Squeezed through the birth canal, many babies are born with pointy, cone-shaped heads. Others, delivered by caesarian section, start off life with round heads. Few babies begin with a flat head. But as parents put babies on their backs to sleep in accordance with Sudden Infant Death Syndrome prevention guidelines, babies are developing flat heads. 

Called positional plagiocephaly, a young infant’s head flattens when prolonged pressure is placed on one spot. Tricks to prevent positional plagiocephaly all encourage equal pressure over the entire head. Because babies’ heads are malleable, parents can prevent and treat the flatness. In fact, the flat shape begins to correct itself as babies spend less time lying down and more time sitting and crawling. Additionally, increased hair growth hides some of the flatness.

To prevent positional plagiocephaly, place your baby prone (belly down) frequently WHILE AWAKE, starting in the newborn period. This tummy time decreases pressure on the back of the head. Some babies are not fond of tummy time and will cry until they are back on their backs.  For those kids, check out our post on making tummy time more tolerable for your baby.

Encourage your baby to look to both sides while lying down. Too much time turned to one side will cause flattening on that side. Alternate how you place the baby in crib so that sometimes she turns to the right and other times she turns to the left to face into the room and away from the wall. If your baby seems to prefer looking only to the right or only to the left, place toys or bright objects toward the non-preferred side. If bottle feeding, switch off which arm you use to feed your baby, so that the baby sometimes turns to the right and sometimes to the left . If breastfeeding, start and end on the side that the baby tends to avoid. These actions will help prevent neck muscles from becoming too tight on one side and thus allow your baby to turn easily to both sides.

Some babies wear helmets to correct their abnormal head flattening. Neurosurgeons, who are head and brain specialists, and plastic surgeons prescribe these helmets for babies who have extreme flattening. Fortunately, the majority of babies with positional plagiocephaly do not need to wear helmets.

You also may have heard of babies who need corrective surgery for an abnormal head shape. This condition, called craniosynostosis, is rare. Pediatricians monitor the size and shape of the head , check the soft spot on the top of the head and for ridges on the skull at every check-up. A baby’s skull develops in pieces as a fetus, and these pieces eventually come together at predictable places called sutures.  If the pieces come together too early or the soft spot closes too soon, corrective surgery may be needed.

So, avoid head flatness by rotating your baby’s position frequently (think rotisserie chicken!) and provide plenty of “tummy time” when awake. Start when the baby first comes home.

If you are worried about your baby’s head shape, just head on over to your baby’s pediatrician and bring up your concern. It is unlikely that your concern will “fall flat.”

Julie Kardos, MD and Naline Lai, MD

photo credit: Laikipia Pixabay.com

The Zika virus in the news these days reminds us of another microcephaly-causing virus which scourged our world in the not-so-distant past. In the years right before the Two Peds doctors were born (late 1960s), the virus Rubella routinely swept through the United States and the rest of the world. The airborne germ Rubella, just like the mosquito-spread Zika virus, caused most people just a mild illness that they usually never even knew that they had. After they were sick, they became immune to the virus. But when pregnant women contracted Rubella early in pregnancy, their unborn children sometimes ended up with microcephaly.

Microcephaly is a condition where a small, underdeveloped, or abnormal brain leads to a small head at birth. Many children with microcephaly have significant mental disabilities.

So what happened to Rubella? It’s the R in the MMR vaccine. We give this vaccine to all children, first at 12-15 months, and again at 4-6 years of age. We vaccinate girls to protect their unborn fetuses when they are pregnant, and we also vaccinate boys. Although boys will not become pregnant, they can contract the disease and spread it to others who are pregnant. It is standard practice for obstetricians to test all of their pregnant patients for immunity to Rubella. If a woman is not immune, she is given the MMR vaccine after delivery to prevent coming down with Rubella during future pregnancies.

Because of the success of this safe vaccine, it is extremely rare to have child born with Congenital Rubella Syndrome and its accompanying problems. The syndrome  not only included the mental impairments associated with microcephaly but also was associated with blood disorders, heart defects, deafness, visual impairment, developmental delay, and seizures. In the United States where the vaccine rates are high enough, no cases have been reported since 2004. In the rest of the world, cases still occur in countries with limited access to vaccines against Rubella.  Approximately 100,000 cases of Rubella worldwide per year still occur according to the Centers for Disease Control.

