Leonard H. Schwartz, Principal, Mill Creek Elementary School

We’re pleased to bring to the Greater Phildaelphia Area our “Scoop on Poop” post which was published in the Healthy Kids blog for Philadelphia Inquirer’s philly.com.

Although many can not talk about the topic without snickering, face it. “Poop” is an essential of life. If pooping gets thrown off, everything gets thrown off. The kid who won’t poop in the potty sets everyone else in the household off kilter, and leads to bribes, threats and chaos. A constipated kid is a grumpy kid.  Constipation can lead to tantrums, refusal to eat, and even an inability to fall asleep. If you still have have infant and toddler poop questions, check out our podcast on potty training and our post “When potty training gets hard: constipation.”  On a related topic, please also visit our post “It’s a Gas, your young infant’s burps and farts.”

Until you are a parent, you can never fully appreciate the fierce desire for “everything to come out okay in the end.”

Julie Kardos, MD and Naline Lai, MD
©2012 Two Peds in a Pod®

The Tooth Fairy rocks!

For kids, the Tooth Fairy takes the worry out of the stage around five to seven years when they start to worry about their “body integrity.” Kids are concerned about keeping their bodies intact. This is the age of Band-Aids and boo boos, of skinned knees on the playground and falls from bikes without training wheels. When a child loses her tooth, a PIECE of her BODY falls off. Often the child experiences discomfort as the tooth gets very loose. Many become anxious and have difficulty eating when the tooth gets to the “hanging by a thread” state. Kids BLEED if they lose a tooth by biting into an apple or knocking into something. Yet adults convert this potentially anxiety-provoking event of losing a tooth into an exciting rite of passage. Without the Tooth Fairy, we’d have a batch of kids mortified by a normal physical change. Who ever invented the Tooth Fairy was a GENIUS!

Our patients have taught us interesting “facts” about the tooth fairy over the years:

• Some tooth fairies leave the token under the pillow, others leave it at the bedside.
• Some tooth fairies leave money, others a small toy, and some write messages.
• Some tooth fairies are boys and some are girls.
• Some look like Tinker Bell and others look like trolls.
• Some tooth fairies don’t have change for a twenty dollar bill.
• Tooth fairies can look like someone the child already knows, even a mom or dad!
• Tooth fairies can sense a missing tooth even if the child loses the tooth on the playground or swallows it by mistake, so it’s okay if the tooth is not left under a pillow for the Tooth Fairy. She’ll still come.

Pediatrician dentists recommend children begin regular dental visits within six months of getting their first tooth. Most babies get their first tooth between four months and twelve months, so by eighteen months of age your child should have had her first dental visit. Don’t forget to start brushing as soon as that first tooth appears. With this being said, it isn’t just kids who need to look after their teeth. No matter what age you are, you should clean your teeth at least twice a day. 

It’s okay to brush with water alone or use a baby tooth and gum cleaner. Add toothpaste by age two years, when kids can learn how to spit. Ask your dentist or pediatrician about fluoride supplementation if there isn’t any fluoride in your water supply. For more tooth tips see our guest blog post by Dr. Paria Hassouri and take advantage of this free tooth brushing chart which you can personalize with your child’s name. Take good care of those primary teeth, even though they are destined to be taken away by the Tooth Fairy.

Julie Kardos, MD with Naline Lai, MD

©2012 Two Peds in a Pod®

Dr. Kardos feels nostalgic. Her oldest child, who stopped eating for the two days before his first baby tooth fell out, just lost his last baby tooth last week. And yes, the Tooth Fairy did visit her twelve-year-old.

Our fantastic Two Peds in a Pod photographer Lexi Logan recently put in a request for a post on bloody noses. I cringed, thinking any photo would not be pretty. “No problem,” she replied,” I’m thinking just a tissue and a top-of-nose shot… pinch angle.”

I was aghast. “Looks like you fell for the number one myth associated with bloody noses,” I said.”That’s the wrong spot to pinch.”

“See,” she told me,”that’s why I need the post.”

