Dozens of kids are pouring into our offices or calling from the shore because of swimmers ear. Time to bring up from the archives info about swimmer’s ear and ways you can prevent reoccurrence.

No set of blog posts about summer time plagues would be complete without a discussion on swimmer’s ear (Otitis Externa). 

Ear infections are divided into two main types: swimmer’s ear (otitis externa) and middle ear infections (otitis media).

An understanding of the anatomy of the ear is important to understanding the differences between the two types of infection.  Imagine you are walking into someone’s ear. When you first enter, you will be in a long tunnel. Keep walking and you will be faced with a closed door. The tunnel is called the external ear canal and the door is called the ear drum.

Swimmer’s ear occurs in the ear canal. Dampness from water, and it can be water from any source- not just the pool, sits in the ear canal and promotes bacterial infection.  

Next, open the door. You will find yourself in a room with a set of three bones. Another closed door lies at the far end.  Look down.  In the floor of the room there is an opening to a drainage pipe. This room is called the middle ear. This is where middle ear infections occur.

During a middle ear infection, fluid, such as during a cold, can collect in the room and promote bacterial infection.  Think of the sensation of clogged ears when you have a cold. Usually the drainage pipe called the eustachian tube,  drains the fluid.  But, if the drain is not working well, or is overwhelmed, fluid gets stuck in the middle ear and become infected. 

Because a swimmer’s ear infection occurs in the external canal, the hallmark symptom of swimmer’s ear is pain produced by pulling the outside of the ear.  Since middle ear infections occur farther down in the ear, pain is not reproduced by pulling on the outer ear.

Swimmer’s ear is treated topically by your doctor with antibiotic drops.  To avoid dizziness and discomfort when putting drops in, first bring the ear drop medicine up to body temp by holding the bottle in your hand.

Home remedies to prevent swimmer’s ear:

·     After immersion in the water, tilt your child’s head to the side and towel dry what leaks out. 

·         Mix rubbing alcohol and vinegar in equal parts.  After swimming, place a couple drops in the ear.  Do not put these drops in if there is a hole in your child’s eardrum. 

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

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

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

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

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

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

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

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

After we complete a Two Peds in a Pod planning or edit session, our conversation inevitably turns to the question, “What are you cooking for dinner tonight?”

We know parents are always searching for simple ways to move beyond macaroni and cheese suppers. Here are two chicken dishes Dr. Kardos’s kids love and one tofu dish Dr. Lai’s children enjoy. For picky eaters, please note each item is well demarcated- no food has to “run into” or “touch” the other items. All can be eaten with a fork or with fingers for younger toddlers.  They have flavors that adults like but are not too strongly flavored to turn a kid off.  Best of all, they are easy to prepare.  

Gram mom’s Chicken-in-a-Pot

Need: One 5-8 lb oven stuffer roaster chicken, carrots, onions, spices, cast-iron pot/dutch oven

Rinse off chicken and discard innards/gizzards. Pat dry. Sprinkle with spices that are kid friendly (no hot pepper unless your child really likes it). I use garlic powder, onion powder, salt, and tarragon. Place chicken into a cast-iron pot/Dutch oven. Add cut up carrots or “baby” carrots and either frozen pearl onions or a fresh onion chopped up. Other vegetables that will not fall apart/become mush would work as well. DO NOT ADD WATER.

Cover the pot, place on stove on low heat, and cook for 2-3 hours, until chicken is tender.  It makes its own juices as it cooks so you never need to add water. When done, the chicken falls off the bones with minimal prompting. Carefully discard bones.

Result: easy to chew, pleasantly but not strongly flavored chicken, and cooked carrots. Dr. Kardos’s kids love to eat this with applesauce (two like to dip the chicken), raw carrots (only one of her kids likes cooked carrots), rice or noodles (juices from chicken taste great on either one) and fresh strawberries or other kid-pleasing fruit.