Scientists are working on a vaccine against the Zika virus because, as is often the case, preventing a disease is often easier, less costly, and more successful than attempting to cure it. For a basic explanation of how vaccines work, please see our prior post on this topic. Trials for a vaccine for Zika may begin as early as summer 2017.

But if we look at history, Rubella was once a dreaded virus too. Now, with the widespread use of a vaccine, although still dreaded, the rates of Rubella have dropped dramatically.  Zika hopefully will not be far behind.

Naline Lai,  MD and Julie Kardos, MD

©2016 Two Peds in a Pod®,  updated April 2017

Dr. Kardos’s fourth child wears her coat in the snow without fuss.

There is snow on the ground, so every morning I ask my elementary school-aged son if he wears gloves and a hat at recess. Every morning I get back the same blank stare and the question, “Why?”

It’s an age-old battle between parents and kids. Parents insist the kids are underdressed and the kids insist they are overdressed. In fact, I remember in fourth grade many an embarrassing moment when my mother would suddenly appear with mittens at the bus stop. So how can parents decide how warmly to dress their children?

Infants are particularly poor at regulating their own temperatures. In general for cool weather, dress a baby in one more layer of clothing than you are comfortable wearing. Another good way to keep a newborn from losing too much heat is to keep the hat on for a couple of weeks. It’s not an old wives tale; people do lose a fair amount of heat through their heads.

However, beware of over-swaddling. Over-heating has been suggested as a factor in death from SIDS (Sudden Infant Death Syndrome). If your partner insists on keeping the house the temperature of a sauna and you are sweltering all year, then dress your baby in a simple onesie. Just as infants have difficulty regulating body temperature in the cold, they also have difficulty regulating their temperature in heat. In general, if you feel cold, your baby will feel colder. If you are warm, your baby will feel warmer than you do. There is an official indoor temperature recommendation for daycare centers: in cold weather, keep indoor temperatures to 68-75F.

Sleep always seems to bring out red cheeks and sweaty heads in toddlers. Are they too hot or cold? As you peek in on them after tucking them to bed, feel their hands and cheeks. Warm (but not flushed) cheeks mean they will be comfortable even if their hands are a bit cool.

For older kids, simply dress them the same way you dress yourself. Make sure areas prone to frostbite such as toes, ears and fingers stay warm. Quick tidbit: do not re-warm nearly frostbitten areas by massaging. The rubbing action causes more injury. Instead, place the area in warm water.

Sorry, you can’t use the rational, “Dress warmly or you will catch a cold.” Cold temperatures do not cause colds. Germs cause colds. However, there is one study on mice that suggests cooler noses allow the rhinovirus (a common cold germ) to grown more easily. Also, there is a phenomenon called nonallergic rhinitis which manifests itself as a drippy nose which can be set off by cold air. Likewise, inhaling cold air can set off coughing in kids with asthma. For more about the health benefits and hazards of cold weather for both kids and adults, check out this article from Harvard Health Publications.

Why it’s not “cool” to stay warm, I’ll never understand. At least for the older boys, parents don’t need to take into account the weather. The kids will wear hoodies whether it’s seven or seventy degrees outside.

Naline Lai, MD with Julie Kardos, MD
©2016 Two Peds in a Pod® revised 1/2019

(For a laugh: we love this tongue-in-cheek post about how kids dress for cold weather).

This drives us crazy: Listed on many pediatric developmental milestone charts, there is the six month milestone, ” can hold their own bottle. ” Unfortunately, this is the last thing we want our patients to do. Babies who feed by holding their own bottle tend to suck for a longer period of time than when they are at the breast or when a parent holds the bottle. Prolonging the time any sweet substance, whether breast milk, cow’s milk, or watered down juice is in the mouth can produce cavities. Even in toothless babies, the sugar can seep through gums and rot the teeth producing cavities called “bottle rot” in the two front teeth. As shown above, sucking on a sippy cup constantly can also produce the characteristic damaging pattern and cause rotten teeth.

