introducing many new ingredients at once and avoid added salt and sugar.

Not all kids like all foods. Don’t worry if they hate carrots or green beans or apples. 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 one milk feeding with a solid food meal. Some babies are up to three meals a day by 6 months but should be receiving more calories from breast milk or formula than from solids. Also at six months you can offer a cup with water at meals. Juice is not necessary to give if your child eats fruit.

Sample menu by 6-7 months:  breakfast: cereal mixed with formula/breast milk and fruit, lunch: fruit and vegetable, dinner: cereal and vegetable. Cereal has the highest calories and best nutritional content and should be offered at least twice daily. Jar baby food meats can be omitted: most kids don’t like them and cereal and breast milk/formula have plenty of protein. You can wait with meat until offering finger foods.

Finger foods can be given when your baby can sit alone and manipulate a toy without falling over, usually between 7-9 months. Even with no teeth your baby is able to gum 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.  Feed them while other family members are also eating. Babies imitate at this age and learn how to eat by watching others.

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.  By nine months, kids can eat most of the adult meal at the table, just avoid these choking hazards: raw vegetables, chewy meats, nuts, 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 16-24oz of formula daily or 3-4 breast feedings daily.

Avoid fried foods and highly processed foods. Do not buy “toddler meals” which are small versions of adult TV dinners and very high in salt and “fillers.” Lastly, do not give honey before one year of age because honey can cause botulism in infants.

A word about food allergies: Even the allergists lack a definitive answer of what makes a child allergic to a food. A general rule of thumb is that if there is a known food allergy in a family, avoid THAT food as long as you can. If no food allergies run in the family, focus more on avoiding choking hazards (see above) than on potentially allergenic foods. Please refer to our blog post on food allergies for more information.

Julie Kardos, MD and Naline Lai, MD

©2009 Two Peds in a Pod®

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 a pediatrician I 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 I 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. I still remember my husband’s and my surprise over our eldest’s first “sweet potato poop” as we 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:

1.       They are afraid of the toilet or potty seat.

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

3.       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 this 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 I refer you to our podcast on this subject.

My 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

©2009 Two Peds in a Pod®

After completing my pediatric training, I worked for a couple of years in a large pediatric office before I had any children of my own. I was always struck by the Life Event of a child’s first birthday. This milestone carries so much meaning and emotion for families. My patients’ parents described huge birthday parties with characters such as Elmo walking around or Moon Bounces, large catered affairs with numerous friends and family members and entire neighborhoods.

Often I would see a child sick in my office a few days before such an event with parents who were panicked that their child might be sick on his Big Day, or I would see a child for his one year well check and hear many details about the enormous party. Of course I also saw plenty of children a few days after their first birthday party who became ill, most likely, from a well-intentioned friend or relative who was already sick and passed the illness on to the birthday child at the party. I heard about the kids who clapped for the Happy Birthday song and kids who cried and one who vomited from excitement… all over the birthday cake. Many of my patients had their first full blown temper tantrum during their own over-stimulating first birthday party.

I remember not quite understanding why parents go through such effort and expense to throw a party that their child will never remember at a developmental stage where 99 percent of children are having stranger anxiety and separation anxiety, often forgoing daily routine to skip naps, eat at erratic times, and then expect their birthday child to perform in front of a large crowd singing loudly at them. “My husband and I will do it differently,” I would tell myself.

Now, three of my own children later, I must apologize for not quite understanding about that first birthday. I remember waking up on the day my oldest turned one year. My pediatrician brain first exclaimed “Hurray! No more SIDS risk!” Then my mommy brain took over, “Ohmygosh, I survived the first year of parenthood!” This day is about Celebration of the Parent. I finally understood completely why my patients’ parents needed all the hoopla.

Because I am actually a little uncomfortable in large crowds, my son’s first birthday party included all close relatives who lived nearby, people he was well familiarized with. Some pediatric tips I had picked up which I will pass on:

1)      Sing the Happy Birthday song, complete with clapping at the finale, for about one month straight leading up to the birthday. Children love music and hearing a very familiar song sung by a large group is not as overwhelming as hearing an unfamiliar song.

2)      Plan mealtime around your child, not the guests. If you are inviting people close to your heart, they will accommodate. Dinner can be at 5:00pm if that’s when your child usually eats, or have a lunch party that starts midmorning and then end the party in time to allow your child to have his regularly scheduled afternoon nap. Most one-year-olds are usually at their best in the morning anyway.