So, how does one squelch the fountain of red which spews from a bloody nose? Apply pressure to the SIDE of the nostrils—not up near the bridge of the nose. More blood vessels lay near the bottom of the septum, the divider which separates the nostrils, than near the top. Pinch the nose firmly. Since kids never seem to apply enough pressure on their own, go ahead and pinch for them.  You’ll find it easier to pinch both nostrils simultaneously even if the blood is dripping from only one side.

Now hold. Hold. Hold. Hold in the middle of the night until you nearly fall back to sleep. Hold until the pot of spaghetti boils over. Hold for at least ten minutes before peeking in order to allow the blood to clot. If the nose is still oozing, pinch for another ten minutes. Have your kid sit up straight or lean slightly forward. Otherwise, blood will drip down the back of her throat and cause nausea and vomiting.

Do not be surprised after an episode if the next couple of nights bring more bloody noses.  At night during sleep kids tend to rub their noses. Any scab that formed from a recent nose bleed gets sloughed off.

To prevent reoccurrence, protect those fragile blood vessels by keeping the inside walls of the nose moist. Once or twice a day, spritz saline into the nose, then apply a thin layer of petroleum jelly. Try running a cool mist humidifier in your child’s bedroom.

Prevent nasal irritation by decreasing environmental irritations such as cigarette smoke or dust. Teach your child to dab at his nose or blow gently when he has a cold. Ironically, some steroid nasal sprays, which treat runny noses caused by allergies, can irritate nasal passages.

Your kid is having too many bloody noses when you start to carry around tissues or your child sleeps with a box of tissues next to his pillow “just in case.” Go to your child’s doctor if this occurs.  Also, go if there are signs of a clotting problem such as easy bruising, bleeding gums, or heavy periods. Likewise, if bloody noses take more than twenty minutes to clot, or if the nose bleed requires an emergency room visit or packing in the nose, make an appointment. Other reasons for more evaluation include if your family has a history of clotting disorders, your child gets speckled flat rashes that look like broken blood vessels (petechiae) which do not blanch (lose color for a second when you press on it) or if a nosebleed is caused by trauma.

Your child’s doctor may recommend sealing vessels with cauterization or investigating for possible blood clotting problems. Depending on your child’s age, she may also recommend a short course of oxymetazoline (eg Afrin). Be sure to use oxymetaxzoline according to directions- overuse can cause rebound symptoms.

Ultimately, you may find that your kid’s bloody noses are just the result of the perfect storm: dry air and a kid who picks his nose. In the meantime save that thirty percent-off Kohl’s coupon. You might be buying a lot of pillow cases.

Naline Lai, MD and Julie Kardos, MD
©2012 Two Peds in a Pod®

You wake up in the middle of the night to the sound of a seal barking inside your house. More specifically, from inside the crib or toddler bed. Unless you actually have a pet seal, that bark is the sound of your child with croup. 

The news is filled with stories about boys wearing pink nail polish, a baby whose gender will be kept a secret by his/her parents, and Chaz Bono’s new book and identity as a man.  What’s the deal with gender, and why have the media waves exploded in the past few years?  Is gender variance becoming more common, or just more recognized?  And what should you do if your son wants to wear pink or your daughter cuts her hair short?

First, some definitions. 

–Gender is one’s internal sense of self as male, female, or neither, while sex is assigned at birth based on external appearance.  As one astute child told me, “sex is what’s between your legs, while gender is what’s between your ears.” 

–Gender expression is how one chooses to portray his or her sex or gender—for example a male child (sex assigned at birth) who feels he is a girl (gender) might still wear boys’ clothing and hairstyles to fit in with peers (gender expression).  Or, a female child (sex) feels she is a girl (gender) but prefers to wear boys’ clothing (gender expression) and chooses a gender-neutral name. Her gender expression is masculine. 

–Gender variant, gender diverse, and gender nonconforming refer to a child who expresses gender identity or expression that is different than what one expects based on sex.  These terms refer to a wide range of children—from the little boy who likes to play with Polly Pocket dolls to the male child who insists he is a girl and wears dresses to school.  Some gender variant children will be transgender, which refers to a child who persistently feels the sex assigned at birth is incorrect.