Sippy cups are like daytime bottles. In the “old days” if a child wanted a drink, the parent would give him a cup, he would take his drink, and then the cup would be put away so it would not spill. Sippy cups are easier to leave around for kids to grab when they need it. They are easy for kids to carry and graze from while playing. They don’t make a mess in the car. But because kids can nurse a sugar-containing drink all day, it becomes easy for a sweet drink to have constant contact with teeth, thus producing the problem you can see in our photo.

How to prevent rotten teeth:

• Once they are toddlers, give your kids beverages at meal or snack times only. Let them drink and then put the cup away. Otherwise, forward to the future, and imagine your sippy-cup-toting toddler becoming the perpetually-drinking-coffee office coworker down the hall. We’re sure your coworker’s teeth are not pretty. The only exception to giving a beverage only at meal or snack times is the quick after dinner cup of milk when they are very young (toddlers). If your toddler drinks a cup of milk before bed, make sure he brushes his teeth before going to sleep. Brush-book-bed is a good routine to institute.
• Limit juice. Whether 100%, or organic, or watered down, juice contains enough sugar to rot teeth over time. Dr. Kardos remembers a friend lamenting, “I bought only 100% juice for his sippy cup and had no idea it could hurt my son’s teeth like that!” Eventually, her friend’s son underwent a tooth repair under anesthesia.
• Encourage good tooth brushing at least twice a day with fluoride-containing toothpaste, starting when your child gets his first tooth. Before that point, wipe out your baby’s gums with a wet gauze or wash cloth.
• Schedule regular dental visits for your child starting around or soon after his first birthday. Going to the dentist is a vital part of preventing rotting teeth.
• Ask your pediatrician or dentist if supplemental fluoride may be helpful.

Some final food for thought: snacks of pouch-pureed fruits and vegetables are increasing in popularity. We don’t think we need to wait for a scientific study to say that prolonged sucking on a packet of “healthy” fruit puree will probably result in the kind of teeth pictured above .

For more tips check out the American Academy of Pediatrics and the American Academy of Pediatric Dentistry.

Julie Kardos, MD and Naline Lai, MD

©2016 Two Peds in a Pod®

Questions: Why does that child run into the road? Why does that child hit other kids?

Answer: Because no one ever taught him not to.

Toddlers need lots of teaching, so where do you start? To help teach your on-the-move, act-first-and-ignore-the-consequences toddler how to become more civilized, first make sure BOTH parents agree on the rules. Teach your toddler that you mean what you say. When you call your toddler and he does not come right away, GO TO HIM AND  LEAD HIM BY THE HAND OR PICK HIM UP no matter what the situation. Also remember that civilizing a toddler is a work in progress, not an afternoon project.

These are negative behaviors we want to train out of our toddlers: hitting, kicking, biting, pinching, and in any way inflicting pain on others. Excitement and anger are normal reactions in toddlers, but these negative responses to excitement or anger are always unacceptable.

Before we go further let’s review normal toddler behavior. These are things that you just can’t punish a toddler for, but rather you can try to capture on camera and to enjoy the memory later:

• Making a mess.  All toddlers are messy. They can’t help it. They don’t have the fine motor coordination to prevent dropping food or for keeping toys contained to one area. (I am recalling with a smile a home-movie of my twin toddlers double-fisting a spaghetti dinner). Besides, to a toddler (and to many adults for those of you who used to watch Dave Letterman) it’s always fun to watch things splat on the floor. That being said, kids are never too young to teach “clean-up.” Make it fun and light-hearted, not onerous. All kids love to use brooms, so encourage them to help clean up the Cheerios that coat the floor after a meal.
• Touching everything. They will touch  themselves and others- they are just curious.
• Speaking their minds. Toddlers are truthful and literal, not malicious or insinuating. My oldest son at age 3 saw a man with one arm and said very loudly, “Look, Mommy, that man has only one arm!”