A ma’s (Taiwanese for gram mom) easy Tofu

Need: extra firm or firm tofu, rice, soy sauce, sesame oil, dried basil (Mrs. Dash has a tomato-basil-garlic spice mixture which is great, but tough to find)

Cut a block of  tofu into one-third inch thick square pieces (approximately one and one half inch by one and one half inch). Liberally coat the bottom of a frying pan with sesame oil, add tofu and soy sauce, sprinkle dried dried basil over pieces. Cover and cook on high heat until starting to brown, then flip pieces over and cook on medium heat until other side starts to brown. For the picky kid, mush with a fork into rice and serve in a big bowl with fruit and vegetables on a separate plate. For everyone else, consider adding pepper and serve over steamed white or brown rice. 

Mom mom’s baked chicken

Need: Boneless/skinless thicker cut chicken breasts, herb or Italian flavored breadcrumbs, grated parmesan cheese, butter (or Smart Balance).

Melt butter in one bowl. In another bowl, mix equal parts breadcrumbs and parmesan cheese.

Rinse chicken, pat dry. Dip the chicken first into the melted butter, then into the breadcrumb mixture until well coated, then place onto baking pan. Drizzle any remaining melted butter onto the chicken. Bake at 350° for 25-30 minutes (until chicken is cooked through).

Serve with rice, noodles, couscous, or bulgur wheat, salad or frozen mixed vegetables that steam right in the bag, and fresh pineapple or other kid-pleasing fruit.

Bon Appetite,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In today’s podcast we discuss how to spot the rash of lyme disease, what to do about poison ivy, and  how to avoid sunburns. Pictured below is a creative way one child found to block the sun effectively. Notice there’s  no burn underneath the areas of skin which were once covered by temporary tattoos.

Naline Lai, MD and Julie Kardos, MD

©Two Peds in a Pod®

“I see green stuff all over my car and I park  in the garage,” a mom said to me today.

The pollen count is high on the east coast and with it comes green cars and  itchy eyes. Eighty  percent of the older kids I saw today, including those seen for routine check-ups, had red irritated eyes.

So what to do?  Pollen directly irritates eyes, so start with washing the pollen off. One parent told me he applied cool compresses to his child’s eyes. This is not enough- get the pollen off. Plain tap water works as well as a saline rinse. Filter the pollen out of your house by running the air conditioning. Some people will leave shoes outside the house and wipe the paws of their dogs in order to keep the green stuff from tracking into the house.

Oral medications do not help the eyes as much as topical eye drops. Over-the-counter antihistamine drops include ketotifen fumarate (eg. Zatidor and Alaway). Prescription drops such as Pataday or Optivar add a second ingredient called a  mast cell stabilizer. Avoid use of a product which contains a vasoconstictor (look on the label or ask the pharmacist) for more than two to three  days to avoid rebound redness. Contacts can be worn with some eye drops– first check the package insert. Place drops in a few minutes before putting in contacts and avoid wearing contacts when the eyes are red.

Hopefully allergy season  will blow through soon. After all, as a couple teens pointed out-prom is around the corner and allergies can make even the young look haggard. One teen male told his mom that he shaved today  because having a beard and blood shot eyes made him look THIRTY years old.

Miserable allergies!

Naline Lai, MD with Julie Kardos, MD

©2011 Two Peds in a Pod® , rev 5/8/2013, rev 2015

One of Dr. Lai’s patients burned his arm on a hot cookie sheet. The child stopped further injury by immediately running the area under cool water. However, his well-meaning great-aunt decided to then apply butter to the burn. Please, do NOT put butter immediately on a burn. It’s like putting butter on a hot skillet.

We’re not sure where the myth of putting butter on a burn comes from. A better idea for pain control, after applying cool water for a few minutes, is to offer the child a pain reliever such as acetaminophen (Tylenol) or ibuprofen (Advil, Motrin).

Burns caused by fire or burns covering large body areas are best treated at a hospital, but your first response, as you call 911, should be to get that burn in cool water. Run the water for several minutes. To avoid shock or extreme cold injury, do not use ice water. Don’t remove clothing stuck to skin but go ahead and put the burn and the stuck clothing in cool water. 

Most burns sustained at home are mild or may cause blisters. Burns are easily infected because when you burn away skin, you burn away an excellent barrier to germs. Washing the affected area with soap and water and applying a topical antibiotic such as Bacitracin twice daily can prevent infection. Avoid popping blisters- you will take away a protective layer of skin.

Please remember that unlike for cookie batter, butter is not better for burns. Please pass this post on to anyone you know who cares for your children…it’s “hot off the press.”

