A mom wrinkles her brow and  hands me a bulging bag of inhalers. “Which medicine is the ‘quick fix’ inhaler? And which medicine is the ‘controller’ inhaler?” she asks.

Perfecting a treatment regimen for a child with asthma initially can be tricky and confusing for parents. But don’t panic. There are simple medication schedules and environmental changes which not only thwart asthma flare ups, but also keep lungs calm between episodes. The goal is to abolish all symptoms of asthma. Here are some commonly used measures used in non-hospitalized patients:

For asthma flares

Albuterol (brand  names Proair, Proventil, Ventolin). When inhaled, this medicine works directly on the lungs by opening up the millions of tiny airways constricted during an attack. Albuterol is given via nebulizer or inhaler. A nebulizer machine areosolizes albuterol  and pipes a mist of medicine into a child’s lungs through a mask or mouth piece.

For kids who use inhalers, we provide a spacer, a clear plastic tube about the size of a toilet paper tube which suspends the medication and gives the child time to slowly breathe in the medication. Without a spacer, the administration technique can be tricky and even adults use inhalers incorrectly. Albuterol in a drinkable form does exist but is less effective and has more side effects.

Prednisone (brand names include Prelone, Prednisolone, Orapred): Given orally in the form of pills or liquid, this steroid medicine acts to decrease inflammation inside the lungs. The kind of steroid given is not the same kind used illegally in athletics. While steroids in the short term can cause side effects such as belly pain and behavior changes, if needed, the advantages of improving breathing greatly outweigh these temporary and reversable side effects. However, if your child has received a couple rounds of steroids in the past year, talk to your pediatrician about preventative measures to avoid the long term side effects of continual steroid use. 

Quick environmental changes One winter a few years ago, a new live Christmas tree triggered an asthma attack in my patient. The only way he felt comfortable breathing in his own home was for the family to get rid of the dusty tree. Smoke and perfume can also spasm lungs. If you know Aunt Mildred smells like a flower factory, run away from her suffocating hug. Kids should avoid smoking and avoid being around others who smoke.

For asthma prevention

Taking preventative, or controller medicines for asthma is like taking a vitamin. They are not “quick fixes” but they can calm lungs and prevent asthma symptoms when used over time.

Inhaled steroids (brand names Flovent or Pulmicort, for example) work directly on lungs and do not cause the side effects of oral steroids because they are not absorbed into the rest of the body. These medicines work over time to stop mucus buildup inside the lungs so that the lungs are not as sensitive to triggers such as cold viruses. 

Monteleukoclast (brand name Singulair)  also used to treat nasal allergies, limits the number and severity of asthma attacks as well by decreasing inflammation at a different point than steroids. It comes as a tiny pill kids chew or swallow daily.

Avoid allergy triggers  (see our allergy post ) and respiratory irritants such as smoke. Even if you smoke a cigarette outside, smoke clings to clothing and your child can be affected.

Treat acid reflux appropriately. Sometimes asthma is triggered by reflux, or heartburn. If stomach acid refluxes back up into the food pipe (esophagus), that acid could tickle your child’s airways which lie next to the esophagus.

Avoid Respiratory Viruses and the flu. Teach your child good hand washing techniques and get yearly flu shots. Parents should schedule their children’s flu vaccines as soon as the vaccines are availiable.

Use Peak flow meters. Peak flow meters are small, hand-held devices that measure how well your child’s lungs are functioning and can detect an impending asthma flair before the cough or symptoms are obvious. The child blows as hard as he can into the small plastic air chamber and gets a number score. Baseline scores depend mostly on a child’s height, and the meters come with charts to guide what your child’s best score on a good day should be. The child tracks his scores daily until his baseline is well established. Then, if the child starts with a runny nose, he begins using his peak flow meter. If the number drops from baseline, treatment medicine (albuterol) is started. An asthma attack may be prevented because the attack is treated before symptoms get bad. 