How to discipline:

Catch ’em being good. This works wonders if you are consistent about it. Be specific about your praise. Tell your toddler, “I like how you are not hitting your brother right now,” or “Good job playing quietly while your baby sister naps,” or “Great job putting the legos away in the box!” instead of “You are being good now.”

Teach consequences: If he throws a toy, say “NO throwing that toy,” and take the toy away for a minute or two to make your point.

Chastise the behavior, not the child. Say to your child “No hitting,” not “You are bad for hitting.”

First make it clear that a behavior is not acceptable. Toddlers are not mind readers. If you never told her, “Don’t rummage through the garbage can,” she will not know better.

Parents need to be on the same page. Discuss in advance, not in front of your child, what the consequences are for misbehavior. If one parent”gives in” to a tantrum and one does not, your toddler will become confused, then anxious, and then learn how to pit parents against each other. He will throw longer, louder, more destructive tantrums because he knows, if he hangs on long enough, ONE person will give him what he wants.

Have immediate consequences. Avoid “Wait until your mom gets home.” Also avoid “When we get home from the store, you are in trouble.” As determined as they can get, toddlers also paradoxicaly have the attention span and memory of a flea. However, in order to give an appropriate, immediate consequence, plan your consequence before you need it or else you may give out one that you regret.

For example, if you and your toddler are having a fine time at the playground with other parents and their toddlers, you may regret this warning: “Stop hitting Billy with your toy car or we will leave the playground.” If your child ignores you, then you are stuck leaving the playground. And leave, you must! If you fail to heed your own warning, your toddler will learn that you do not mean what you say. He will see you as a wimp and will always try to take advantage of you. A better way to stop your kid is to say, “Stop hitting Billy with your toy car or I take that car away from you.” Then take it away if he continues the behavior. Here are the benefits:

1-Teach your child that you mean what you say.

2- Protect others from your toddler’s dangerous behavior.

3- Preserve your own sanity. Why should you have to miss out on talking to other mommies while enjoying the day with your toddler? Sure, your toddler may tantrum in response to his lost car, but after the tantrum your toddler and you can continue to have fun at the park.

Don’t nag. Toddlers are professionals at ignoring parental nagging. Just follow through on your consequence for failure to obey you.

Ignore whining. Whining is very hard to stop once you allow your toddler to get what he wants when he whines. Instead, ignore his whining and nagging (just as your toddler does so easily and naturally when you do it to him). Only grant him your attention when he uses his regular voice. Tell him once: “I can’t understand when you talk that way. I only understand your Joey (insert your child’s name here) voice.” Then ignore him until he uses his “regular” voice.

Catch teachable moments. If you see another toddler misbehaving OR behaving well, point out the behavior to your toddler. You could say, “Oh, she hit her sister. I am so glad you are not hitting now. You know that our rule is No Hitting!” Also use books to point out desirable behavior. Plenty of books that you read to your children have examples of children having fun together or working toward a goal together without hitting, biting, or kicking each other. Point that out!

Time out and its permutations:

Time-out is a consequence. The goal of time-out is to stop the undesirable behavior and to give negative associations to the bad behavior.

The traditional way of giving a Time-out in response to an aggressive or otherwise inappropriate behavior is to place your child in a chair or stool or on the floor in a corner or other quiet, boring place in the house for one minute per age of the child. Try not to use a spot which is associated with relaxation and sleep such as his crib.

Time-out is more of a mental place than a physical place. Years ago when I was out with Dr. Lai and our kids, her then 18-month-old hit her 3-year-old sister. Dr. Lai firmly told her 18 month old, “NO hitting, Mommy is not talking to you for one minute!” and she turned her back and folded her arms, making it a point of not looking at her daughter (Of course I was there to make sure her 18- month-old didn’t run into trouble). Her 18-month-old had a tantrum but she got the message.

My own twins were a handful- often they would bite or hit each other over a toy that they both wanted. Rather than attempting to put two twins in two Time-Out chairs, I put the TOY in time-out on top of the refrigerator, where they could see it but not reach it, for the number of minutes of my twins’ age. Yes, I had to endure a double tantrum but the undesirable behavior, namely the hitting, stopped. Over time they learned to think twice about hurting each other. Read more about twin toddler discipline tips here.