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

Revised 5/17/2015

The antihistamine quandry

Junior’s nose is starting to twitch

His nose and his eyes are starting to itch.

As those boogies flow
You ask oh why, oh why can’t he learn to blow?

It’s nice to finally see the sun

But the influx of pollen is no fun.

Up at night, he’s had no rest,

But which antihistamine is the best?

It’s a riddle with a straight forward answer. The best antihistamine, or “allergy medicine” is the one which works best for your child with the fewest side effects. Overall, I don’t find much of a difference between how well one antihistamine works versus another for my patients. However, I do find a big difference in side effects.

Oral antihistamines differ mostly by how long they last, how well they help the itchiness and their side effect profile.  During an allergic reaction, antihistamines block one of the agents responsible for producing swelling and secretions in your child’s body, called histamine.  

Prescription antihistamines are not necessarily “stronger.” In fact, at this point there are very few prescription antihistamines. Most of what you see over-the-counter was by prescription only just a few years ago. And unlike some medications, the recommended dosage over-the-counter is the same as what we used to give when we wrote prescriptions for them.

The oldest category, the first generation antihistamines work well at drying up nasal secretions and stopping itchiness but don’t tend to last as long and often make kids very sleepy.  Diphendydramine (brand name Benadryl) is the best known medicine in this category.  It lasts only about six hours and can make people so tired that it is the main ingredient for many over-the-counter adult sleep aids.  Occasionally, kids become “hyper” and are unable to sleep after taking this medicine. Other first generation antihistamines include Brompheniramine (eg. brand names Bromfed and  Dimetapp) and Clemastine (eg.brand name Tavist).

The newer second generation antihistamines cause less sedation and are conveniently dosed only once a day. Loratadine (eg. brand name Alavert, Claritin) is biochemically more removed from diphenhydramine from than Cetirizine (eg. brand Zyrtec) and runs a slightly less risk of sleepiness. However, Cetirizine tends to be a better at stopping itchiness.

Now over-the-counter, fexofenadine (eg brand name Allegra) is a third generation antihistamine.  Theoretically, because a third generation antihistamine is chemically the farthest removed from a first generation antihistamine, it causes the least amount of sedation. The jury is still out.

If you find your child’s allergies are breaking through oral antihistamines, discuss adding a different category of oral allergy medication, eye drops or nasal sprays with your pediatrician.

Because of decongestant side effects in children, avoid using an antihistamine and decongestant mix.

Back to our antihistamine poem:

Too many choices, some make kids tired,

While some, paradoxically, make them wired.

Maybe while watering flowers with a hose,

Just turn the nozzle onto his runny nose.

Naline Lai, MD with Julie Kardos, MD

©2011 Two Peds in a Pod®

As spring break approaches, here are some ways to handle sickness while traveling with your children when you are far away from your children’s primary care provider.

• If your child has a health condition that is intermittent, such as asthma, bring his inhaler, spacer, or any other medication. Even if he hasn’t had a flair up for months, it is much safer to travel prepared. Don’t forget your child’s epi-pen if she has a history of food allergies. If your child’s healthcare provider holds a United States license and you are not in the United States, your healthcare provider can not call in routine medications.
• If your child has a complicated health history, bring a typed summary of his health history including current medications. 
• Decide beforehand where you will seek medical help if your child becomes ill . Maybe it is a pediatric or family medicine office that accepts new patients, a walk-in clinic, or an emergency room that sees children. Your child’s health care provider’s ability to diagnosis and treat your child is limited over the phone. Kids are much safer diagnosed in person with the benefit of a thorough physical exam.
• Travel with the basics: 1) pain reducer such as ibuprofen or acetaminophen for headaches, minor injuries, or aches associated with fever, 2) a quick acting allergy medicine such as diphenhydramine (brand name Benedryl) in case of an allergic reaction such as hives, 3) anti-itch cream such as hydrocortisone in case of annoying bug bites or contact rashes such as poison ivy, 4) a topical over the counter antibiotic in case of skin scrapes, and 5) band aids. Remember to first wash any break in skin with soap and water.
• Bring your child care provider’s telephone number. Even if she cannot provide a final diagnosis, she can provide advice and guidance as to whether or not you need to take your child to a local health care provider.
• Make sure your child is fully vaccinated. You can’t vouch for the health of other people you encounter on your travels. It is much easier to prevent illness than chase it after it strikes. Likewise, practice good hand washing hygiene.
• Travel outside of the United States may require specific vaccinations or preventative medications.  Call a local travel clinic or check www.cdc.gov for advice on specific countries.