Some parents are familiar with asthma because they grew up with the condition themselves, but these parents should know that health care providers treat asthma in kids differently than in adults. For example, asthma is one of the few examples where medicine such as albuterol can be dosed higher in young children than in adults. Also some treatment guidelines have been improved upon recently and may differ from how parents recall their own asthma was managed as children.  A doctor friend now in his 50’s said his parent used to give him a substance to induce vomiting. After vomiting, the adrenaline rush would open up his airways.

Don’t do that. We can do better so that both you and your child can breathe easy about asthma.

Julie Kardos, MD with Naline Lai, MD
©2010 Two Peds in a Pod℠

Today our dear friend, pediatrician, and mom, Wendy Lee shares insights and personal experience on how to tell your child he is adopted.

My husband and I had waited three long years for “the phone call” letting us know who would become our baby.  Only three short weeks prior to boarding a plane to China, we got the news we would not be bringing just one beautiful girl home from China, but TWO. Twins. We should have known right at that moment we would begin living a life of improvisation.

As with all parenting, there are endless numbers of issues to tackle.  One unique to families formed by adoption is how and when to tell your child he is adopted.  There are many differing opinions on how to do this right, but all agree children should be told.  It wasn’t so long ago that “the experts” deemed it to be psychologically damaging for a child to know about his adoption, and recommended not revealing this information.  Thankfully, things have evolved, and we are faced not with if, but how, to best share the news about adoption.

Just as with many aspects of child rearing, it is often best to take cues from your child.  If your child is younger, as were our girls (thirteen months old at the time we first met them), it is a good time to discuss adoption openly so it takes on a normalcy.  We read a full library of children’s books to them about adoption, and show the girls pictures and videos of our trip over and again.  We speak with them about our “Gotcha Day” (the day we got them and they got us).  And we celebrate this day each year with some of the families who traveled to China and got their daughters on the same day.  We talk about their birth parents in China and celebrate their heritage which, although similar to ours, is not exactly the same (I am Korean, and my husband is Cambodian). 

We gave ourselves a little pat on the back one day when we told our children one of our friends was going to have a baby, and they in turn asked which plane the parents were going to ride to get the baby.  They certainly thought adoption was a normal way to have a baby, but now we were faced with telling them other ways this could happen!  

As children grow, they enter new stages which may require improvisation.  A child’s age and temperament will guide you in your discussions regarding her birth and adoption.  Some children will never have any questions and will be satisfied with the here and now.  Others will have lifelong struggles to try and understand their history.  At certain stages, children will want nothing else but to fit in.  Being adopted, at that point, may set them apart from others and become something they will not want to advertise.  While “Gotcha Day” right now is another opportunity for our girls to have cupcakes, presents, and company, at some point it may be a day that reminds them of what they have lost and how they are different from their friends. They may choose not to celebrate this day any longer.  For some children, curiosity about their birth parents will be all-consuming and for others, it may just bring fleeting thoughts. 

Regardless of the age, stage or temperament of your child, my advice is to be truthful, open, supportive and positive. As your child grows, you will share more information. At some point, probably during his/her adolescence, your child should be given all the information that is known regarding his or her history, even if it may be difficult to share.   Discussions will move from simple explanations to potentially heart-wrenching, tear-ridden sessions where answers aren’t available.  I think whatever reaction your child will have to this part of her past, the longer she has to process it, and the longer you have to deal with your child’s emotions in this regard, the better it will be for all.

Wendy C. Lee, MD, FAAP
General Pediatrician

Presently full-time mama to two beautiful twin girls adopted from China

Anxiously awaiting a third child from Korea

© 2010 Two Peds in a Pod℠

\
Last week a nurse in my office rushed a one year old girl back to one of my exam rooms. She was sitting in her mom’s lap, anxious and breathing hard. Her nostrils flared with every breath she took, and when I had her mom pull up the child’s shirt, I could see her ribs every time she inhaled because she was using extra muscles in her chest to breathe.  Her belly was moving in and out as well. Her breathing had just become labored an hour before the office visit.  The child had similar experiences in the past and now carries the diagnosis of asthma.