Teaching self-calming is different from disciplining misbehavior/unsafe activities.

Your kids may throw tantrums often in response to your discipline. This is perfectly fair. Toddlers are allowed to feel frustrated and angry (“If you’re happy and you know it clap your hands; if you’re angry and you know it throw a fit!”). Just ignore the tantrum and remove any breakables from the line of fire. The goal is for your child to have a bad feeling about making a bad choice. If she has a tantrum, she may later remember that if she throws a toy at someone, it will be removed from her and She Will Feel Bad about it. We will give you more tips about helping to stop an endless tantrum in our next post. Remember, though, that once time out is over, it is over. Move on and don’t continue to talk about the incident.

We do not recommend hitting your toddler as punishment or as a way to stop them from some undesirable behavior. Toddlers mirror your behavior. They will pretend to swipe a smart phone. They will blow kisses back to you. Toddlers will suddenly will start spewing inappropriate words because they hear their parents using those words.  So, be on your best behavior. If you hit your child,  you will model hitting as a proper response for anger. Try not to hit your child even in jest. You don’t want to be explaining to other parents on the playground that your hitting child “doesn’t know better.”

Be aware it will feel like you are reiterating the same teaching points endlessly You will often feel you are talking to yourself. Even though you told a toddler once not to rummage through a garbage can, you’ll have to repeat the instructions the next time you see a different garbage can. As my brother-in-law says,”You don’t ever stop. Kinda like practicing layups or free throws in basketball.”

Remember to take a deep breath: It is easy to lose control of yourself when you spend a lot of time with a toddler because toddlers, even though they are all adorable, can be infuriating, unreasonable, and irrational. Remember who is two and who is thirty-two. You NEED to be in control. If not, give yourself a timeout.

If you find a day with your toddler particularly tough, just do what melted my heart when my boys were toddlers. When asked,  “Who will you marry?”  they would always say “YOU, Mom.”

Julie Kardos, MD and Naline Lai, MD

©2015 Two Peds in a Pod®

Based on our original 2009 podcast about toddler discipline- you can listen to it here.

Riding into toddlerhood

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 he wasn’t sick.

Parenting toddlers 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. Don’t be afraid of spoiling  your child; be afraid of raising a child that acts spoiled. 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. The kids 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. Instead, you can 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 , “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. Also the toddler decides when he is brave enough or feels grown up enough to sit on the potty. Never force a toilet training child to sit on the potty. After all, did you force your toddler to learn how to use a remote control for your television? Of course not- he learned to use it by imitating you and wanting to be like you and by being pleased with the result (Cool! I turned on the TV!). The same principle applies to potty training. He will imitate you when he is ready, and will be pleased with the result when you praise him for his result.

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 toddler 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 and giving a bottle to sleep. Everyone deserves to learn how to fall asleep independently (and to brush their teeth before bed). 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.

Julie Kardos, MD with Naline Lai, MD
©2015, revised from 2012
Two Peds in a Pod®

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

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

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

General tips for visiting:

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

We wish you all the best this new year!

Julie Kardos, MD and Naline Lai, MD

©2014, 2015 Two Peds in a Pod®
Updated from our 2009 articles on these topics

Why do babies cry? In short, newborns cry to communicate. Remember, newborns cannot talk. They can’t even smile back at you until around six weeks of age.
Ah, but what are they trying to tell us? Babies cry when they…