When gender variant children reach puberty, they may become aware of their sexual orientation, or who they are sexually attracted to.  They may find that they are attracted to the “opposite gender” and have a straight (heterosexual) orientation, or they may be attracted to the same or any gender, and identify as gay, lesbian, or bisexual.  Of course, these labels become especially confusing when discussing gender variant teenagers. For example, is a female-bodied teen who identifies as a man (transgender) and attracted to women heterosexual or homosexual?  For this reason, many young people choose to identify as queer, an umbrella term with a positive connotation that conveys many ways of loving people with different bodies and gender expressions. 

How common is gender variance?

International epidemiologic studies estimate the prevalence of transgender adults to be anywhere from 1 in 1,000 to 1 in 30,000.  That’s a huge range.  When you include children who are gender variant but not transgender, the numbers are much higher.  For example, Gender Spectrum, an organization that I work with in California, conducts trainings at schools that have identified a gender variant child who is facing bullying or discrimination.   To date, they have been invited to nearly every elementary and middle school in their geographic area.  Most schools in this area have approximately 100-500 students, so my best estimate of gender variance in my geographic area is 1 in 500.

How do you know if a child is gender variant? 

The child tells you.  Many of the gender variant children I know recall telling their parents at an early age that they felt different.  For example, some transgender boys (i.e. born in a female body, identify as male) I know corrected the adults who tried to call them girls as children, insisting they were boys.  One parent recalls her transgender son telling adults “I am a boy now, but when I grow up I will be a mommy.”

Most kids exhibit some sort of gender exploration in their early childhood, and this is a normal part of development.  However, a child who is shows gender variance generally makes claims that are early and persistent, and then develops distress when corrected by adults.  The “test” becomes when a child is given the freedom to express his/her internal sense of gender.  In gender variant children, this distress will be alleviated. 

What do you do if this describes your child? 

The emerging consensus among experts is to let your child guide you, and to aid your child in his or her gender exploration by working with local resources to create a supporting and accepting environment.  In the past, some experts recommended a sort of reparative therapy, for instance removing all “girlish” toys from a boy-bodied child’s home and insisting that he wear only “masculine” clothing.  While this may have worked for a short time, the child’s distress often emerged later on, often in puberty, with depression and suicide.  In fact, a survey of transgender adults showed that one-third of them had attempted suicide in their life, some as young as age seven or eight.  These are good reasons to pay attention to your young child.   Research shows that children raised in supportive families have more positive outcomes.

Parents raising gender variant children worry about their safety and acceptance in their schools, neighborhoods, and extended families—and for good reason.  Gender variant children are bullied and face discrimination, abuse, and violence at rates much higher than their peers.  Often, parents do not agree with each other—as one parent may allow more gender exploration than the other.  The child’s gender presentation may not be accepted in churches or within the family’s religious belief.  It is imperative that families obtain professional help, especially when there is disagreement between parents on how to support the child.  In addition, there are many parents groups and conferences where families can meet each other for mutual support.

If you are concerned about a child in your own life, there are wonderful organizations that can help you. 

Resources:

Resources: Gender Spectrum www.genderspectrum.org

Family Acceptance Project http://familyproject.sfsu.edu/

Trans Youth Family Allies http://www.imatyfa.org/

My favorite blogs, articles, and videos about raising Gender Variant Children

Sarah Hoffman’s Parent Blog http://www.sarahhoffmanwriter.com/

A Boy’s Life from the Atlantic http://www.theatlantic.com/magazine/archive/2008/11/a-boy-apos-s-life/7059/

Two Families Grapple with Son’s Gender Identity from NPR http://www.npr.org/2008/05/07/90247842/two-families-grapple-with-sons-gender-preferences

Transgender Kids recent CNN segment http://www.cnn.com/2011/09/27/health/transgender-kids/index.html

Ilana Sherer, MD

Returning guest blogger Dr. Ilana Sherer is the Director of General Pediatrics of the Child and Adolescent Gender Center at UCSF. She is a recipient of the Chancellors Award for LGBT leadership at UCSF and also of the American Academy of Pediatrics Dyson Child Advocacy Award.

