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

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

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

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

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

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

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

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

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

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

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

When the first news of the earthquake and subsequent tsunami rolled in from Japan last week, my family started to track down news of my cousin who resides in Tokyo with her husband and two sons. We were relieved to hear of shaken china and toppled bookshelves but no injuries. My nephew was on a school field trip that day and the bus was delayed, but he got home safely the next day. They were physically safe, but mentally shaken.

Even though the event may be half a world away, explaining a large scale tragedy such as what happened in Japan to children is tough; especially in this case when the uncertainty of a nuclear meltdown still looms and images of a struggling Haiti still fill the newsfeeds.

Understand that kids sense your emotions even if you don’t tell them. Not telling them about an event may make them concerned that they are the cause for your worried hushed conversations. Break away from your discussion with adults to say, “ Do you know what we are talking about? We are not talking about you.”   

Tell the facts in a straight forward, age appropriate manner. Answer questions and don’t be afraid to answer with an “I don’t know.”  Preschoolers are concrete in their thinking—dragons are real and live under their bed, so don’t put any there that do not exist. For a preschooler a simple “Mom is sad because a lot of people got hurt,” will suffice. Young school age kids will want to know more details. And be prepared to grapple with more high level questions from teens.

If the kids ask,” Will that happen here?” or “Why did that happen?” Again, reassure in a simple straight forward manner. For instance you can say, “Many people are working hard to prevent something like that here.” Consider answering the question with a question. Asking “What do you think?” will give you an idea of exactly what your child fears. You can also reach out to other family supports for help with answers. Say to your child, ”I wonder what our minister or school counselor has to say about this, let’s ask.”

Routine is reassuring to children, so turn off the background 24 hour television coverage and make dinner, take them to sports activities, and get the homework done.

Give your kids something tangible to do to be helpful. Help them set up a coin donation jar at school or put aside part of their allowance for a donation.

If your child seems overly anxious and fearful, and her worries are interfering with her ability to conduct her daily activities, such as performing at school, sleeping, eating, and maintaining strong relationships with family and friends, then seek professional help.

You may not hold the answers to why a large scale tragedy strikes, but you do hold the ability to comfort and reassure your children.

Naline Lai, MD with Julie Kardos, MD

©2011 Two Peds in a Pod®

In Part 1 of our talk, we presented the problems with pediatric obesity and provided six seemingly  simple rules to follow that can help encourage your kids to become or maintain a healthy weight. But why is it so hard to follow these rules? In Parts two and three of our talk, we play out several common scenarios that illustrate our culture of over eating and suggest ways to change this culture.

[youtube https://www.youtube.com/watch?v=euhF3MAoWeY&w=480&h=390]
[youtube https://www.youtube.com/watch?v=z09_uj2tP_I&w=480&h=390]

As always, we welcome your comments and suggestions.

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

A parent was interested in our thoughts about placement for twins in school: Should parents separate them into different classrooms or keep them together?

Results of studies that look at how twins fare academically and socially when placed together versus in separate classrooms come as no surprise – it depends on the twins. Most teachers recommend placing twins separately to avoid competition and to encourage a stronger sense of self-identity. The importance of self-identity should not be taken lightly. My twins at seven, who look nothing alike and who do not dress alike, still refer to “our birthday” rather than “my birthday.”

Ask yourself, would putting them together help make each individual child more confident, more able to accept new people and situations, and encourage better behavior? Or would the two children cause one another to become more competitive? Does one tend to speak for the two of them? Does one become jealous of the other if one tries to befriend another child?

Twins, just like singletons, have endless personality differences. Some twins truly are like “two peas in a pod” while others could not be more different from each other. Sometimes one twin has more difficulty learning, or socializing, or behaving than the other twin. In some cases, placing these twins in the same class may inspire confidence, improved behavior, and security. Or placing them separately may help the “weaker” twin to “grow into his own.”

While parents should take into account the teacher’s recommendation, parents need to trust themselves to make the correct decision. Some schools give parents the final vote and some schools insist in separating twins unless, of course, there is only one class for the given grade. I had a family place their first grade twins apart only to have one join his sibling half way through the year to cure his separation anxiety and daytime “urine accidents.” Reuniting these twins helped both to perform better for the rest of the school year. Although they did poorly with separation in first grade,  two years later they adjusted fine to separate classrooms.

Try to refrain from doing what is easier only for yourself. Of course one set of homework and one birthday party class list is easier for a parent but it’s more important to do what is right for the twins. Parents can encourage individual interests, hobbies, and athletic abilities, even if that means forming carpools to make sure that each twin can make his own team practice or music lesson. It helps to think of twins as “two children with the same birthday” rather than “one set.”

Although we encourage our twins’ individuality, sometimes they just want to be alike. I cracked up when my twins came downstairs both dressed in blue jeans and Eagles t-shirts and said, “Look, Mom, we’re TWINS!”

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

Guest blogger Lee Anne Hartwell, a licensed clinical social worker, joins Two Peds in a Pod® with advice on how to tell your children about divorce.

Telling your children about the decision to divorce is one of the most agonizing tasks parents face as they navigate the divorce and separation process. How do you maintain focus on the best interests of the children while you are suffering tremendous emotional upheaval?