• Are tired.
• Are hungry.
• Feel too cold.
• Feel too hot.
• Need to be changed –I never really believed this reason before I had my twins. My firstborn couldn’t have cared less if he was wet and could nap right through a really poopy diaper. Then I had my twins.  I was amazed that their crying stopped if I changed the tiniest bit of poop or a wet diaper. Go figure.
• Are bored. Perhaps she is tired of the Mozart you play and prefers some good hard rock music instead. Maybe she wants a car ride or a change of scenery. Try moving her to another room in the house.
• Feel pain. Search for a piece of hair wrapped around a finger or toe and make sure she isn’t out-growing the elastic wrist or ankle band on her clothing.
• Need to be swaddled. Remember a fetus spends the last trimester squished inside of her mom. Discovering her own randomly flailing arms and legs can be disconcerting to a newborn.
• Need to be UN-swaddled. Hey, some like the freedom to flail.
• Need to be rocked/moved. Dr. Lai’s firstborn spent hours tightly wrapped and held by her dad in a nearly upside down position nicknamed “upside-down-hotdog” while he paced all around the living room.
• Need to burp. Lay her down for a minute and bring her up again to see if you can elicit a burp.
• Are gassy. Bicycle his legs while he is on his back. Position him over your shoulder so that his belly presses against you. You’d be gassy too if you couldn’t move very well. The gassy baby is a topic for this entire post– talk to your doctor for other ideas.
• Are sick. Watch for fever, inability to feed normally, labored breathing, diarrhea or vomiting. Check and see if anything is swollen or not moving. Listen to his cry. Is it thin, whimper-like (sick) or is it loud and strong (not so sick)? Do not hesitate to check with your pediatrician. Fever in a baby younger than eight weeks old is considered 100.4 degrees F or higher measured rectally. A feverish newborn needs immediate medical attention.

What if you’re certain that the temperature in the room is moderate, you recently changed his diaper, and he ate less than an hour ago?

• • Walk outside with your baby– this can be a magic “crying be gone” trick. Fresh air seems to improve a newborn’s mood.
  • Offer a pacifier. Try many different shapes of pacifiers. Marinade a pacifier in breast milk or formula to increase the chance your baby will accept it.
    Pick him up, dance with him, or walk around the house with him. You can’t spoil a newborn.
  • Vacuum your house. Weird, but it can work like a charm. Place him in a baby frontal backpack or in a sling while cleaning.
  • Try another feeding, maybe he’s having a growth spurt.
  • When all else fails, try putting him down in his crib in a darkened room. Crying can result from overstimulation. Wait a minute or two. He may self-settle and go to sleep. If not, go get him. The act of rescuing him may stop the wailing.
  • If mommy or daddy is crying at this point, call your own mom or dad or call a close friend. Your baby knows your voice and maybe hearing you speak calmly to another adult will lull him into contentment.
  • Call your child’s health care provider and review signs of illness.

If you feel anger and resentment toward your crying baby, just put him down, walk outside and count to ten. It is impossible to think rationally when you are angry and you may hurt your child in order to stop your frustration. Seek counseling if these feelings continue.

Now for the light at the end of the newborn parenting tunnel: the peak age when babies cry is six weeks old. At that point, infants can cry for up to THREE HOURS per day. Babies with colic cry MORE than three hours per day. (Can you believe people actually studied this? I am amused that Dr. Lai won a prize in medical school for a paper on the history of colic). By three months of age crying time drops dramatically.

While most crying babies are healthy babies and just need to find the perfect upside-down-hot-dog position, an inability to soothe your baby can be a sign that she is sick. Never hesitate to call your baby’s doctor if your baby is inconsolable, and don’t listen to the people who say, “Why do babies cry?…They just do.”

Julie Kardos, MD and Naline Lai, MD
©2015, 2010 Two Peds in a Pod®

photo by Lexi Logan

The guidelines for school are straight forward. If your child is sick, the school nurse will tell you exactly what criteria your child needs to meet before she returns to school. The list generally looks like this: no fever of 101 degrees or higher for over 24 hours, no constant running to the bathroom, no vomiting for 24 hours, etc. However, Grandpa’s house is not school. A friend’s home is not school. The guidelines to attending holiday gatherings are not as straightforward.

First and foremost: If you are invited to a social gathering and you have an ill child, tell your family and friends who will be there that you have an ill child. You never know if there will be people present who are particularly vulnerable to illness. Some of you have an Uncle Harry who has been too embarrassed to tell you that he is undergoing chemotherapy for prostate cancer or a sister Sarah just found out she is pregnant. Young babies and the elderly are more likely to develop complications if they are ill. On the other hand, if family members or friends all have intact immune systems and have no special risk factors for illness complications, they may be more forgiving and will want to see their ill nephew/cousin/friend who they just flew 400 miles to see. The key is communication.