Asthma. Parents initially cringe at the diagnosis. But what is it? Most children with asthma never show up in the office with an attack as severe as the child I described above.

Asthma is a condition where the millions of airway tubes (called bronchioles) throughout the lungs get clogged with mucus (inflammation) and also get narrower (constrict) and thus become harder to breathe through. Medicine reverses the effects of asthma. Think of asthma as sensitive airways.  A nasty cold virus or the billowing dust cloud from cleaning the garage makes everyone’s airway spasm. In kids with asthma, the spasm may be more severe, resulting in more cough or airway tightening.

Asthma is the most common on-going illness in children. Many babies and toddlers who have asthma have a good likelihood of outgrowing it by age three. Another subset of children, again especially below age three, have ONE episode that looks for all the world like asthma, but then they never have another episode.  Other kids have asthma that stays and these kids and their families must proactively manage their asthma long term.

Asthma symptoms can start at any point, from infancy through the teen years. Adults can be diagnosed with asthma for the first time at age fifty.  Dr. Lai has had symptoms of asthma since childhood but Dr. Kardos first had symptoms of asthma when she turned thirty.

The tendency to develop asthma is genetic, but there are environmental triggers in kids who carry the asthma gene. The most common triggers of asthma flares are cold viruses, cigarette smoke, and environmental allergies (animals, pollen, etc). Also, air pollution, exercise, and very strong scents (new house paint or perfume, for example) can trigger an asthma attack. It is also common for someone with asthma to have allergies and/or eczema (excessively dry, irritated skin).

How do you know your child has asthma? No one test can definitively identify asthma.  Chest x-rays cannot show asthma. Sometimes Pulmonary Function Testing  in older children helps doctors diagnose asthma, but younger kids often have a hard time performing the test.

Pediatricians diagnose asthma by studying the past experiences of the child.  Not every child is out of breath like the patient I saw in the office. The most common symptom of asthma is cough.  Watch for the following symptoms:

1. Night time cough most nights of the week, usually starting somewhere after midnight. The child may or may not wake up because of the cough.
2. Cough that shows up with exercise, usually after several minutes of running, swimming, jumping, even laughing.
3. Cough with a common cold virus that lasts much longer than what is typical—longer than two weeks after the onset of a cold when most other kids or siblings with the same cold are better.
4. Cough that is accompanied by increased work of breathing. Your child’s nostrils may flare in and out with each breath, or her ribs might stick out with each breath, or her breathing rate is much higher than baseline as if she were just running hard even when she is just resting. She might not be able to talk in complete sentences, drink, or eat because she is too short of breath.
5. A wheeze— a high pitched sound heard during exhalation. The sound is not the strange, hoarse sound heard during inhalation (e.g. in a child with croup) nor is it the mucus/rumble you hear from the back of the throat of most kids with a cold.
6. Cough triggered by cold: eating an ice pop or breathing cold, winter air, for example.

Don’t worry about labeling your child with the diagnosis of asthma.  Gone is the stereotype of a child with asthma as a sickly kid who sits in the corner and is told not to participate in sports.  A large percentage of Olympic athletes have asthma.  The diagnosis of asthma will open up a world of medication and lifestyles which can soothe your child’s irritated airways.

Stay tuned for Understanding Asthma, part 2: the treatment of asthma.

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

Panic.

Off to the mall today with my children. Everyone was strapped in the minivan ready to go.  But where were the gift certificates the kids just got for Christmas from the relatives? I was perplexed and scuttled back into the house. Inside, I recreated in my head the scene at grandma and grandpa’s where I had last seen the gift certificates. At their house, after the children had properly said their thank yous, I remembered carefully folding the certificates in tissue paper and tucking them into the sparkly blue gift bag which was to go to my parents on behalf of my in-laws.  As an added guarantee that they would not be forgotten, I deliberately placed the blue bag with the other presents we had received. Where could they be? After all, they were safely in the big black trash bag with all of the other presents.

