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.
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®
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.
As always, we welcome your comments and suggestions.
Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®
We wish to thank our attendees for their many questions and for engaging in thought- provoking dialogue at the end of the session. Stay tuned for part 2.
Naline Lai, MD and Julie Kardos, MD
©2011 Two Peds in a Pod®