©2012 Two Peds in a Pod®

As a call to service in honor of Martin Luther King Day, we bring you an eye opening child advocacy post from guest blogger Dr. Heidi Román, who works with underserved children and their families in California .

Early in my pediatric residency training I entered the exam room to see a one-year old patient. Her mom blurted out excitedly, “We finally have a place to live.” It turned out that they had been living in motels or with relatives for most of the child’s life. I paused for a moment as I realized that it had never really registered. She had been seen in our clinic for multiple visits, but no one had noticed the changing addresses. No one had asked the questions in a way that allowed her to tell us. They were homeless. This was my wake up call. Since then, I have met many families affected by homelessness. Many hard working families are pushed into poverty and homelessness by loss of a paycheck, foreclosure, or divorce. They are reluctant to talk about it. Children and families are the “hidden” homeless.

While the mainstream media consistently covers the recession, quoting jobs numbers and the like, there is a disturbing new set of data out that doesn’t seem to be getting much press. Last month the The National Center on Family Homelessness released their report on child homelessness entitled “America’s Youngest Outcasts 2010“, and the news is not good. During the time period of the recession (2007-2010) there was a 38% spike in the number of homeless children. Currently, there are 1.6 million homeless children in the United States. Children now make up almost 40% of the homeless population and families with children are the most rapidly growing segment of the homeless population.

That’s a lot of kids and families. And, as children are often not included in homeless statistics, the number is probably higher. Why don’t we hear about it more? Well, homeless families tend to be the invisible segment of the homeless population. They fly under the radar. They move from place to place. They “double up” with friends or relatives for a few months, and then stay in a shelter or motel for a while. They sleep in their car. Parents may not even report that they are homeless to teachers or health care providers for fear of losing their children. There are various reasons that families become homeless. Certainly worsening poverty, due to job loss or changes in welfare programs, is a major cause of housing loss for families. But, domestic violence or parental separation is also very often to blame.

Once families become homeless, it is very difficult to escape. Even if the parents are lucky enough to find a job, it will likely pay only minimum wage. Adequate housing is still out of reach for these families. This is true regardless of the state, city, or town the family lives in; and the gap between income and housing costs is even greater in areas with a high cost of living. 

Experiencing homelessness profoundly affects a child’s physical, psychological, and educational health. Homeless children have higher incidence of trauma-related injuries, poorly controlled asthma, developmental delays, growth problems, and anemia, among other health problems. Homeless children are far less likely to have a medical home or adequate health insurance. They are far more likely to utilize the ER for care at a later stage of illness. Homeless adolescents have much higher risk of being victims of violence or sexual abuse and have higher rates of substance use, HIV, and teen pregnancy.

Homeless children, regardless of cognitive ability, do far worse in school. They are more likely to change schools during the year or miss more school days, greatly affecting their ability to do well academically and flourish socially. Even simple things, like being asked by a teacher to draw their room or describe their house, become awkward and painful.

What’s being done about this? Sadly, not much. Per the State Report Card on Child Homelessness, only seven states have extensive plans relating to services for homeless families. In the current economic and political climate, the number of homeless children and families continues to increase and the services provided to them are shrinking.

What can we do?

• If you or someone you know is at risk of homelessness:
  • Talk to someone you trust- a physician, teacher, church staff, or social worker. Learn about emergency assistance programs in your area.
  • If you will be homeless in a few days or weeks, The National Coalition for the Homeless has a list of things to do. It includes making sure you have a current and available ID, packing a bag of essentials for each family member, and applying for public and transitional housing. Search the Coalition’s directory of homeless advocacy organizations and shelters.

• If you are a person who cares about these kids and families:
  • Learn about the “hidden homeless” and start talking to friends and colleagues. Work to change misperceptions about homelessness. Find out how your state is doing in terms of providing services to homeless families.
  • Consider volunteering with or donating to an organization that fights to end homelessness. National organizations include The National Coalition for the Homeless, The National Law Center on Homelessness and Poverty, and The National Center on Family Homelessness. Find a local organization to work with here or via internet search.
  • The National Coalition for the Homeless has a great list of other creative ways to get involved.
  • Finally, contact your congressperson and tell them you support H.R. 32 The Homeless Children and Youth Act of 2011. This bi-partisan bill changes the definition of “homeless person” to include certain adolescents and youth that are currently excluded for technical reasons. Their inclusion would allow them to access much needed services. If I can’t convince you, perhaps these kids can. They testified about their experience being homeless at the H.R. 32 hearing on child and youth homelessness, held by the U.S. House of Representatives’ Financial Services Subcommittee on Insurance, Housing, and Community Opportunity last December.