The trash bag? Oh dear.

Suddenly I remembered arriving home from my in-laws to a family room cluttered with gifts from Santa. I told the kids to clear everything out. When the dust settled I saw a big black trash bag in the center of the room. I grabbed it and threw it in the garage. Then a Christmas miracle happened.  In the midst of holiday hub-bub, my husband remembered that it was trash pickup day and took out the trash.

Gone were the gift certificates. Gone were my in-law’s presents to my parents. Gone was the plug in Star Wars game module. Gone was the “last copy” of a book of Chinese folk tales lovingly picked out for my daughter. And gone was the silly Bop- it game, a crazy game of Simon Says where one of the commands is to “bop” the toy against your tummy.

For a brief moment I contemplated running down to the dump and trolling through the garbage. After all, there were probably only a couple thousand black garbage bags. If I started now, I could be done by next Christmas.

Laughing (what else could I do?), I made my way back to the car where I broke the news to my kids. I too was disappointed, but I couldn’t go back and undo the event.  I had no choice but to laugh.

Together, between the tears, we stepped through lessons learned.

Lesson #1 Be more careful with our things

Lesson #2  Forgiveness is hard but essential for moving forward

Lesson #3 We were happy two days ago and that was before the presents arrived

Lesson #4  Let your kids play with their new toys the moment they get them- you never know when they will disappear

And the most important lesson #5 Use clear trash bags

My oldest smiled slowly and pointed out that I had declared to the kids, “Any presents not cleared out of the family room and put away in your own rooms will be thrown out.” I had unknowingly carried out my threat. Gradually, murmurs of disappointment gave way to laughter as we all imagined a scruffy bearded hobo going through the garbage picking up gift certificates from the girly stores Justice and Abercrombie.  Somewhere there is a stylin’ hobo with a scruffy beard in a fur trimmed hooded puffy coat and tank top, hopping up and down, playing Bop-it.

The minivan shook with laughter.”Oh, mommy, I’m laughing so hard my stomach hurts,” my daughter said. “Mine too,” my other two moaned between giggles.

The cost of “the stuff”:

A lot.

Making kids laugh so hard that their stomachs hurt:

Priceless.

Naline Lai, MD
©Two Peds in a Pod℠

Kids are noisy. A noisy child is usually a healthy child, so we pediatricians welcome noise. Today we give you Top Ten Sounds we are grateful for this Thanksgiving:

10. The sound of a six-month-old baby’s belly laugh.

 9. The sound of a two year old trying to say “gobble, gobble, gobble.”

 8. The sound of a three year old saying “why?” about 100 times a day.

 7. The sound of a chatty first grader who tells you about her favorite part of her day in one gigantic run-on sentence.

 6. The sound of a grade school orchestra concert (as heard through ear plugs).

 5. The sound of a high school orchestra concert played by the same students you remember playing in their grade school concert.

 4. The sound of a teenager confiding something very important during a check up and then answering “yes” to the question “Do your parents know about this?”

 3. The sound of a high school senior saying he got into his first choice college.

 2. The sound of children (and their pets) breathing as they sleep.

 1. The sound of a child’s small voice at Thanksgiving dinner leading her family in thanks.  

Wishing you all a noisy Thanksgiving.

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod℠

Your child wakes up hot with fever but no other symptoms. She seems hungry, eats a great breakfast, and after a dose of Tylenol, she is no longer feverish and is now jumping off the couch. Are you a mean mommy or an unethical daddy if you send her off to school? Maybe not. Last month we had the privilege to address an audience of early childhood educators at the Bucks County Association for the Education of Young Children’s annual conference about when a child should leave school for medical reasons. In our podcast, When to keep your child home from school, we share some of the medical scenarios we discussed with the teachers: fever, vomiting, diarrhea, head lice, and pink eye.

Guidelines are based on Managing Infectious Diseases in Child Care and Schools, 2^nd edition, Editors: Susan S. Aronson, MD, FAAP and Timothy R. Shope, MD, MPH, FAAP published by tThe American Academy of Pediatrics. 