Kids have a knack for knowing just which week of the year their family will travel and then get sick during that one planned-for week.  I remember the spring vacation that our twins awoke with fevers on our first day away from home. Fortunately, my children travel with their pediatrician. Families who leave their pediatrician behind when they go on vacation can empower themselves with the knowledge of how to handle illness away from their medical home.

Or, there’s the option of inviting the pediatrician along… especially if you’re headed somewhere warm…

Julie Kardos, MD with Naline Lai, MD

©2011 Two Peds in a Pod®

Recently I had the pleasure of taking a three-year-old neighbor out to dinner. My own kids and I greatly enjoyed our three-year-old friend’s conversation and antics so afterwards I decided to write about three-year-olds.

THEY HAVE GREAT IMAGINATIONS. My three-year-old friend was playing “Tinkerbell” and I was Tinkerbell’s mom. “So who are the boys (my kids)?” I asked her.  “Are they Peter Pan and the Lost Boys?”

“NO,” she explained, “we are NOT playing Boys right now, we are playing Tinkerbell. I live on Pixie Lane.”

Three-year-olds are great at pretending. The problem/charm is that they also often believe what they pretend. So to them, they really saw an elephant on the way to preschool that morning. They really “go to preschool” even if in reality they merely PLAY “preschool” at home. When three-year-olds tell “tall tales,” they believe what they are saying.

This same belief in the pretend world also makes them easily frightened. Refrain from watching any potentially scary show, including the weather channel, in their presence; a three-year-old may be afraid of a tornado that touches down half way across the country. They also can be very concerned about body integrity. A small paper cut might signal that their finger will fall off and may necessitate ten band-aids. Not surprisingly, nightmares are common in three-year-olds.

They are easy to teach because of their natural curiosity and their willingness to try what others are trying. In the deli, my three-year-old guest happily tried pickles because my kids were eating them. Three-year-olds behave better than two-year-olds because they follow rules more consistently as long as they feel somewhat in control. She chose which of my boys’ hand to hold when we walked across the parking lot because she was told to hold a big person’s hand. She handed her butter knife to me because “The waitress must think that I am BIG but really I am little. She didn’t know that!” She sat nicely in the booth and talked to us because my kids were doing just that.

Three-year-olds get the hang of waiting, taking turns, and sharing MUCH better than they do as two-year-olds. They start to play simple games with rules. But they are also very literal and it’s easy to forget what they do not know.  I recall my twins’ hysterical laughter when they were three and I referred to their “bare feet.” They insisted that they had “BOY feet, not BEAR feet, Mommy!” When we asked for a doggie bag after dinner at the deli, my three-year-old neighbor laughed hysterically over the image of a bag that looked like a dog, then at the thought of her dog getting the dinner remains. We explained that even though the family dog could eat the food from the doggie bag, she also could eat the leftovers the next day for lunch. This concept cracked her up, which in turn cracked US up.

I like to point out features of three-year-olds in my office to parents and caregivers. Yes, they can still be irrational, yes they can still have temper tantrums, yes, they can “get stuck” in an undesirable behavior pattern such as always crying at school drop-off (yet they have a wonderful day that starts after the parent’s car pulls away) or refusing to poop on the potty. Because three-year-olds have no sense of time, they don’t understand schedules and feel no sense of urgency to get to a birthday party before it’s over. They can develop irrational fears at the drop of a hat. They vacillate between wanting to be “big” and wanting to crawl back into the womb. But I encourage parents to take the time to enjoy their three-year-old’s charms and antics.

I still remember the “let’s pretend” game I played with my first born who would spend hours playing “explore outer space” where we would build a pretend spaceship out of sofa pillows, make maps to chart our journey, and go to Mars “to visit the Marshmallows.” Never again will (or should) your children hope to marry you. Enjoy their antics now… four and fourteen-year-olds are just around the corner.

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