3)      If your child becomes sick, cancel the party. Your child will not be disappointed because he won’t understand what he is missing. You as parent would have a lousy time anyway because all of your attention will be on your ill child and you will be anxious. Your guests who are parents will appreciate your refraining from making them and their own children sick.

Recently while performing a one-year-old well child check I asked about my patient’s birthday party and her parent told me “Oh, we didn’t have a party. It was like any other day, although we did give her a cupcake for dessert.”

Now THIS is a pragmatic approach to parenting  because, again, no child will ever have memories of her own first birthday. However, I hope the parents did take time, at least with each other, to congratulate themselves and to feel really good about making it to that huge milestone in their parenting career. I hope they savored their accomplishment as much as their child savored the cupcake.

Julie Kardos, MD and Naline Lai, MD

©2009 Two Peds in a Pod®

Are you exhausted because your baby wakes up at night?  Tune in to our podcast to find out how to teach your baby to sleep through the night.

When it comes to our children, we want the best that money can buy. However, in these difficult economic times, I want to offer some suggestions from the medical perspective that can save you money without compromising your child’s health or safety.

Don’t buy “Sippy cups.” Just teach your child to drink out of regular open cups. Sippy cups are for parents who don’t like mess-they are not a required developmental stage.  They are actually bad for teeth when they contain juice or milk and they do not aid in child development.

Buy generic acetaminophen (brand name = Tylenol), ibuprofen (brand name = Motrin, Advil), diphenhydramine (brand name = Benadryl), allergy medication (brand names Claritin, Zyrtec). If your child’s health care provider prescribes antibiotic such as amoxicillin (for ear infection, Strep throat, sinusitis), ask the pharmacist how much it costs because usually the cost of paying for this commonly prescribed antibiotic out-of-pocket is less than your insurance copay.

Accept hand-me-down clothes, shoes, etc. The purpose of shoes is to protect feet. Contrary to what the shoe sales-people tell you, cheap shoes or already-worn shoes will protect feet just as well as expensive, new ones. Just make sure they fit correctly.

Don’t buy “sleep positioners” for the crib. Place your newborn to sleep on his back and he will not/cannot roll over. If you need to elevate your baby’s upper body to prevent spit up or to provide comfort from gas, don’t buy a “wedge” but instead put a book under each of the 2 crib legs so the entire crib is elevated. Wedges and positioners are NOT shown to prevent SIDS (Sudden Infant Death Syndrome) and are NOT endorsed by the American Academy of Pediatrics.

Make your own baby food and do NOT buy “baby junk food” such as “Puffs” for finger food practice. Instead buy “toasted oats” (brand name = Cheerios) which are low in sugar, contain iron, and are much less expensive. “Stage 3” foods in jars are finger foods so just give your kids what you are serving the rest of the family cut into small bite-sized pieces instead of buying the expensive jars. One exception: do buy the baby cereals (rice, oatmeal, or barley) because they contain more iron than regular oatmeal and babies need the extra iron for their growth.

The best toys are ones that can be reconfigured and used again and again. Legos, blocks, crayons/markers/chalk, small cars, dolls, balls come to mind. Avoid one-time only assembly type items, breakables, etc. Have a “toy recycle” party or a pre-Halloween costume recycle party: everyone brings an old costume/toy they would like to trade and everyone leaves with a “new” item (kids don’t care if things are brand new or not, only if you teach them to care will they care). Along these same lines, inexpensive paint can turn a pink “girl’s bike” into her younger brother’s blue “boy bike.”

Borrow books from libraries instead of buying them in stores or look for previously owned ones at yard sales, thrift shops, etc.

Do not buy endless videos for your child. First of all, despite claims made on the packages, NO video has been shown to advance baby/toddler/child intelligence. In fact, almost all studies show that the more screen time a child logs in, the worse they fare in their language and intellectual development. Also there is some evidence that TV/video viewing in babies can be detrimental to their brain development. Now, as a pediatrician mom, I am not saying that I never sat down and watched Sesame Street with my children (I am a product of the “Sesame Street Generation,” after all). I’m just saying that I recommend using moderation and taking advantage of free offerings on public television instead of spending money on videos. Many libraries also offer free lending of videos if you and your child want occasional “down time” in front of the screen.

Julie Kardos, MD