 Happy listening. Some of the answers may surprise you…

Julie Kardos, MD and Naline Lai, MD

©2010 Two Peds in a Pod℠

Whether you are discussing after dinner cleanup or explaining a complex issue such as an impending divorce, keep in mind talking to a young child is not the same as talking to a “little adult.” Our guest blogger, child psychologist Dr. Barry Ginsberg, a child and family psychologist since 1969 and the originator of the Parent-Adolescent Relationship Development Program (PARD), illustrates how to communicate with preschool and young school aged children.  

Julie Kardos, MD and Naline Lai, MD

  Children’s Questions

It’s important to be receptive to what we call teachable moments. Be prepared to

respond when you perceive that your child is ready and then follow your child’s lead.

Here’s such a moment: Johnny, age three, asks Sam, his dad, “Why do I have to go to day care?”

Sam could explain that it’s important to be with other children, or that he has to go to work. But instead, he realizes that he first needs to respond to Johnny’s feelings.  So he says, “You’re not happy about going.”

Johnny says, “Yes, I want to be with you.” 

“It makes me feel good that you want to be with me,” Sam says, going to a positive feeling first.  Then, he refers to his own feelings by saying, “That’s important to me, too.”

Only after Sam says this does he become specific and answer Johnny’s question with facts:  “It’s important to go to day care because I feel better knowing where you are and that you are safe when I’m at work.”

This was a teachable moment.  Sam paid attention to Johnny’s feelings, acknowledged both their feelings, and offered a reasonable explanation.  This demonstrates Sam’s respect for his son.  As a result, Johnny truly “heard” his father.

When talking with young children, keep the following in mind:

1. Young children express themselves mostly through play.
2. Play is how they go about understanding their world and experiences.
3. Letting a young child lead you in play helps you understand the child better.
4. It may be hard to get a young child to let you know that she understands you. Forcing her to respond may be threatening to her and frustrating for you.
5. Even though children may not seem to be showing you that they understand, they probably do.
6. Keep your comments short and simple.  As much as possible, try to phrase things in children’s terms, let them know you understand their feelings and use your feelings when you want to let them know what you want. For example, “You’d like to keep playing but I’m unhappy that the toys aren’t picked up,” and “The rule is that toys are put away before dinner.”
7. If you want children to understand or do something, you need to be patient; repeat it a few times; gently convey through your movements what you want; and try not to act out of your frustration.
8. Try to be consistent, and have clear rules and expectations.
9. Pay attention to children’s feelings when talking to them.

Read these nine suggestions over a few times. It takes a little practice to use them consistently. Be patient with yourself. You’ll get it after a while.

Barry G. Ginsberg, PhD, ABPP, CFLE
The Center of Relationship Enhancement (CORE)

215-348-2424
www.relationshipenhancement.com

Reprinted with permission from  50 Wonderful ways to be a Single-Parent Family.

photo credit: Lexi Logan www.lexilogan.com 

This monstrosity arrived at my house last week. It’s the neighborhood snow blower my husband and several neighbors purchased together to share. As I stared at the machine, I thought about all the little arms and legs that could potentially be churned up as the monster chugs through the snow.  Paranoid? Perhaps. Although, I console myself, it would be hard to ignore a snow blower coming at you.

Unfortunately, one of the biggest winter hazards is not so loud and obvious. As the temperature drops, deaths rise from this insidious poisonous gas: carbon monoxide.

According to the Centers for Disease Control, about 400 unintentional deaths occur a year from carbon monoxide poisoning. Carbon monoxide results from the incomplete combustion of fuel. The gas causes a chemical suffocation by competing with oxygen in your body. The colorless, odorless gas is impossible for human senses to detect, and unfortunately, loss of consciousness usually occurs before any symptoms appear.  Those lucky enough to have warning symptoms before passing out may experience headaches, nausea or confusion.