Following these guidelines can keep you on track and lay the foundation for creating a co-parent team that gives your children the security and support they need as the family situation changes.

*Work together as a couple to develop a plan of what is appropriate to share with your children. But above all else, children need to hear that they are not at fault for your failed marriage.

* Tell your children about your divorce together, in the comfort of their own home and during a relaxed family time.

*Convey to your children your love and ongoing assurance that their needs are important.

*Communicate that as their parents you will be working together to make the transition as smooth as possible. Explain the process of determining visitation, custody, and changes in their living situation. Avoid placing major decisions on their shoulders.

*Give your children space and time to ask questions and to share their reactions. Validate their feelings. Answer their questions as factually as you can and with an eye to keeping details of marital struggles separate. Children may also need time to themselves after hearing the news.

Preparation can go a long way to helping all members of the family adjust to this challenging time. Oftentimes, when parents are ending their own relationship, seeking the guidance of trained professionals can be instrumental in giving everyone in the family much needed support and direction.

Lee Anne Hartwell, M.S.W., L.C.S.W. is a licensed clinical social worker in private practice in New Hope and Yardley Pennsylvania with expertise in individual, couples, and family therapy.

©2011 Two Peds in a Pod®

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

You may not think of your kitchen as a convenient pharmacy, but parents used common kitchen items successfully to treat various maladies long before CVS and Walgreens were invented. 

Crisco– may not be healthy to eat, but smeared on skin, it’s an old fashioned but effective treatment for eczema or dry skin.

Oatmeal– crush and put into the end of a hosiery sock. Float in the bathtub for a natural way to moisturize skin.

Olive Oil– a couple drops into the ear three times a day will loosen ear wax (don’t put in if your child has a hole in their ear drum eg. myringotomy tubes). For cradle cap, rub into your baby’s scalp and use your fingernail or a soft brush to loosen the greasy flakes. Use to kill lice through suffocation.  Work the oil through the scalp, tuck hair into a shower cap and wash off in the morning. Although studies are unclear on how well this method works on lice, it certainly is worth a try.

White vinegar– dilute vinegar in water and soak feet to stop athlete’s foot. If swimmer’s ear is suspected, mix rubbing alcohol one to one with vinegar and drop a couple drops in the ear to stop the swimmer’s ear from progressing.

Ginger– boil ginger to make a tea to take the edge off nausea

Honey– shown to soothe coughs-give a teaspoon of dark (buckwheat, for example) honey three times a day. However, NEVER give honey to a child who is younger than one year of age because it may cause infant botulism

Lemon– an old singer’s trick—combine with honey in tea to alleviate hoarseness

Baking soda: Mix with water to make a paste to help soothe itchy skin, from maladies such as poison ivy . Can also be mixed with water to make toothpaste if you run out of your usual minty whitener.

Sugar: mix into weak tea (or your ginger tea from above) and give small amounts frequently to soothe your older child’s nausea and help rehydrate after vomiting.

Kitchen sink: excellent place to wash any cut, scrape, or bleeding wound under running water with soap. Also immediately after a burn, rinse the burned skin under cold water for several minutes to limit the extent of the heat injury. Contrary to popular lore, DO NOT put butter on a burn. You may, however, put butter on your toast. In small amounts.

Naline Lai, MD and Julie Kardos, MD

©2011 Two Peds in a Pod®

Come visit us in Bucks County Monday February 28 from 7-8:30 pm for an interactive session on the prevention of childhood obesity. The talk, sponsored by Doylestown Hospital and CBCares, will be held at the Health and Wellness Center, VIA auditorium, Warrington PA   register here for this free talk

I spent all day doing laundry. All right, maybe it wasn’t all day but it sure felt like it. Cleaning up after a vomiting child can be tough in the winter time. Unfortunately, it’s too cold to rinse off any sour curds outside. As I scraped off the sheets into the kitchen sink, I wondered how long the germs could live. I turned to my Disease Prevention Manager, Clare Edelmayer  at Doylestown Hospital, PA to find the answer.

She says depending on the germ and the surface it lands on, a germ can live for hours to days and sometimes months.

Most bacteria and viruses die within hours if they are outside the body. Surprisingly, survival does not depend on how deadly the germ is. For example, HIV virus in blood will die as soon as the blood dries outside the body.  However, some strains of flu viruses can survive 24-48 hours on non-porous surfaces such as your kitchen counter or on the handle of a plastic spoon and 2-8  hours on porous surfaces such as your toddler’s sleeve or on paper tissues. 

Methicillin Resistant Staphylococcal Aureus (MRSA), a bacteria which can cause skin infections filled with pus, stays alive for several hours to several days on surfaces.  Hepatitis B virus, a cause of liver disease, can stay viable on surfaces for 2 weeks or more, and the bloody-diarrhea producing Clostridium Difficile can live on surfaces up to 5 months. 

In other words, most germs die within hours, but don’t count on germs dying before they have a chance to enter your unsuspecting child’s mouth or nose. A dilute bleach solution works well to clean surfaces outside the body and of course, have your children frequently wash their hands.

The next time one of my kids throws up this winter, I’m tempted just to bury the sheets under the snow out back and fetch them in the spring.

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