Babies under two months old, because of their age and unimmunized status, are vulnerable to life threatening infections. Remember that a nagging cough in a toddler can be a life threatening cough for an infant. So you might reconsider bringing your coughing toddler to a gathering where there will be very young infants.

Don’t get lulled into believing that germs are killed by Tylenol (acetaminophen) or Motrin (ibuprofen). Even if you have hidden your child’s fever with a fever reducing medicine, she is contagious as long as something is spewing from any orifice (nose, eyes, mouth, or bottom).

So if you are going to a family gathering, and your child is mildly ill, here’s how to minimize spread of germs:

1. Handwashing – wash your ill child’s hands often to prevent spread of their germs. Also you should wash your healthy children’s hands to prevent illness.
2. Handwashing (again!) -wash hands before eating and after bathroom use
3. Handwashing (again!!)- wash your own hands after you have helped your child do the above suggestions.
4. When all the children are piled in a heap watching The Grinch, take time to separate your ill child from the batch. Daycares put two feet between sleeping cots in order to minimize spread of germs. Protect airspaces.
5. Elderly people will be happy to observe your runny-nosed children frolicking about from the distance. No need to force your five year old with the runny nose to kiss great- grandma’s face.
6. Teach kids to cough into crook of elbow, to use tissues…and then wash hands.

If you realize that you will be dragging a medicine cabinet with you to a party, reconsider going. One mom says she cringes whenever she sees her sister show up to parties carting along a medication nebulization machine for her child. Consider what is best for your child. No matter how much your child, and you, have anticipated the holiday gathering, home is always the most comfortable place for a child to recover from illness.

Thinking hard about whether or not you should attend a holiday gathering? Then you are thinking too hard. Just stay home. Besides, you haven’t been a real parent until you’ve missed at least one party because of a child’s illness.

Julie Kardos, MD and Naline Lai, MD

©2015 Two Peds in a Pod®, revised from our 2009 post

A foster mom brought a new child into the office the other day and I smiled picturing her with her last foster child. This thanksgiving, Two Peds in a Pod is grateful for the foster parents who open their homes for dinner today and everyday. Dr. Heather Forkey, Clinical Director of Foster Children Evaluation Service at UMass Children’s Medical Center, provides a post on becoming a foster parent. –Dr. Lai with Dr. Kardos

There are approximately 400,000 children in the US foster care system, with 225,000 entering each year. Most of these children spend time with foster families who open their homes and lives to kids that need a safe nurturing environment while their own parents take the time to address issues which put the child at risk. All types of people make great foster parents, but it is not for everyone. Foster parents must be able to meet the physical, emotional and developmental needs of a child or teen in partnership with community agencies, social workers, schools, and counselors.

If you are considering foster parenting, consider whether you can:

• Provide 24-hour care and supervision on a daily basis
• Be able to care for yourself financially without the child’s stipend
• Be flexible, patient and understanding
• Have a sense of humor
• Recognize the impact of trauma
• Have a home free of fire and safety hazards
• Complete a criminal/protective services background check
• Have the ability to work as a member of a team

If interested, you need to become licensed or approved by your state or county, and that process is different in each locality. One should start by doing an internet search for “becoming a foster parent in (your state or county)”. The child welfare agency for your state (Department of Children and Family Services or Department of Social Services) will also have information about how to start the process.

Children come to foster care often after adverse experiences which we know have health, emotional and developmental consequences. Foster parents who can look at the child’s health and behavior from a perspective of “what happened to the child” rather than “what is wrong with the child”, and observe a child’s behavior through the trauma lens (and help foster and child welfare personnel to do the same) allow the child in their care to view their health and emotions as normal adaptations to unhealthy situations, rather than evidence of illness. This allows the child to go forward with a better understanding of their experience, their own responses and, ultimately, foster health.

Heather C. Forkey, M.D.

Dr. Heather Forkey serves as the Clinical Director, Foster Children Evaluation Service (FaCES) and the Chief of the Child Protection Program at Mass Children’s Medical Center

2015 Two Peds in a Pod®