Because carbon monoxide is a by-product of incomplete combustion, sources are related to energy use.  Poisoning occurs more during the winter months when fuel is used to heat closed spaces and ventilation from exhausts is poor. My sister, toxicologist and Harvard medical school instructor, Dr. Melisa Lai, tells the story of a snowplow operator a few years ago who left the house early in the morning to plow snow, only to return and find his family dead. The reason—snow blocked the exhaust pipe from the furnace and caused lethal levels of carbon monoxide to accumulate in his home.

Carbon monoxide also occurs in warm weather. To avoid carbon monoxide buildup in all climates:

–Install carbon monoxide detectors. My sister says a $20 detector such as Kidde works as well as the  $150 models. Put them on every level of your home and check that the batteries work. Smoke detectors are not the same as carbon monoxide detectors. However, combination detectors are available.

–Ventilate all appliances, heating units, and your chimney adequately.  Have them serviced yearly.

–Be wary of the exhaust from of any vehicle. 

Parents have put their infants in running cars while they shovel snow, unaware that the car’s tailpipe is covered in snow. By the time they return to the car, the infant, who is extremely susceptible to carbon monoxide poisoning because of his size, is dead. Even opening the garage door when you run your car is not enough ventilation to prevent poisoning.  

Like cars, boats also produce carbon monoxide. Since boats are less energy efficient than cars, they spew more of the gas. While your teen boogie boards behind a motor boat, the carbon monoxide can knock her tumbling unconscious into the water.

–Keep anything meant to burn fuel outdoors, OUTDOORS.  Even an innocent barbeque can turn into a nightmare if you decide to grill inside your garage.  Emissions from any type of grill, charcoal or gas, can send carbon monoxide levels skyrocketing. Additionally, hurricane season in the southern United States is known by toxicologists as “Carbon Monoxide Season.” During hurricanes, people buy outdoor generators and auxiliary heating units. They work so well that people then bring them indoors, trapping fumes in their homes. 

My sister says she has hundreds of stories about carbon monoxide poisoning, all which end tragically. Maybe I’ll let my husband store that larger-than-life-take-up-car-space neighborhood snow blower here this winter.  Then, at least I know I’ll be able to make sure no one starts up the blower in a garage.

For more details please visit http://www.cdc.gov/co/faqs.htm.

Naline Lai, MD with Julie Kardos, MD
©2010 Two Peds in a Pod℠

Lately my office staff has taken to giving out Sillybandz as rewards for kids who bravely endure the sting of vaccines , cooperate during exams, or just behave well while along for the ride at a sibling’s doctor visit. The kids LOVE them. Better than stickers. Healthier than lollipops.

You poured out all of your two liter soda bottles, replaced all the potato chip snacks with fruit and signed all your children up for winter sports.  Just when you thought your family’s activity and diet balance was perfect, along comes Halloween, that fabulous candy-filled holiday to thwart your efforts. Ways to keep the candy deluge down to a trickle:

-Let your children know Halloween (and most holidays) lasts only one day. Live it up on Halloween then dump the extra sweets into the trashcan the next day.

-Buy back the candy with toys or money.  Alternatively, have the sweet tooth fairy come overnight, pick up the candy and leave a present behind.

-If you decide to keep a small bag of candy around, watch out, your children will be tempted to eat some daily. Candy becomes an ongoing “must have.” Instead, designate a day to eat candy during the week such as Sweet Saturday or Candy Friday. If the kids whine for candy on any other day of the week, you can say, ”Sorry, it’s not Sweet Saturday.”

-One parent told me she discourages her kids from eating Halloween candy by making their dental appointments on November 1—the day after Halloween.

According to an article published in the New England Journal of Medicine in 2000, the average American adult gains about a pound over the winter holidays. Unfortunately, the weight is not shed during the rest of the year.  

Hope your kids don’t grow into that kind of adult. Now, that’s a scary Halloween thought.

Naline Lai, MD with Julie Kardos, MD

©2010 Two Peds in a Pod