Heidi Román, MD

Heidi Román MD, FAAP is a mother and pediatrician who practices in San Jose, California. She has special interest and experience working with under-served families from diverse racial and socio-economic backgrounds. Dr. Román is a passionate child health advocate who works towards improved health for all kids, both in and out of the clinic. She writes about everything from parenting to policy at mytwohats.wordpress.com.

©2012 Two Peds in a Pod®

There is a saying we heard in medical school, “Half of what you learn now will change in ten years… you just don’t know which half.” In pediatrics, where we specialize in change, the saying certainly holds true.  We ring in the New Year by picking the top 2011 changes in pediatrics all parents should be aware of:

Car seats– keep children rear facing in car seats until two years old (or until they physically cannot fit rear-facing any more) and keep your child in a booster seat until a seat belt fits properly– across his chest and not his neck, and low on the waist across the hip bones, not across his belly. Sitting in the back seat is the safest spot for those 12 years and under.  For more information check out our post Buckle up: the latest in car seat safety.

Meningitis Vaccine– A booster dose for older teens is now recommended for the vaccine against the germ Neisserria meningitidis in addition to the dose routinely given to tweens.
 

Flu vaccine– Having an egg allergy is no longer an absolute contraindication to getting the flu vaccine. Turns out there is so little egg in the vaccine, most kids with egg allergies can safely receive the injectable form, though they still should not receive the spray-up-the-nose form. Ask your child’s pediatrician or allergist if your egg-allergic child is a candidate.

Bye-bye food pyramid– The difficult to understand food pyramid finally bit the dust and is replaced by My Plate .

SIDS prevention and safe sleep– keep soft bedding away from baby’s face- no crib bumpers! And continue to place your baby on his back to sleep. AAP Expands Guidelines for Infant Sleep Safety and SIDS Risk Reduction and Sleep Safety: How to decrease your baby’s risk of Sudden Infant Death Syndrome (SIDS)

An old recommendation gets reinforced: in 2011, Dr Wakefield’s paper suggesting a link between the Measles, Mumps and Rubella (MMR) vaccine and autism is reaffirmed as fraudulent. MMR vaccine schedule does not change.

Genital Wart and cancer from HPV prevention in males– HPV vaccine is now not only approved for boys, but recommended for boys, as well as girls, by the ACIP (vaccine branch of the CDC). With over 35 million people having received this vaccine, evidence supporting its safety has become well established.

All liquid acetaminophen products (Tylenol) are now the same strength. Watch out if you have the old formulation in your medicine cabinet, double check the dosing.

Changes in when and how to start solids foods: For about the last fifteen years, pediatricians advised delaying the start of solid foods and the start of commonly allergenic foods such as eggs or wheat to prevent food allergies. Unfortunately, food allergies have risen during this time. Current advice is back to the old advice. According to the National Institute of Allergy and Infectious Diseases sponsored guidelines (November 2011 Pediatrics), solid foods should be introduced by 4-6 months of age and any potentially allergenic foods may be introduced at this time as well.

We look forward to more advances in pediatrics for 2012. Please keep reading and tell parents about us.

Best wishes for a healthy New Year.

Your Two Peds,

Naline Lai, MD and Julie Kardos, MD

©2011 Two Peds in a Pod®

As a new year rolls around and our pockets start to feel empty after the holidays, we look back at an older post for ways to penny-pinch without short-changing your kids: Save money: How to penny pinch without hurting your children. And whether your children receive gift cards, gelt, or cash gifts this season, we direct you to the popular post  Teaching kids money smarts for ideas on how to help them manage their new stash. 

Best wishes from your Two Peds,

Drs. Kardos and Lai
©2011 Two Peds in a Pod®